General Practice: A Well Kept Secret

I’m delighted to write about my long career in family medicine. But how can I describe my medical life; a wonderful undergraduate education in Scotland where I made some friends who I still see 40 years later; ‘house jobs’ as intern year was called in those days in the UK NHS with a blissful surgical placement in Perthshire before a 3-year GP vocational training scheme in and around York.

That is where general practice grabbed me. After six months in accident and emergency, I was placed in a two-handed country practice where the GPs were embedded in the local community. I learnt lots from my trainer but even more from my patients. I was young and eager but gradually became confident enough to let the patient lead the consultation. We teach you about shared care and patient centred medicine, but it is difficult to do it well. I learnt to listen and not interrupt for the first minute or so of the consultation. Don’t be afraid of recording and assessing your consultations.

To fill in the gap between training and taking up a partnership, I joined a group practice in northern Canada. I arrived in Manitoba at the end of the short summer. It gets cold by October and so you have to became accustomed to plugging the car into a block heater, wearing mukluks and parkas long before they became a fashion statement and working in ‘the office’ and caring for any patients I admitted to the hospital.

There are no consultants in hospitals 450 miles north of the US border and so all the GPs had a special interest. I had just finished a paediatric job so was responsible for looking after babies on the special care unit. I also looked after patients with mental illness because of my interest in psychiatry and the need to support the mental health team. Once a week I flew to a Swampy Cree Native Indian Reserve in a four-seater single engine Cessna. The flight landed on ice in the winter and on water or on a temporary airstrip during the summer. One of the pilots was a hunter and spent the journey scanning the undergrowth for moose. This involved rapid dives to get a closer look at some of the wildlife but somehow you felt quite safe. The clinic was held in a portacabin organised by a local health worker who lived on the reserve. We saw any manner of problems and had one spare seat in the plane for urgent cases to be transported the 60 miles back to the hospital in town at the end of the clinic.

Antenatal care in those days was the responsibility of the family physician. This involved pre-natal visits, attendance during labour and then delivering the baby as there was no midwifery service. Antenatal visits were sporadic. Some patients would attend every month, but some would only attend once or twice during pregnancy.

The pay structure for general practice was strictly item for service with EVERY activity having to be recorded on a provincial health service form, so the harder you worked, the better the financial rewards. There was no private (out of pocket) practice because the provincial system was well funded. Perhaps a lesson for all health systems that offer both public and private options where there can be disparity in quality of care.

The two years I spent in Manitoba gave me an opportunity to develop skills and to gain confidence in my own training because it is reassuring how our medical skills are transferable. Some of the Society’s members will be applying for residences in their country of origin and the UCC curriculum is successful at giving our students residency success.

So general practice offers a broad range of clinical focus. It also gives us a front row seat in how health and illness is impacted by bio-psycho-social factors. The model of care in many health systems including the Irish system tends to the transactional model in secondary care and the narrative model in general practice.

A number of you will be able to develop an academic arm to your work. You will have an opportunity to teach undergraduates and postgraduates in medicine and allied professions. You will have a duty to appraise and audit your clinical performance and to keep up to date through CPD. However, the opportunity for research has historically been limited in general practice. The department of general practice at UCC hits above its weight with work around diabetes, medicines management, elderly care, and epilepsy. This work can influence practice and gives an important perspective on how health and illness impact the whole population rather than those just attending hospital clinics.

So do I have any important messages to you all as you start your careers? It is perfectly fine to be uncertain about your medical pathway and be open to the opportunities that will come along. In the intensive environment of medical teaching and the false certitude of your education do remember that we as doctors are at our best when we work with our patients.

I’ll leave you with a word from two giants of medicine who have inspired me:

"Each patient carries their own doctor inside themselves. They come to us not knowing that truth. We are at our best when we give the doctor that resides within each patient a chance to go to work”

– Albert Schweitzer MD: 'Your Inner Physician' a chapter in ‘The Intuitive Healer' by Marcia Emery and published in 1999 by Thorsons in the UK

"Our observations are direct, and the contact is human and we can often supply facts that no other member of the profession can. We see disease in its early stages - very rarely the chance of the specialist - and we can follow it through from the beginning to the end of the illness.”

– Pemberton J “Will Pickles of Wensleydale: the life of the country doctor.” RCGP 1984