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Diary of an FY2 – The Doctor is In

May 26, 2016

The weather is slowly but surely improving. The Earth’s tilt and orbit around the sun are dragging the country, kicking and screaming into British Summertime. The change in climate brings with a change in scenery. I’ve traded in the slicing and dicing (by proxy) of General Surgery for the myriad cups of tea of General Practice.

I like the change of pace. Regular, reliable hours with sensible waking hours. Even as morning person, General Surgery too damn early for me. Waking up earlier than most everyone else (including the Sun) but not so early that you could enjoy the solitude with the morning chorus. Now that the Sun is up and about during all my working hours, I get to work on topping up my Vitamin D.

But it’s than just calcium homeostasis. Instead of running about all over the hospital, clerking and treating patients just before or just after surgery, I have been installed in my room with a computer and a blood pressure cuff (one of the old-fashioned ones with mercury in it) – and the patients come to me! My knees are grateful for this stationary approach but I do miss running down long corridors, with a mind to do medicine and kick butt. Is that shallow?

And instead of surgery, it’s…well, everything. I’ve loved the breadth of General Practice – I’ve always had trouble narrowing my focus and raising the flag for a single organ system. I can see a 96-year-old with a rash, followed by a 4-year-old with a sore throat. I enjoy exercising that “Jack-of-all-trades” mindset, the mental fluidity to go from back pain to palpitations to asthma before back to back pain again.

I’ve been given 30 minute appointments, in recognition that I am a doctor in training, and this does take the pressure off. Even so, I often feel thoroughly “thinked-out” at the end of the day. I can’t imagine working with 10 minute appointments, with three times as many patients, on top of the full complement of paperwork required to run a surgery.

However, time is something I struggle with. In Worthwhile General, I had the full suite of investigations and treatments at my fingertips. We might have to wait until the next day for a non-urgent CT scan, and a bit longer for an MRI scan. Specialist advice was always at the end of a phoneline and if you were particularly silver-tongued, you could even get a SpR (or, Holiest of Holies, consultant) review. We could start treatment and could say within hours if it was working.

All those things are still available but they seem removed from my reach, like Tantalus reaching for the fruit. I can still request blood tests and X-rays, but they take a day to come back (from the time the patient gets the investigation). Specialist advice is obviously still available, but my referrals must first run the gauntlet of fax machines, secretaries and internal mail. And I only know if my treatments are working if the patients come back and tell me so. But this is the art of General Practice – being able to help patients without the largesse of hospital medicine.

But the one investigation and treatment that I underused in Worthwhile General was Time. When patients first present to their GP, the symptoms can be mild and vague; the differential is long. To narrow the differential (like any other investigation), wait diagnostically. Let the illness evolve and resolve. “But what if the patient gets sick! They’re still in pain!” My clinical mind screams. “If they are so sick, they need to be in hospital, send them to hospital. If not, tell them which symptoms mean they are getting seriously sick.” Chides my as-yet-underdeveloped General Practice gland.

And sometimes, I don’t need to pour Tazocin on a sore throat, or Oramorph PRN on musculoskeletal pain. They say time heals all wounds – so let it! The noble art of medicine, as Sam Shem put it in The House of God, is:

LAW 13: The delivery of good medical care is to do as much nothing as possible.

But I’m still getting used to it.




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