Getting though the day – Dr Jamie Wallis – First 5 GP

JamieWallisToday I left work late, exhausted, hungry and mute.
But today I also felt fulfilled.

Today I’ve had people swear at me because I won’t give them non indicated bloods, antibiotics or a scan. I’ve had one patient complain because I was running 15 min late. I’ve had one guy come in drunk and menacing. I’ve had the daily stack letters and bloods to deal with.

But all has been balanced by a home visit to a young dying man. I sat and spent time listening to him. Hearing the frightening journey he has been on so far, eliciting his fears about the journey ahead, trying to offer support to him and his partner, trying to find words to express the awfulness of the situation, trying to swallow the rising lump in my throat as he recounted his life before illness and the impact this has had on the life of his whole family unit.

For the first time in a long time, I forgot time. I ignored my watch and the clock on the wall. And I listened. I didn’t pressure him, finish his sentences for him, pre-empt what he was saying. I just let him speak. At the end he and his partner thanked me. I hadn’t done anything. Just listened. And I felt so humble. And I felt a renewed energy to support him and his young family.

I truly love this job and I wish there was more time. But patients like this remarkable man remind me why I became a GP..

Heart rendering moments where I feel I might be making a difference in some small way.

Amar Rughani – I won the lottery!

 

Amar RughaniI won the lottery! Being a doctor is one of the best ways to live a life and General Practice is the best way of being a doctor. This may sound flippant but I feel both proud and fortunate to be a family doctor; in fact it’s been the making of me and without the challenges that becoming an expert GP presents, I wouldn’t have grown as a doctor and as a person in the way that I have. Let me explain by sharing three aspects of my life as a GP.

Firstly, I have learned to be wary of certainty. I’m privileged to be trusted by my community, and patients bring me the problems and issues that worry them.

These problems, especially the significant ones, rarely have simple answers and I have to learn to manage the uncertainty until a way forward has been clarified. I work with probabilities rather than definites as a result of which:

my expertise begins where the algorithms end

That takes real skill, great judgment and a steady nerve as well as the relationship skills to share without scaring and support without taking over.

The better I’ve become at managing the uncertainty of problems, the less I’ve been frightened by the complexity and diversity of people and the more I’ve tried to understand them rather than just ‘assess’ them.

This leads me to the second aspect, which is that I have learned to see ‘status’ as a barrier rather than an entitlement.

If we really want to help our fellow human beings at their times of suffering, we need to connect with them.

That can’t happen to the degree that generates trust, if we feel in our hearts that we are different (especially, better) than them. We learn to impose our superiority and to feel entitled to do so. We even learn to justify it, for example we say it gives patients confidence in us. But the reality, well my reality, is that when we admit in our hearts that the differences between us are an accident of opportunity rather than a reflection of superiority, we free ourselves to experience empathy and understanding at a much more profound level. And that’s not only good for our relationships, it’s great for problem-solving and risk management too.

The third aspect of being a GP leads on from the second, and is the experience of fulfilment through connection. Learning to connect with people as individuals encourages us to use those skills to connect with communities of all sorts. These might be communities defined by geography or socioeconomic circumstance, but they might equally be communities of thought or belief. Learning to connect leads to learning to respect diversity and the great value of looking at the problems and issues of life from a variety of perspectives, including ones we find difficult or don’t sympathise with. This has made me curious but it has also made me more tolerant.

The feeling of being connected with people, understanding their complexity, respecting our equality and our differences and giving something that they value has been the recipe for a deeply fulfilling life.

General Practice gave me that, and I will find it so hard to walk away from it.

It can give you that too.

“Just a GP” – Liddy Mawer – ST3, Yorkshire

Lydia Mawer

I am not “just a GP”, I am a highly skilled specialist on the frontline of the NHS, a risk-taker, a problem solver and a gatekeeper to finite resources. I am a leader, a teacher, a businesswoman, an innovator and a champion and advocate for patients. I provide consistency and fairness and a helping hand to those at their time of need.

Being a doctor in any specialty is tough in the current political and financial climate. There is an ever-increasing workload as a consequence of increasingly available (and costly) treatments and the subsequent amassing demand from patients with inflated and at times unreasonable expectations. In the context of a growing society and a workforce that’s perpetually shrinking in not only numbers and resources, it’s no surprise that more recently, morale amongst passionate and dedicated doctors is also at an all time low. The current use of the NHS as a political vote wining pawn in an increasingly consumerist and fractured society has resulted in the unsustainable situation of a system with finite resources stretching itself dangerously to cater for patient’s ‘wants’ for services and access to healthcare in strong contrast to the reality of their actual medical needs and what is achievable.

The embers of unreasonable expectation and dissatisfaction may have been smoldering in the background of a 24-hour consumerist society but the flames have been strategically perpetuated by governments and further fanned by a vitriolic media. GPs were the first to take a hit with complaints of inadequate convenient accessibility and non-evidence based accusations that a lack of routine 7-day availability was contributing (amongst other things) to the pressures on A&E attendance and poor patient care. GPs have been maligned as overpaid money-grabbing doctors, clocking off at 5 pm with no regard for their patients’ wellbeing. With this present demonization of ‘fat cat, lazy’ GPs in the press and an increasingly overworked and demoralized workforce, it is easy to understand why general practice is failing to retain GPs let alone recruit young doctors. Add into this the uncertainty of the future structure, funding and expectations of general practice (and indeed the NHS itself) and the open dissatisfaction and ‘burn-out’ of GPs, recruiting future general practitioners seems an increasingly impossible task, already troublingly evident in significantly unfilled training posts.

So, why would any young eager doctor in their right mind even fleetingly consider training to become a GP in this climate? Even within the profession GPs are often depicted as subordinate to their secondary care colleagues: as failed specialists.

As a junior, specialists often commiserated me when I declared general practice as my vocation, repeatedly declaring with tilted head “that it’s a shame that such a good doctor is being lost to general practice”.

This was swiftly followed with the assumption that as a female doctor, I wanted a family and that the flexibility afforded by general practice to accommodate this was the only fathomable justification for ‘settling’ with primary care! It was not considered that I had chosen to become a GP. This subconscious contempt for general practice as a contingency stems from medical school and even now when asked about my specialty I have often described myself as “just a GP”, a line so subliminal and commonplace that it rolls off the tongue.

Recently a colleague asked me why I was a GP; the benefits of general practice over other specialties and how would I ‘sell’ the vocation to young doctors at a time of crisis?

Despite the current climate and ever increasing challenges of the profession I didn’t find it hard to justify my decision and passion to train as a GP or to find many benefits when compared with secondary care specialties.

So firstly from a pragmatic viewpoint there are many benefits. Although I did not choose primary care predominantly for its family friendly work-life balance, I know that many of my colleagues to varying degrees did and lets be honest, the prospect of free weekends and no night shifts after many years pounding the wards out of hours is attractive (whether you are planning on producing children or not) and it is understandable that the prospect of losing this work-life balance is deterring many would-be GPs. However, the fact remains that as a GP trainee and then a practitioner, even with extended working hours and the prospect of working weekends,

the work schedule is still more family friendly than the shifts of my secondary care colleagues (even more so in light of the current political propositions).

As a trainee your working week is for the large part sessional and extremely well supported. It is almost expected that you will bear children during your training and your progression is simply placed on hold until you return from your maternity leave. No scrabbling around trying to plan conception perfectly between work placements. Its sessional base also lends itself to less than full-time training and part-time working once you qualify and unlike secondary care it is quite feasible to work only mornings or to plan your working week to varying extents around your life. There is no worry of where in the UK you may be posted with a small child should you have been unfortunate enough to have not obtained run-through specialty training and there is no long commute once you settle into your regional training program. There is also no fear for your future career or the dreaded trepidation of informing your surgical boss that you are pregnant, that many of my friends have encountered. Your first thought when you are pregnant should not be how you are going to break the news to your boss! And while I’m being pragmatic, you can also park right outside of your office, for free.

No driving around for 30 minutes unable to find a space within a three-mile radius of the hospital that you have paid extortionate amounts for.

This seems a flippant point but I all too well remember being scared whilst running to my car in the early hours of the morning across a huge, poorly lit campus.

Although I cannot comment too much on hospital based training programs what I can say is that GP training is second to none. Where else can you get weekly genuine protected teaching time that is not repeatedly lost to service provision, (a whole day a week) and daily one-to-one teaching, training and supervision? Every day I have the opportunity to discuss every single one of my patient encounters with an experienced GP who is passionate about teaching and has chosen to become a trainer (with actual teaching qualifications), providing constructive feedback and support. My twice daily debrief is precious and enables clinical learning, reflection and often laughter and challenging debate. You also really get to know your colleagues and fellow trainees with such regular contact making lifelong friends and just as importantly, a wide supportive professional network- the key to any resilience and professional sustenance in the longrun. We all congregate every week, learn together, teach each other and most importantly regularly go out for dinner! This intimacy is difficult in secondary care where my colleagues are regularly on the move to different sites and their shifts preclude any extracurricular congregation and coherence. Their formal teaching is increasingly sacrificed to an unmanageable hospital workload and has to be done vicariously and it’s potluck as to how much training, ability and enthusiasm that your overstretched senior colleague has that day. I am not professing that standards are low in secondary care, merely that they simply cannot match the standards of the GP vocational training scheme.

However, if you are only attracted to general practice because of its work-life balance or if you see it as an easy option then your reasoning is defunct and perhaps it is not for you.

The truth is that it is a challenging, difficult and highly skilled specialty requiring a breadth of knowledge and the ability to deal with ever increasing complexity and new challenges and this is what really attracted me to the profession.

I enjoy being a doctor and found that I didn’t want to limit myself to one specialty. I have relished every aspect of medicine that I have worked in and found that general practice could provide me with that variety that I craved. The work is stimulating, increasingly multifaceted and more varied than secondary care. Although the move of many secondary care services into the community has added to our workload, it brings with it challenge, variety and an increased skillset, advancing my ability to treat patients holistically. No two days are ever the same and I genuinely have no idea what the next patient will expect of my aptitudes nor the challenges and problem solving that ensue. As a GP I can obtain a specialist interest and use those skills in secondary care or the community, I deal with acute and chronic conditions, and I can work in the out of hours service, A&E and in people’s own homes. There is nothing like consulting with a patient in their own surroundings to get a realistic insight into their lives and health needs. It is also great to be able to interrupt my day by leaving the office and it can lead to acute medical problems that often test my skills and risk-taking nerve! I have the privilege of working as part of a larger multidisciplinary team, (including my respected colleagues in secondary care) consisting of fun, inspiring and talented people. Working in a smaller setting also facilitates teamwork, cohesion and morale. I have never seen anything other than teamwork during any of my hospital placements but a busy ward with a revolving workforce can never match the consistency of working with the same people over a period of time. You learn to anticipate each other and find a balance. I have always felt more supported in primary care; on many occasions my colleagues have seen a patient of mine when I am running behind, or nipped to do a visit when I am overwhelmed on-call or even just signed my pile of prescription or made me a cup of tea. It’s the little things that make you feel supported and appreciated.

Like my secondary care colleagues I also have the option to take an academic or leadership role and become involved in teaching or research, I can also become more politically involved should I chose, by engaging with bodies such as the LMC or CCG etc. However, unlike my hospital colleagues I am afforded more autonomy as to where I work, who I work with and to a reasonable extent, how I practice and the boundaries that I prefer to work within (obviously within the limits of good practice and regulation).   I can chose to be employed or I can take the leap into business ownership. This opens up the world of business, management and leadership, enabling a GP to actually change things within their own practice in a meaningful way and influence their own working lives. If I am not happy with a system I can change it. If I want to start at 7am and leave earlier I will, if I want to spend a session performing minor surgery I can, if I want to drink a cup of tea at my desk during a busy day, I can and no-one can run in and tell me off! If a giant bound into business isn’t for you then it’s actually an excellent time to be a salaried GP. With the current recruitment shortfall there are more jobs than GPs so unlike our secondary care colleagues whose training positions have been cut and are highly elusive, the employment prospects in primary care are exceptional! There is no danger of having to settle for a practice that doesn’t match your ethos or forces you to relocate half way across the country in the opposite direction to your partner.

Doctors on the whole will proclaim that they were attracted to the profession because they are interested in people and want to help them (at least during their medical school interview anyway!) If that still bodes true then perhaps general practice is for you. The job is fascinating. I deal with a broad section of society full of interesting people of all ages, the vast majority of which (contrary to the current propaganda) are hugely appreciative of the care that they receive amid the constraints of an overstretched system.

I care for people not organs with a continuity that simply cannot be replicated in secondary care. Patients are people and managing their needs entails not only basic medical management but also the added complexity of dealing with their personality, values and beliefs, their wider family and friends and everything in between.

You really get to know people and support them through their lives ‘from cradle to grave’. This is a challenge and at times I feel more like a hostage negotiator than a doctor but it is a privilege to be involved with people’s lives at such a personal level and gives an insight into their health needs and understanding that is otherwise lost. If you don’t know what a patient wants and needs, no amount of medication or reassurance will address the underlying problem.

Despite the wider misconception that the important or life-saving medicine is conducted exclusively in secondary care, this is not the case. GPs do not just dole out statins and paracetamol all day. We make a real difference, even if it’s just ongoing through persistence and consistency, chipping away at a problem over many years. We change lives and we save lives.

I am passionate about general practice and its’ future. It is essential to the NHS and without dedicated and highly skilled GP’s the system will inevitably fail. General practice is understaffed and we need more doctors to commit themselves to this rewarding vocation but to be more specific, we need excellent, resilient and talented doctors that can stand up to the challenges and demands of general practice. Primary care is not a place for ‘those that can’t’ and the question should not be ‘why should I be a GP?’ but ‘what can I bring to the table and offer my community’?

Dr Liddy Mawer
ST3 Barnsley VTS