essay: General Practice

 

Work in general practice                                                    28.6.2010

 

 

Apart from 3-4 year forays into medical administration and forest campaigning, most of my working life has been spent in full time general medical practice.  The communities I’ve practiced in have been quite varied: rural, isolated (PNG and more recently the Northern Territory), a public hospital emergency department, and urban – the latter have included middle income, wealthy and poor communities like the aboriginals of Melbourne’s western suburbs.

 

The nature of general practice work is problem solving: diagnosis and treatment of many and varied personal health problems each day.  It can therefore be quite fragmented, and after a number of years I began to long for bigger picture projects to deal with: hence the foray into forest conservation.  It also led me to an emphasis in my general practice on teaching and preventative care; otherwise it seems that doctoring is just applying bandaids of whatever size and sophistication.  The days can be quite demanding, particularly when fully booked – not unusual in these times of a chronic shortage of GPs.  Then you have to work fast and try not to make mistakes – a situation where experience counts for much.  In the end the amount of stress relates to how many very sick and/or demanding patients turn up in any one day, and this varies a lot.  There is also of course the trade-off between intimacy and detachment.  One is privileged to be a party to intimate and sometimes distressing details from people’s lives, must remain sympathetic and yet offer impartial advice based on clear judgement.  As a doctor of first contact you often meet people who are anxious or angry, sometimes arrogant or abusive.  I don’t like conflict and have slowly learned not to take it too personally, to step back rather than (metaphorically) shape up.  Legal liability is a concern but hasn’t been much of an issue for me over 25 years in practice.  I put that down to good conservative training and the communication skills that you must develop or leave the game to others – but it’s not something you’d ever want to become complacent about.  I hope I know well in advance that I’ve become too old to practice safe, conservative community medicine.

 

General practice has certainly changed since I began my career.  The changes obvious to me are the importance of computers, the increased risk of litigation, and the vast amount of information available to patients on the internet; also perhaps the choice of different types of ‘healers’ and the burgeoning bureaucratic red tape that seems to inevitably accompany taxpayer-subsidized health care.  Computers have been a mixed blessing, with increased ability to do routine ‘paperwork’ quickly and clearly; but dependency on computers makes life very difficult when they don’t work well – a not at all uncommon occurrence, especially in remote practice.  Many people now have pseudo-knowledge of health issues – much information but often without a balanced perspective; so I often have to listen to wacky ideas, trying not to seem arrogant when I have to draw a line in the sand.  Medicare has provided excellent access to GPs for most people by removing big cost penalties.  However there is no doubt in my mind that a significant proportion of patients, perhaps more often but not only the under-educated, seem not to highly value quality healthcare that they get either free or at very low personal cost.

 

Working in aboriginal health brings this out quite often. Sadly, and most likely because their poor health and social conditions demand much aid, many aboriginal people seem to have a welfare mentality.  They can be quite abusive; I suspect it’s partly their under-education, partly not valuing what is free, partly anger towards white society, partly poverty / alcohol /

drugs /despair.  Some are quite hostile initially, but more friendly if they get to know and trust the whitefella doctor.  On the other hand trying to deal with the multiple serious health problems that these people suffer can be curiously refreshing after the precious behaviour and minor health preoccupations of some wealthier folk; ‘curiously’ because the totality of the combined problems facing aboriginal communities can also be disempowering.  That sense of hopelessness may be infectious.  There are days when you feel a profound sense of relief at meeting an aboriginal person who seems happy, balanced, healthy and successfully employed.

 

Being a GP has other even more obvious highs and lows.  Feeling stuck in the same small room day in / day out listening to gripes and complaints can make annual holidays very important and anticipated.  At other times being able to offer meaningful help feels very good, and many people show real gratitude if their care is up-to-the-mark.  Partly because of a shortage of GPs, to some extent you can organize working hours to suit yourself.  There’s a certain flexibility, and doctoring is of course a job that travels.  That flexibility also comes with self-employment: general practices are mostly small businesses, so you’re either an owner or a subcontractor.  You miss out on some employee benefits (paid leave would be nice!), but you have the advantage of rowing your own boat – a feeling, however illusory, of control over your own destiny; and that is meant to be a significant determinant of health – or perhaps it just suits some personalities.

 

What else have I learned from this job about people, life and the universe; and of course myself??  An unfortunately large number of patients, many of them young, no longer (if ever they did) value or understand the importance of continuity of care with a doctor or clinic that knows them well.  It may be because they can’t get an appointment just when they want it; but there’s also a type of (otherwise normal) client who seems to value different opinions and ‘shopping around’ above continuity of care.  I believe that allowing advertising of health care was a bad move; it’s hard enough for most untrained people to choose wisely amid the complexity of health issues, let alone in a market-driven morass of simplistic slogans and hyped promises.  Overall I suspect the privilege of intimate exposure to the highs and lows of people’s lives must impart a certain wisdom, but it’s hard to quantify or describe – perhaps one just acquires strong reflexes for assessing deeply personal issues.  I know that general practice suits my generalist personality; I think the latter came first, but of course it’s an iterative situation.  I also know after years in a service job facing Joe Public that I don’t regard myself as better than anyone else – but nor do I tolerate rudeness or bad behaviour in the clinic.  People who transgress are shown the door quite quickly.  So I guess that makes me a believer in authority, certainly in the value of an authority structure, without which the job would be unworkable.  I treat clients with respect and don’t like keeping them waiting.  With many booked 15-minute slots, I don’t have much tolerance for lateness, and people are quite often late in this area; but they are learning about my peccadillo for punctuality.  In any case, why should everyone be kept waiting because one or two slack individuals can’t arrive on time?  So is age making me more of a curmudgeon?  I doubt it; those tendencies have always been there; perhaps I have become less willing to tolerate poor behaviour.  I get on very well with the other doctors and staff of my black and white clinics.

 

I long ago accepted that I’d be a GP until I drop, and that’s not so bad.  Unfortunately it’s not a vocation I feel passionate about, but it has been good to me.

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