Semester 12 - General Practice (RETROSPECTIVE POST)

My GP (General Practice) Rotation was at a Bulk-Billing Clinic in a rural Victorian Town with 2 other Medical Students. Initially I thought it’d be an isolating Experience not being in Melbourne, but in some ways it was actually nice to have GP as our final Rotation as we’d be away from the “Chaos” of the Public Hospital and the “Hysteria” of other Medical Students prior to our Final Exams, plus I could have a short Break away from my Parents who at Times aggravate me (especially when I’m stressed).

Very interestingly, all bar 1 of the GPs at that Clinic were from the UK, which in some sense made me a bit less self-conscious as I could attribute more of my Idiosyncrasies to “Cultural Differences”. Nevertheless, I told them about my AS, and they were polite and accommodating without being patronizing. In fact I swore one of the GPs was an Aspie based on his Physical Appearance and Behaviour, which really surprised me given that I’d thought he’d made the wrong Specialty Choice and burnout rapidly, but he didn’t recall so.

Communications-wise, the “Aspie” Doctor was very methodical but also displayed some Flexibility depending on the Patients’ initial “opening Speech”. He said that one should aim to give the “Golden Minute” to the Patient’s “opening Speech” because it helped Identify what their Concerns were so you could subsequently direct the Conversation in the right Direction. He introduced to me a very useful Acronym called “ICE” (Ideas, Concerns and Expectations). He told me that as long as I clarified all 3 of those Issues, the Patient would be more likely to be satisfied with the Consultation coz it gave them the Impression of being listened to, even if you have insufficient Medical Knowledge. It was one of the “Soft Skills” that would enable Doctors to sound more caring, fostering the Doctor-Patient Relationship.

The GP Environment struck me to be a lot cleaner and calmer than on the Wards. I loved that the Day started without any Ward Rounds, and I could sit comfortably, focusing on 1 Patient at a Time in a Room which created a stronger Sense of Privacy (as opposed to Curtains by the Bedside). I initially had Issues with Time-Management coz I was going into too much Detail (History or Examination - wise) out of Ignorance and Academic Interest, but became a bit more efficient towards the End of the Rotation by narrowing down the Patient’s Main Concerns from the start and then targeting that, ala ICE. It was excellent Practice for OSCEs coz of the numerous Opportunities to take Histories and Examine Patients (both Differentiated and Undifferentiated) under Time Pressure. I frequently felt like I was asking a List of Questions for Specific Issues, but had to figure out how to make it not sound so Robotic. I usually faced them and took the History in one go and gave little Responses here and there, before typing the Notes on the Computer, to facilitate the listening Impression. I was fortunate that for Clinical Depression in particular, asking about the Symptoms in itself (sleep, appetite, hobbies) indirectly demonstrated to the Patient that you truly cared about them.

The Cost of independently clerking the Patients, however meant that I had to present the Cases to my supervising GP, which was verbally Challenging. I invariably stuck to a Structure when presenting a Patient, but had to look away from the GP when concentrating hard coz the Eye Contact would actually distract me from my Train of Thought (but not painful like my pre-rTMS days).  

I think about halfway through the Rotation, I started feeling like a Waiter, asking the Patients “What would you like today? How can I help you? Is there anything else you’d like to talk about?”, and filling in Scripts and typing Referral Letters, letting the Patient comment whilst I was editing it. Whilst the Referral Letters initially seemed challenging, I actually experienced a sense of Pride in typing them, like I was the Patient’s “Advocate”. I could see myself improving over Time just by repeating various Structures. I was ecstatic that GPs could be paid for Consultations that were purely for Scripts or Referrals, it looked like easy Money, although I’m sure that the Reality is somewhat different!

I did have Gripes in that there seemed to be a significant Proportion of Patients who had chronic Medical Issues, particularly secondary to their Western Lifestyles or dangerous behaviour (Smoking, Junky Diets, Heavy Drinking, non-cautious IV drug use). According to their Medical Histories, it seemed like there was little progress by Way of actual Patient Effort to adjust their Lifestyles in Spite of repeated Appointments and Medical Advice. To be Frank at the Time I was actually very annoyed by a lot of such Patients, who invariably were on Disability Pensions (funded by the Taxpayers) for Complications of seemingly self-inflicted Conditions but didn’t complain about this openly. If these People were in Countries with less generous Welfare or Healthcare Systems, they might be dead by now. It was almost like they were being “rewarded” for chronically bad Behaviour. I wasn’t sure if there were underlying Psychological Issues that weren’t adequately addressed that may have impeded on their Compliance.

I and the other Med Students were frustrated by such “loser” chronically non-Compliant Patients. We actually brought up this Issue in a Tute with the GP Lecturer, but she then quoted from the GP Textbook “John Murtagh’s General Practice”, which VERY SURPRISINGLY stated that we SHOULD NOT TRY TO HELP THEM (!!!), but instead simplify Management Goals (as the Patient wouldn’t comply with complex ones), and maintain respectful Communication. She said that we weren’t the only Med Students to be frustrated, and that the MD Students of the ERC (Extended Rural Cohort) who have far more GP Exposure than us were already “Jaded”. She stated that not all Patients can be helped, and that you’ll eventually have to give up on some of them to minimize Burnout / Frustration, contrary to what other Politically-Correct GPs say. On the bright Side, these Patients still made regular Appointments to see the GP and Nurses, but it was Compliance with Treatment that was poor. Maybe their GPs still have the Chance to use a different Approach to positively influence them before they die, though I seriously doubt it given the Years that have already elapsed and all the Communication that’s been already documented.

In GP, you act as a “Jack-of-all-trades”, which appealed to me due to my relative enjoyment of Paediatrics and Geriatrics. As the first Point of Contact in the Community, the GP also plays a practical Role in Coordinating the Patient’s regular Care. It’s also by far the most flexible Specialty to offer Part-Time Work (including in Training), hence its Popularity with working Mothers. The average full-time Earnings seems to be much less than Hospital Specialists, but for some, the lower Pay is a Compromise for avoiding the Politics and Bureaucracy within a Public Hospital.

I was concerned whether I could handle all the Talking though, coz I was already mentally drained after 4 morning Consultations, having go back to my Student Accommodation for a Nap or sitting in Silence during Lunch-Time. I could always try to work Part-Time instead.

I was also worried that being at the “Frontline” in Community Healthcare, I could get sued by non-compliant Patients’ despite my Efforts to help them, as demonstrated by the ABSOLUTELY RIDICULOUS Lawsuit last year by a morbidly obese Patient against a GP (which eventually got overturned) who eventually developed Liver Cancer (likely as a Complication of chronic morbid Obesity). Cases like these make me pissed off, coz it gives the Impression of absolving the ***Legally-Competent*** Patient with no Physical Disabilities, any personal Responsibility in looking after themselves, penalizing the Doctors instead. IMHO it also disempowers them from taking Control of their own Lives. Had that Case not been overturned (and set a Precedent), who the Hell would want to look after Obese Patients and/or chronic Smokers then? Smokers could potentially sue GPs for developing COPD and having an impaired Quality of Life!!! Ie tons of Lifestyle-related ticking “Lawsuit-Timebombs”.

It really seems that none of the Medical Specialties are a 100% Fit for me, and that I’ll have to aim for one that best suits my Strengths, Weaknesses and Interests. Given the current Dearth of Pathology Trainee Positions, perhaps I could initially train in GP for the Job Security, and then work on the Weekends for the purpose of having a bit of Patient Contact, if I got into the former later on?! I’m not sure how feasible this is. Too bad I’m not interested in Haematology which has both Clinical and Laboratory Aspects…