And New Workplace

The Friday just gone marked the last day at my previous GP practice. And I cannot believe it has been a year already. A year of seeing and managing patients on my own.

My last day was filled with sadness, as I was moving away from a place of comfort to a new unfamiliar place. I think I’ll miss my supervisor, and the friendly work environment.

I ended up getting a cheesecake for the practice, and a bottle of shiraz for my supervisor on the Thursday (2nd last day of work).

Tomorrow is the start at my new practice. It is a practice that has book in appointments.

“You’ll probably find at your new practice, it’s not going to be as organized as this current practice” said one of my work colleagues. I sort of believe him, because having met the new practice manager, she seemed extremely disorganized. Missed calls and texts and emails, which take 2-3 days for her to get back to me on. Not to mention that she advised me once to rock up at 7:30 am for some computer program training 4 weeks prior to when I was due to start, and forgot the date, only realizing when I rocked up to the practice. And had an entire hour wasted when I was told to “just muck around with the program”, when I had thought that my supervisor would sit down to teach me the basics of the computer program.

Oh, and not to mention that I didn’t find out that apparently I was scheduled to work the first Saturday until I emailed her first (I do alternate Saturdays with the other registrar).

Yeap, I’m already starting to stress over the current practice manager. I have a feeling that the first day, it’s going to be absolute chaos, such as not being able to login to the program (when I last visited the practice, my login still wasn’t working, and that was about 2 weeks ago).

Anyway, I shouldn’t grumble so much. I’m only going to be 2 minutes away from my work practice yay!

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The Curse of the Chaperone

Medicine is an interesting field that is a mix of science, ethics and art in a way. There is an art in how you apply theoretical knowledge, and a science behind the art of practicing medicine.

For a field that is quite objective and founded on the scientific approach (ie hypothesis based testing and evidence based practice), it seems a bit odd that there are still some superstitions held by practitioners. In emergency departments for instance, one should never mention the “Q” word (which in this case refers to the word quiet), lest there be a sudden increase in patient numbers with complicated issues and emergencies.

Taking that outside of medicine, I tend to believe that there are people that seem to bring trouble all around them ie that they are a “shit” magnet. I’ve heard many colleagues say that about themselves – everything seems to be going well, until the said person starts their shift, and then all hell breaks loose. Or that other person that just seems to bring about rampant chaos around them. A colleague told me that when they started their first shift as a general physician registrar, there were 3 metcalls during her first shift.

Yesterday, I did a shift of house call doctoring. A 6 hour shift. There were quite a few unusual things that happened during this shift, and perhaps it was just coincidence, but to the superstitious, you could attribute it to something other than just pure coincidence.

Perhaps the first sign of something not right, was the fact that I was sent off to see patients in another city, rather than the city I was living in. Then there was the fact that there were bookings from patients who logged jobs over 5 hours ago. I later found out that apparently 2 doctors who were supposed to be seeing patients where I was working had called in sick.

The chaperone (my driver and colleague who helps sort out the medicare details, bookings and phone calls – non medically trained) was a female who looked in her late 30’s to early 40’s. Very talkative and friendly, but appeared to speed quite a lot in the car. A few minutes into the drive, and she informs me that “people seem to say I’m a shit magnet”. At that point, I think it’s probably just coincidental.

In total, there were 18 jobs booked in, although I managed to see 13 patients only, with a few cancellations, and 1 job taken off and assigned to another doctor. I saw my last patient at 11:28pm, and advise that we should get going home.

10 minutes down the freeway, it’s pitched dark, with barely any cars around. On the left shoulder is a truck parked with hazard lights on. Twenty metres on, and I see a man on the side of the road face down.

“Oh my goodness, there’s a guy on the road” I mention to the chaperone.

“Oh, do you want me to stop and go help?”

I hesitate for a moment. We had passed the man for a good 50 metres, and I was concerned about reversing backwards on a busy freeway. I thought to myself that it was probably a drunk person on the side of the road. The car slowed down from 100km/h to 50km/h.

“Yea ok. Let’s go check it out.”

I start to feel some panic as I step out the car. What if it’s not just a simple case of someone passed out drunk? I walk out calmly and approach the scene. Three bystanders are on scene, with one other crouched over the man. At this point, my worst fears are realized. On the road, was perhaps a litre of blood, some of it congealed and caked. Above the man, is a bridge overpass about 10 metres high.

“Hi there, I’m Dr X, a house call doctor. What’s happened?”

“I just got here a moment ago, and found him on the ground. I’ve checked all pulses including pedal pulses but can’t find anything.”

I later established that he was a medic previously. I attempt to check a radial pulse, but don’t feel any. Of note is the icy cold hands. I put my stethoscope on his heart, and hear no heart beat. I open his eyes and check for pupillary reaction, with dilated non responsive pupils greeting me back.

This patient has died already. CPR won’t do anything. Where is the ambulance? What am I doing here?

“He’s not responsive. Should we start CPR?”

I snap out of my daze. The medic was right. We needed to start CPR no matter how bleak it was. CPR on a probable corpse was better than no CPR, because there could still be a very slim chance the man was still alive. We roll him onto his back, and take turns doing CPR. The medic started first. With each chest compression, blood foamed out of his mouth, with the tongue rhythmically moving in and out of his mouth. I attempt to do a jaw thrust, which seems to help prevent the tongue coming out. I ask the chaperone to get the guedel’s airway out, which I use to some effect. Unfortunately, my car has no defibrillator, nor any bag valve mask, so we end up just doing CPR for about 8 minutes before the ambulance arrive on scene. The police arrive later as well.

When the ambulance arrive, I let them takeover. They continue for a further 15 minutes. The medic approaches me, advising that him and the paramedics have noticed clear fluid leaking out of his ears. An extremely bad sign of cerebrospinal fluid leaking out. An ECG tracing is taken. From the distance, I look at the printout and note a flat tracing. A white towel is draped over the man shortly. My chaperone and I leave the scene later on.

“This would be the 5th incident that I’ve witnessed or participated in CPR of someone,” says the chaperone in a matter of fact manner on the drive back home.

It gets worse.

“I’ve also been involved in 13 car accidents in which I was a passenger. 4 of them resulted in fatalities. I have witnessed 4 other accidents as well in which CPR had to be performed. And I was also a passenger in an aircraft accident on the runway”.

I can understand if someone is involved in a car accident with a fatality occurring once in their lifetime, but this chaperone has witnessed it 4 times! I am in shock of this chaperone, and I can understand now why she was a “shit” magnet. Maybe this person really was cursed in a way. I certainly thought nothing eventful would come from my shift, but even on the way home, something like this happens where I witnessed a horrific fatality.

The curse of the chaperone? Or merely a coincidence?

Patients Lie

There’s a saying that “if you want a thing done right, do it yourself”. There’s also the saying “trust no-one”.

I think both of these are most relevant in the field of medicine. If a patient requires an urgent referral to hospital, don’t delegate the fax referral to administration staff. Do it yourself so you know it was followed up on. And if another doctor has taken a history and done an exam, don’t believe them. Do it all over again yourself to verify everything again.

Doing the above things really throws efficient time management and all things learnt about productivity out the window. But with something as important as healthcare and patient’s lives at stake, you can afford to sacrifice efficiency for safety.

The saying of “trust no-one” not only applies to other doctors, it applies to patients as well. Don’t believe everything that the patient says. Reasons why you shouldn’t always believe everything the patient says are:

  1. The patient is an unreliable historian. Or is extremely clueless about everything related to them .. ie an idiot. Eg “Q: when did you last have sexual intercourse? A: I don’t know doc”
  2. The patient has some secondary gain from intentionally misleading you Eg Lying about their pain to swindle some endone from you.
  3. The patient filters everything according to their biases

Recently, I came across a patient who fits under reason number 2. A 29 year old gentleman presented for the first time on Saturday around 6pm (afterhours) advising that he had 5 seizures since Thursday to Friday. He had been checked over by the Emergency Department at a tertiary hospital, and stated that no brain imaging was performed. When asked about substance use, he denied using any, except some marijuana every few weeks. Thinking that it was incredibly unusual for ED to not image a person who had seizures of unprovoked cause, I phoned the department, who noted he had taken 3 MDMA tablets and 3 tablets of Lyrica prior to the seizures.

When confronted about why he did not tell me he had used MDMA, he told me that he was afraid I would contact the police in regards to his illegal substance use.

I kindly advised the patient that with such a history of substance use, he wasn’t likely required to undertake brain imaging, and it would be safe to follow up with a regular GP (the patient came from across town to access our afterhours GP service) who could organize a brain scan if they felt it was clinically indicated. Being a Saturday, he would not have been able to get a CT scan till Monday if I gave him a request form anyway.

I think the above case best illustrates the importance of collateral history. It may seem like a lot of work (and it sure will take a lot of extra consult time), but the rewards are high. Without the knowledge that his seizures were provoked by substances, I would have wanted to order the panel of bloods and imaging as soon as possible, plus trying to manage the fact that this patient wasn’t likely to follow up (because he lived over 15km away, and was told not to drive due to his seizures – why would he continue follow up with me?).

 

 

Just a little wobbly

If it was any of the organs systems that seem to scare me as a general practitioner, it is probably neurology. It is something that can be so subjective, and non specific in general, with sometimes no notable significant neurological signs. In particular, dizziness is one of my pet hates. But when there are actual demonstrable neurological signs, that’s when things get interesting.

A couple of weeks back, I had the fortune of seeing such a gentleman with significant pathology. He had spent the weekend at a location about 8 hours drive from where I work, doing a bit of crane driving for a mining project.

His daughter accompanied him in to the practice.

“Doctor, I’m concerned about my father. Today is the first day I’ve seen him back after his weekend job, but he is not himself. He can’t even walk properly. Something is seriously wrong.”

Unfortunately, it was the first time I had seen this gentleman, so I had no baseline to compare his current self with. What I did notice, was an unsteady gait however.

On exploring his history, he had apparently been involved in a truck rollover accident, for which he went to a tertiary hospital and had head scans which did not reveal any significant bleed. He was not on any anticoagulants or blood thinners, and had no significant past medical history.

Examination revealed 3-4/5 weakness of the left upper and left lower limb regions in power, with cranial nerves intact. PEARL

Thinking this could potentially be a stroke, a CT brain was ordered. The radiologist phones me up.

“The CT brain scan has some significant findings with bilateral subdural haemorrhage and a 5mm midline shift. ”

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That was all the information I needed for an urgent referral to the Emergency Department.

A few weeks later, I see the man again, and he is walking normally.

“Doc, they cut my head open and drained out all the blood. I’ve just come in to see you to determine if my staples are ready to come out yet.”

A neurological examination was completely normal. Here was a man who a few weeks ago, had trouble walking and seemed vague at times, and now he was walking normally with everything back to normal.

It was at that point that I marvelled at the wonders of modern medicine and how much of a difference could be made to the patient.

The patient later revealed that apparently, the hospital were not certain if there was a small bleed in his brain 6 weeks ago after his truck accident, and had advised him to return for regular check up with information advising him of this. He didn’t read that information, so didn’t think much of it. This may have lead to a continuous ongoing bleed, up till the time of presentation when there was too much blood present.

Antidepressant

Once upon a time, patients were less informed about the different kinds of medical conditions, much less the treatment advised for certain medical conditions. Nowadays, medical information is so ubiquitous with the internet accessible to anyone all within a pocket’s reach.

I don’t mind patients learning about their medical conditions through the internet, and coming up with questions to ask me in regards to some medical conditions. In fact, I welcome patients reading and learning about their medical conditions. What I do mind however, is the patient who relies solely on the internet, and believe this information is a substitute to the doctor. Dr Google in essence can help treat the patient’s medical condition, and all they need to see the doctor for is so that they can stamp a prescription that Dr Google has advised them they may need for their (potentially misdiagnosed) medical condition.

I have had one argument with a patient in regards to this very same issue.

One patient stands out, just in the fact of how ridiculous his demand was. He was in his 40’s, and had been on sertraline for his depression, having been started on this by another GP at my practice about 3 months ago.

“Doctor, I’ve come here for some more antidepressants. But that last one I had been given is really causing issues with erectile dysfunction. I looked up information about antidepressants, and I want to get some bupropion since it has less side effects of erectile dysfunction. Actually, the last GP that saw me even advised that I could get some bupropion in the next visit.”

I look through the past notes of his last visit, and note no mention at all about use of bupropion. I am confused in fact. Surely, bupropion is only used for smoking cessation from memory? The fact that the patient has brought this up makes me feel like I may have not learnt about the “antidepressant” properties of bupropion.

“I am fairly certain that bupropion is not recommended as a suitable antidepressant as per the guidelines, but I will double check to make sure. ”

I google bupropion, and confirm that it is definitely used for smoking cessation, and it is not used as an antidepressant.

“Having looked up the information and guidelines, bupropion is only used for smoking cessation and not used as an antidepressant. Unfortunately, I am unable to prescribe bupropion for you to use as an antidepressant.”

The patient glares at me. “I don’t understand, the previous GP said he would give it to me. Why don’t you just prescribe it to me?”

“I cannot prescribe it because it is not used as an antidepressant. I have no record in the past notes ever documenting that the previous GP recommended use of bupropion as an antidepressant either. ”

“Are you for real!!!?? You had to look up this information on Google. All you have to do is just write me the script! It’s that easy!”

“As I told you, the medication is not suitable for use as an antidepressant. I am happy to prescribe your previous antidepressant sertraline however.”

“I’m going to report you!!!!!” And with that, the patient left the consult room.

What I learned from that experience was to never let a patient pressure you into doing things just for the sake of keeping them happy.

I think at my current practice, there is going to be a whole lot of such patients who think that a 10 minute Dr Google search can replace the extensive medical training and clinical experience that I have acquired over the last 8 years. I don’t mind patients looking up information to get a better understanding of a certain condition, but I just hate it when they use that information as a substitute for proper professional medical advice.

Does not want to see…

At my current practice, they operate on a voucher basis. The patient registers at the reception, and can either ask for a certain doctor, or the next available doctor. In general, I find this system both good and bad, but I’ll discuss that another day.

What surprised me first about this voucher system, was that some patients specifically ask not to see certain doctors. For instance, if they do not want to see Dr Joe Bloggs, the voucher would say “First Available. Not JB”. One particular doctor is outstanding in the number of patients that do not want to see him (this is the same doctor that gave 120 tablets of endone in my previous entry). I always try to sneak a glance at his face when he sees one of those vouchers with his name on it. But his face is just normal – business as usual

Every time I see those vouchers, I wonder what the doctor did to the patient to warrant this. Perhaps the patient did not like the doctor. Perhaps the doctor mismanaged the patient. Whatever it is, I’ll never know, since I am not the patient, neither am I that doctor who dealt with them.

I received my first name on one of those vouchers today, and it makes me wonder and reflect on what I did to that patient to end up in this position.

I remember this patient. In fact, I saw him a couple of days ago. He was a gentleman in his 40’s who came to see the first available doctor, due to issues with hesitancy of urine for the past 2 years. His urine MCS was clear and recent PSA was normal essentially. Taking a history was as painful as pulling teeth. He kept on saying “I don’t really know doctor”. This was to some questions like “do you remember how your symptoms first started?” He later mentioned how it was his PTSD symptoms that caused him to not really remember.

Perhaps it was the fact that I did not understand his history, and wanted to explore his background in some detail. Being too thorough can have its disadvantages in situations like this I guess. The patient believed that I would be able to know almost everything about him from reading previous notes. The only problem: the previous doctor’s notes aren’t all that detailed at all. If they were detailed, I would not have had to enquire as much. That was last week Friday.

Yesterday, when I took the patient’s voucher and greeted him, he muttered under his breath “oh, it’s as rare as winning the lottery”. I sensed that he wasn’t too pleased to see me again. His partner came in with him, and while doing the consult, he at one time spoke loudly to his partner “yea, he asked me like a million questions last time”.

I’m only human, and if a patient is outright showing such disrespect in front of me, I’m happy to not see such a patient again. After he said something so blatantly rude, I became more and more curt in the consult, outright telling him “well, we can’t do anything about your enlarged prostate at the moment. You’ll have to wait for your specialist urology appointment. ” Well, it was sort of true, I didn’t really know what else to do. Although one of the textbooks had said could start on some medications like prazosin, although I was not comfortable prescribing it, and I didn’t think I would have liked to prescribe it to such an ungrateful and rude patient.

So, all the things in medical school about countertransference came to me. How we should try and limit it – almost as if it is something we have complete conscious control over. I am angry, I am frustrated, and I am beyond caring for this rude patient. How can I choose to consciously try and care for a patient like this???!!!! I can’t, and if that’s the case, I think it’s best someone else looked after him.

I passed by him today on calling my next patient, and heard him mutter to his partner “oh yea, I don’t like this doctor”. I thought to myself “and I don’t like you either one bit”.

Such is general practice I suppose – dealing with all types of people. Some people make you angry, and depressed. And some are pleasant to work with. We have to deal with them all, and it’s probably an essential job requirement – being able to deal with people in general.

There is a chinese saying “一样米养百样人 ” which translates to “the same kind of rice provides for one hundred kinds of people”. This patient, was just one of those one hundred kinds of people.

Oxycodone

Working in a first available GP clinic gives me the wonderful opportunity to see how other doctors in my practice are managing these patients who come in to see the first available doctor. I must admit, sometimes I am scared.

Take the case of Mrs X, a woman in her mid thirties. She came on a Saturday at 7pm. Having had a read of her medical summary at the start of the consult, I note that she has had issues with back pain, having had a recent back injury, likely a simple musculoskeletal back strain. I quickly glance over at the previous treating GP’s notes, and see a few prescriptions of endone. I seriously hope she doesn’t ask me for more endone.

“What brings you in today Mrs X?”

“Well, there’s really only two things today doc. I’ve been having these flu like symptoms for the past 3 days. And the other thing was that I just wanted a pregnancy test. I’ve heard that there have been some recalls with some brands of home pregnancy kits with false negatives.”

After doing the usual history and examination, I give the patient a urine jar to collect a urine sample, and advised to come back into the room afterwards.

With the patient out of the room, I snoop back to the previous GP’s notes and the entries made.

2nd March 2017 – Presents for review of back pain. Wants Endone repeat.  


Scripts written: Endone 5mg, quantity 120. 5mg QID PO

 

15 March 2017 – Review of back pain. Needs more pain relief.


Scripts written: Endone 5 mg, quantity 120. 5mg QID PO

 

Having had a read of these notes, there are many things wrong. First are the extremely brief notes. Having read many of this doctors notes, his notes are at maximum 2 sentences. They hardly document anything at all, and I would believe theses notes will not hold up in a court should he need to give evidence.

Secondly, the fact that a whopping 120 tablets of endone needed to be given. Add to the shock, that 120 tablets should last 30 days, yet this patient has needed to get another script in just about 2 weeks.

Having been at this practice for just 6-7 weeks, I have only prescribed 10 tablets of 5mg endone to one patient who had excruciating hip pains from a work place injury. Even then, I had trialled him on just some panadeine (paracetamol + codeine) prior to stepping up to endone.

This makes me conclude that some GPs probably just end up giving anything the patient asks so that the consult won’t extend over 5 minutes (which in my opinion, is a very shocking way to practice medicine – at the end of the day, I will make my own decisions according to my own independent assessments, not on recommendation of the patient). I have had the temptation to do that at times just because it seems like the easy way out, but I always tell myself, the easy way out may sometimes be the wrong way out and end up later on, being the hard way out (eg when asked to justify decisions, or when in court for such decisions).

 

 

When patients think I’m too young

What often annoys me, is when patients think I’m too young, and therefore they perceive that I’m not experienced enough. It doesn’t help that I’ve only just started work as a GP, and every now and then I have to phone up my supervisor for advice. In fact, I probably still am quite inexperienced, but which starting GP registrar isn’t inexperienced? It comes with time, and right now, I’m doing the dam best that I can to improve my knowledge and experience, something which patients can’t appreciate in that 10-20 minute consult that I conduct. Never mind the weekends that I end up spending trying to study up on the cases that I didn’t know much about during the week.

I remember in the first few days of work at my practice, one of the patients said “oh, it seems that doctors are getting younger and younger”. In reality, I feel flattered that I look young for my age (I’m around 28 years old this year), but at the same time, I feel like that me being so young means that the patient won’t have as much confidence in my diagnoses, in my management plans.

Just yesterday, I had a 20 year old patient talk about “closing the gap” program, to which I advised that I wasn’t entirely familiar with it.

“Are you sure you’re a doctor?”. Fed up at this so called “joke” (what an utterly tasteless joke by the way), I shot back matter of fact “Yes, of course I’m a doctor”. From what I make of it, I don’t believe that she would have made such a “joke” if I perhaps looked much older. The fact that I was feeling a little stressed out at the time didn’t help, as the patient mentioned irregular vaginal bleeding. In my mind, I was trying to work out what the best approach was. Thoughts about ruling out pregnancy, ruling out STIs and ordering blood tests swirled through my head. But this patient’s a lesbian. Do I still do a pregnancy test? She seemed the patient that was easily offended, and very crass with her comments. I opted to do some blood tests, and stealthily added a “serum bhcg” to the form.

Being the youngest in the practice (every other doctor has greying hair), it would appear that if patients had a choice, they’d obviously go for the greying hair doctors. I mean, who would trust a young doctor who just started out over someone who’s had 20+ years experience as a doctor right? What they forget though, is that being young and still learning, I’m probably more up to date with the most recent guidelines, more technologically savy as well, and well um, less cynical as well.

But I don’t think all that matters in the 10-20 minute consult. It’s just first impressions. At the end of a consult, if I am able to convey a sense of confidence, an attitude and an approach that seems beyond my years, I hope that the patient won’t just think that I’m too young and inexperienced just based on how I look. That behind the young face is someone who has worked hard, studied hard, and knows what they’re doing to do a great job of treating the patient.

 

 

Now that I’m a GP, I get to see all sorts of people

As a GP registrar, I’ve come to see many different things. Some things are straightforward, some are a little more complex. The challenge is being able to manage both fairly well.

For those straightforward cases, they are time savers, and give me that little bit of confidence that I’m doing something right. But those more complicated ones, I end up spending time looking up databases and management guidelines to figure out what to do. And even then, I may still have to speak to my supervisor.

Working today, I got the opportunity to essentially to tell a drug seeker to get lost. Well, not so bluntly, but essentially, I told him “I’m not allowed to prescribe you that”. He ended up saying he’d go to ED (after possibly having a fractured hand because he punched someone yesterday – all in the name of ‘self defence’). Trying to tell this man up straight that I wouldn’t prescribe it was pretty tough I must say. The patient persisted and persisted, but I had to hold my ground and just say no.

My next patient was a woman who came in for review of her test results. Of course, being the curious one and trying to do a thorough job, I had to enquire why the tests were ordered in the first place. It was largely due to hair loss. A quick inquiry into her social background revealed more about her possible hair loss than any blood test could tell. She was having a strained relationship with her daughter, she was essentially cut off from family due to her current partner, and her father was quite ill. My hypothesis is that her hair loss could be from stress. The patient also revealed, that her partner just told her that he was leaving her right before dropping her off at the practice. She broke into tears right in front of me. I offered her some tissues, and tried to advise her about constructive ways of dealing with this difficult event ie don’t drink alcohol, get some exercise, get social etc.

We’re I’m currently working at, I see all sorts of interesting people. Probably because of the low socioeconomic status group that come through. Really, I see a lot of blue collared workers. I could have potentially seen more well off people by working across the road at the mall. But I don’t think I would learn as much, and wouldn’t be made ‘tough’ from the relatively well off people there.

Having come across a variety of people in the last few weeks, I realized that there’s going to be lots of stuff I don’t know. And also lots of people who may not be the most reasonable of people to talk to.

And this is perhaps where I think it’s important for me to stick to my principles. I believe in being respected as a doctor, rather than liked as a doctor. I think I’ll go further if I’m respected, rather than if I’m only liked.

First Day

So I can happily say that I survived my first day of being a GP registrar. I stayed back late too, and I wasn’t actually grumpy about that, unlike being in a hospital rotation. Which I thought was quite unusual actually.

After an awesome 2 days at an island resort attending official orientation with the GP training organization, I was a little apprehensive about starting today. Thoughts filled me with dread about what to do with the extremely difficult patient. What if the patient doesn’t like me? What if I bother my supervisor too much? What if I forgot to do a critical investigation?

So I went in this morning to the practice, all tensed up and nervous. I got the software training, and had a tour of the place. Can’t believe there is a CT scanner downstairs at the practice!

And when I got around to seeing my first patient, it wasn’t actually so bad. Having experienced ED at the hospital, the patients there had been very unwell, and it always felt like I was waiting for a consultant, and constantly waiting for someone to make a decision because I wasn’t experienced to make that call. And if patient’s had built up, the whole department got stressed, with team leaders pretty much yelling if you were too slow.

I didn’t experience any of that today fortunately. And the patients I saw were pretty lovely to be honest (which I guess I wasn’t really expecting working in a low socioeconomic status suburb).

My very first patient – menorrhagia after going off the implanon. This has been for 2 years since removal of the implanon. Should I put her on the pill, or should I refer her? When is the normal time frame after implanon removal when patient should have regular period again? All this I didn’t know, so asking the supervisor, he advised that I should refer her. And to do a speculum, since last one was done about 1 year ago when she had her pap smear.

And at the end of the day, I have a list of stuff I need to look up in more detail to fill my gaps in knowledge. Things like implanon contraception, hypertension management and investigations, and tinnitus.

My supervisor later told me how specialists would be well gunned for complex and really heavy illnesses, but for common things, would have no clue how to approach. He shared the example of a paeds consultant not knowing how to manage a child with VSD who got a simple finger laceration. The patient got stitched, and given gentamicin (which is overkill). But hey, in general practice, a good GP knows how to manage simple problems, and if its out of their scope or requires specialist intervention, a referral is appropriate.

In a way, that’s why I chose general practice. A specialist is excellent in their field of specialty, but for other things – they have no idea how to treat. A GP knows how to manage basic conditions for almost everything, but not to levels of expertise like a specialist. But for things like a rash or bump/lump, I can imagine the cardiologist telling a patient to “go and see the GP”.

Having worked in the hospital for the past 3 years, I can say that the first day of any of my rotations have not been as satisfying and bringing content as general practice.