For most of us our first few days and weeks in general practice are the hardest and scariest working days of our lives. Most of your learning to date has been in the confines of hospital departments with perhaps only the occasional glimpse of general practice.
Flashback to all the times you were in ED or on a ward round and a patient asked, ‘what is this spot?’, or ‘why does my thigh ache?’ or ‘what do I do if the pain killers don’t work?’, and you or your registrar replied with ‘go and see your GP’. Well, guess what, they are all coming your way now.
You’re entering a markedly different way of practising medicine. In the hospital, you may have felt that most presentations have a consistent approach, test protocol and diagnosis flow. General practice is complex, information is chaotic, histories not well formed, timelines uncertain, disease process might be in the very early stage. Each tummy pain could be appendicitis, pancreatitis or cancer. You can not order an ECG, Chest X-ray or Trop on every chest pain that walks through the GP door, nor do you need to (pleasingly, most presentations of chest pain to general practice are noncardiac).
When you are first facing the full waiting list of patients, with untold numbers of different complaints that don’t fit easily into a textbook answer or algorithm, rest assured we have all been there before. With time and care for your patients, it will all fall into place.
Here are a few of the key tips that help my registrars get through their first term as a GP.
Care
Show interest and care for each patient you see. This makes your job easier and more enjoyable and improves patient care. Enjoy getting to know your patients, ask them about their life, interests, work and family. Try and understand what your patient’s agenda is and what their main concern is for their presentation to you, and do your best to address it. After a history and exam, you might have a different agenda to theirs but it is always important to address your patient’s concerns directly.
Call one of your patients at least once a week. Much of our learning in general practice comes from observing medical conditions over a long timeline, be it one week or one year. Check in to see how your patient is doing with their sore knee/cough/headache/sick child. Patients love hearing that you care and you will learn an immense amount about how a disease progresses (rather than waiting for them to come back).
Take time
Remember you have time to make your decision. It is not an exam and you do not need to fix everything at once! Thankfully most conditions that present to us in GP do not require immediate nor even urgent intervention. Don’t be afraid to ask people to come back to explore further, or to review. If I receive a complex patient, I will often break it up into 4 or 5 consults over a few weeks as I get to know them and develop a plan. Take some time to explain your thoughts, differentials and proposed plan, even if there is uncertainty.
Testing
Try and be aware of some of the costs of tests or investigations you want to order. Also consider tests in the context of travel time, inconvenience and cost to your patient. Many hospitals now have ‘Health Pathways’ which can serve as a useful starting point for investigations and referrals, so ask if there are some for your region.
Billing
Billing and understanding Medicare codes is perhaps the worst part of community general practice. Read the MBS schedule, especially explanatory pages. Read in full each of the MBS codes before you bill them, at least once (a place to start is 3, 23, 36, 44, 2713, 2715, 2717, 2717, 16500, 721, 723, 732). You are responsible for your codes (not the practice) and you will be accountable for each one billed in your name including any debt recovery by Medicare. Speak to your practice manager and supervisor about billing policies. Go through your billing codes with your supervisor to check you are on track but be careful not to learn bad habits.
Follow the rules
Be aware of Authority Prescriptions and Restricted PBS scripts. Read the rules – they are there to be followed. It is not ok to break Authority restrictions (for example Seroquel for non-bipolar or schizophrenia) or even Restrictions on PBS meds (no, Panadol Osteo is not on PBS, there is a restricted PBS indication only for Aboriginal or Torres Strait Islanders). The reality is that private scripts are sometimes cheaper than PBS meds and you don’t need to risk a PSR investigation by lying on the Authority forms!
Embrace the unknown
Be ok with not knowing. Sometimes the best course of action is to do nothing. Feel free to sit on your hands and see if the symptoms develop/improve/worsen. Resist the temptation to keep doing tests until you find ‘the answer’. In general practice, a large number of our patients presenting complaints are never found to have a specific diagnosis.
It is ok to Google and follow guidelines! Most GP consultations fall within a small, 30 or so number of clinical conditions. There are guidelines that cover most of these. Use e-TG, Up to Date, NPS, RACGP and ACRRM guidelines and publications, Royal Children’s Hospital Melbourne clinical guidelines, Heart Foundation, Lung Foundation, Allergy Foundation guidelines and prescribing guidelines as a starting point (don’t prescribe Augmentin Duo Forte for everything just because you saw someone do that in hospital).
Avoid ‘just in case I am wrong’ antibiotic prescribing. Hospitals use antibiotics more than in GP land as they are seeing sicker patients, the risks of getting it wrong are higher and the bugs are different. In GP land you should use the therapeutic guidelines, withhold antibiotics unless there are clear indicators. It is often better to just ask mum and dad to bring the child back the next day, or even in the afternoon, than it is to throw down some Amoxil because you are worried about getting it wrong.
Unlearn
Use the change of scenery to identify and unlearn some potentially bad hospital habits. GP land is much more about shared decision making with the patient than you might find in the ED and surgical ward. Building rapport, trust and a relationship with the patient is the key. Sometimes it can take six months to help a person move from not ready to quit smoking to asking about their options.
Connect with the local team
Use your supervisor – they are there to teach and offer advice and support. So much of GP learning comes from pattern recognition and experience. Keep a list of patients to discuss with your supervisor each week. Make a point to get a bit of exposure to every aspect of the general practice. See how reception do their work, triage phone calls and bill. Spend some time in the treatment room, do some wound care and actually give childhood immunisations and take the measurements. See how the sterilising process works, ask the nurses how recalls and follow up reminders are sent. Do a full care plan or two, don’t just delegate to the nurse. Meet the nearest pharmacist and introduce yourself. You’re now part of a community team and everyone has their part to play.
Enjoy the change
Enjoy your time in general practice. Enjoy working during business hours without a pager or Dect-phone. Enjoy having one patient at a time. Enjoy your weekends and being home at night and for dinner.
Final thoughts
GP training is hard work, but immensely rewarding. Unfortunately, the rewards tend not to show until you have been there a few months and they get better over the years. Rewards include the fact you get to know most of the patients and the families you see each day in clinic, so you do not have to re-hash history and you have already gained their trust. You share jokes and stories and a little bit of yourself with each patient. Over the years you find you often get as much joy out of the interaction as the patients do. The financial rewards tend to build over time as our Medicare system rewards chronic medical disease management more than acute care, but these patients tend to stick with a favoured GP rather than the new doctor.
Welcome to community general practice. Our regional, rural and remote communities need you in community general practices as much as they need you in their rural hospitals.
Dr Michael Clements | RGTA and General Practice owner
