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.

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.

In the Deep End

I remember my very first formal interview – it ended in failure. What made it so depressing too was that it was THE interview that my future depended on – medical school.

So having failed at that, I realized that either I was an immature 19 year old that lacked life experience, or that I lacked interview experience. I chose to realize the second option, and vowed that some day, I would be great at interviews.

Since then, I suppose interviews just happened. Interviews for entry into the GP program, some interviews for part time jobs. With each interview, I picked up basic skills, such as knowing what to say, and what not to say. I learned to never offer more information then was required to answer a question. And that advice has served me well.

It just so happens that on the 1st of June, all GP registrars could apply to practices for next year, and of course, this would mean submitting a CV, cover letter, and attending an interview.

So in my holiday in China, I spent a great deal of time updating my CV, looking back at the past 3 years and deciding what to put on my CV. I put effort into making it look neat, and to also demonstrate my well roundedness for GP (to my credit, I have done lots of different rotations including surgery, medicine, ED, psychiatry, Paediatrics, O+G and orthopaedics).

Having submitted my cover letter and CV for 5 different practices, I was offered 3 interviews. It was just a matter of preparation.

I think I may have over prepared for these interviews, since I anticipated questions asked, and thought of thoughtful answers to say. And then I reflected on past cases seen, and what I really wanted out of the practices I applied to. And research. Probably the most important thing was knowing about the practice I applied to.

It was a total pain trying to attend interviews when I’m on ED because of the weird rostering. So I ended up attending an interview even though I finished a night of ED. So, I rocked up probably with only 4 hours sleep.

In the end, I managed to get an offer from all 3 places that I interviewed at, which I was pretty impressed with, since I had failed so miserably in my first ever interview. The interviews were so easy compared to what I expected, and I felt a tad silly for overpreparing. But I don’t think one can ever overprepare for an interview.

Again, I stress the importance of research, because I was asked by one interviewer what I knew about their practice. And that’s when I said “I understand that your practice opens 365 days per year, and holds an excellent philosophical principle of providing affordable and accessible health care which is exactly in line with what I believe health care should be.”

In the end, I chose a practice that would be very busy and most likely stressful. But hey, at least I’d learn a lot from it. The supervisor even told me that he would “throw me in the deep end”, so I even got a warning that it was going to be stressful. But isn’t that how one grows and learns, by being outside of their comfort zone? So why not.

Next year’s going to be interesting….. And probably stressful too.

 

GP Placements

Having just had about 4 weeks of annual leave, I wish I could say that I had a pleasant holiday. However, aside from going to a foreign country that has a great big firewall *Cough* *China*, I have to say that it felt incredibly busy, almost as if I was working.

For starters, on return from my trip from China, I would have to sit a Chinese written exam. I suppose being in China helped somewhat with this by being exposed to the language, but what we get tested on is entirely based off a textbook, which I had to carry around and study in my spare time while at the hotel.

The next most annoying thing, was that I had somehow organized an oral assessment task for my paediatrics diploma for the 3rd of June, also a few days after I returned back home from China. So I ended up studying for that as well, staying up late at night in the hotel to study. It was only after 2 weeks into my trip to china that my assessor advised me that she couldn’t make the 3rd of June, so I was able to push it back to the 17th of June.

Another thing (the tasks just keep piling!), was that I had to do some research into the application process for next year’s GP practice intake. This involved lots of boring reading online about the steps needed, the rules and regulations etc… And I also needed to update my CV, and write a letter of application, not to mention thinking about interview questions and how to best answer them. So this too involved long late nights of work in the hotel as well.

So my holiday kind of went like this….

  1. Arrive in Guangzhou, China all exhausted
  2. Find hotel and place to stay
  3. Study
  4. Go to Guilin and Qingdao by train and plane respectively
  5. Study on the train and on the plane while going to destinations
  6. Start stressing out as date of chinese exam, paediatrics assessment task and GP application date starts approaching
  7. Big sigh of relief once assessor postpones oral assessment task
  8. Continue to study in hotel till late night anyway despite the above

After that, I came back home, having happy memories of my time spent studying in the hotels…….

Well, I still need to work on my applications for GP, which I shall hopefully submit tomorrow.