What is the truth about General Practice?
The truth about General Practice is that it is challenging.
Ha! Now that would be too easy and tremendously disrespectful to my General Practice colleagues.
So, what is it that makes General Practice challenging?
But firstly and most importantly, what makes General Practice such a rewarding speciality and central to health care?
For me, General Practice was rewarding because it was “a beautiful mess of humanity and medicine, pity and tragedy, personal growth and self-reflection”.
General Practice tells the unfiltered story of life.
From the wonder of conception to birth to the innocence and vulnerability of infanthood General Practitioners (GP’s)are there to help. From the tenderness of childhood right through the often confusing and trying years of adolescence, General Practice is there to serve. From the promise of young adulthood to the beautiful busyness of middle age, GP’s are there. And then from the golden, reflective and hopefully productive years of retirement towards the final walk (or run) towards our last days, GP’s play a major role in supporting a person’s lifespan and healthspan.
Interspersed within this story and the practice of clinical medicine is the tragedy of accidents, the sorrow of suicide, the unjustness of cancer, the pain of broken relationships but more rewardingly, the glory of forgiveness, the joy of finding purpose and everything in between!
General practice is medicine for life.
And life is not often easy and we need advocates, gatekeepers, wise guides, attentive heroes and empathetic, down-to-earth, wonderful humans as our GP’s.
General Practice – for those who find a calling here, is truly the wisdom of all medicine.
Knowledgeable is how most GP’s start, fresh and polished from their exams and ready to make a difference. But wise is only who a few in all of medicine become.
For the beginning of wisdom is having a healthy fear of the complexity and uncertainty of disease and understanding that we do not know everything! Wisdom is then having the humility to recognise that each and every patient is able to teach us something, should we take the time to truly hear the language that our patients are speaking to us.
I’ve heard many of my well-meaning specialists colleagues and trainee’s say of themselves and GP’s:
“I couldn’t possibly become a General Practitioner, its just too hard to sit there and see patients all day”
“I don’t how my General Practice colleagues do it. General Practice is hard!”
Whilst I place NO value on the thoughts and reflections of those who have never worked in General Practice, the question remains,
What makes General Practice challenging?
Up until a few months ago, I hadn’t been able to articulate my thoughts until my registrar asked me why I had left GP land to work full-time in Palliative Care and Anaesthesia at our regional hospital.
This piece is the genesis of that thought as I began to reflect and give him the most honest answer I could.
I started with this.
General Practice is the coal face of medicine.
General Practice brings doctors to the frontline of humanity.
Unfiltered humanity — beautiful and wonderous, hopeful and tragic, hilarious and depressing and sometimes life-altering!
And often within the confines of a long-scheduled day of appointments with multiple demands, this type of work can be challenging.
But schedules can be hacked, appointments can be interspersed with breaks and most GP’s are in charge of their time-tabling. The real challenge of General Practice for me as I told my registrar, was seeing humanity up close — experiencing this each day and the toll it can have on GP’s if we are not careful.
For me, the true nature of General Practice exposed my weaknesses.
See in the hospital system there were multiple layers of care that I was able to hide within and not give my whole-self to patients. A person’s whole care is shared across a few doctors, many nurses and a team of allied health staff. And by not having direct responsibility for the governance of a patient’s care, this made me slack in truly understanding what “caring” for my patients really meant.
General practice is challenging because it has the possibility to expose our weaknesses.
These are weaknesses that we hide very well. The secret thoughts, points of view and beliefs that we hold, which we may never share with anyone! And sometimes these weaknesses are questionable habits or behaviours that wish no one to know about. But more often it can be the way we approach this type of work, unprepared for what lies ahead and next on our appointment list.
Here are a few weaknesses that may be exposed.
For those with poor coping techniques, unmanaged anxiety and psychological instability — GP land may unravel you.
For those with loose morals and secrets, GP land will present multiple opportunities to bend the rules, cross the line and go beyond the doctor-patient relationship.
For those with no clear plan of self-care and maintaining their psychological, emotional, spiritual and physical well-being, General Practice will burn you out very quickly if you are not intentional about your self-care.
For those motivated by money, General Practice may seem lucrative and a great place to make money. But chasing profit over caring for people erodes quality and produces a fast race to the bottom of consumerism and destroys your soul.
For those with fixed ideas and poorly formed points of view about gender, religion, race, social class, ethnicity and sexuality, General Practice will be confronting and a very quick lesson in humility!
For those who want to find something “easier” to do than hospital medicine, the wake-up call is stark. The work that our patients in General Practice expect for you is complex and takes deep thought. There is great subtly in disease, multiple permutations of normal and only those with a keen eye for the work of General Practice Medicine will see the nuances in identifying significant disease. A lax attitude is exposed in General Practice. You deserve to see coughs and colds in General Practice if you have a poor attitude and practice bad medicine. The interesting cases and joyful patients will be saved for your colleagues with a better attitude, humility and more inquisitive mind.
Whilst my thoughts may be harsh — cold hard reality bites!
For me, the true nature of General Practice unravelled me and burned me out very quickly. I didn’t have any protective mechanisms against the psychological and spiritual warfare that raged in my head, induced by very challenging and demanding patients. Not to mention the very sick whose plight and worry, I carried home with me, to bed, the dinner table and everywhere else I went.
As I’ve talked about before in some of my very early blog posts — all of this stopped me in my tracks and made me question my vocation as a doctor.
But wise counsel, regular professional supervision and most importantly becoming intentional about my self-care, saved my career and allowed me to continue serving as a doctor.
A calling to Palliative Care — Why I left General Practice
So why did I did leave General Practice?
Well, it was through General Practice that I found a calling towards Palliative Medicine.
As a GP Registrar in 2012, I was vehemently opposed taking on any Residential Aged Care (RACF) patients — as reflect on this time in self-awareness, I was personally and clinically immature. But when our practice principal said that I had no choice and that this was part of every good GP’s job, I relented like an obedient Indian boy — following out of fear!
But little did I know that his push into RACF work would open the doors in medicine to a clinical life that I could have never imagined!
It was a new wide-open space.
In serving my patients and their families in Residential Aged Care, I learned about the purpose of good medicine, the dignity of a good death and utmost importance in communicating with families and having difficult conversations. Soon my 6 RACF patients turned into nearly 40 (with many dying along the way!) and I was willingly spending a great deal of my time in residential aged care (which is slow stream hospice), loving the clinical challenge and enjoying working with dedicated nurses, carers and patient care assistants across our regional town — this was the best part!
I was growing in clinical confidence and had a joy streaming from me that was unmoved by circumstance.
Residential Aged Care was where I learned about the foundations of Palliative Medicine. In handling complex and challenging patients across the community, hospice and in Residential Aged Care, I worked closely with our Regional Palliative Care service and I was thoroughly drawn into their world! I met some truly inspiring Clinical Nurses and a passionate and supremely clever Palliative Care Specialist who took a personal interest in my career. This only allowed my interest in Palliative Care to grow which eventually turned into an open door of opportunity.
I left General Practice to complete a Clinical Diploma of Palliative Medicine in August 2017 but made my choice permanent in September 2018. Working in Palliative Care brought forth an energy and enthusiasm that I had never before experienced in medicine.
It was the God-created, perfect intersection of my innate personal qualities, whole-person medicine and my deep peace with death, dying and transcendence.
I had found my calling in Palliative Care.
A moment about finding a calling…
A calling is something that you are not simply interested in, but a direction in life that fills you with energy and uplifts your spirit — sure you need to rest but it is also working that replenishes you.
A calling allows your mind to race with infinite possibilities and ask questions that have never been asked before.
A calling allows you to operate within the flow state — routine work happens effortlessly, challenges and difficulties engage the thrill of high stakes risk balanced with masterful skill. You see a path through mess and distress and busy days are your fuel.
A calling allows you to operate at your highest level with very little prompting. There is no motivation or effort required in a calling. The energy from your work sustains your interest, fuels your passion and the result is poetry.
And the most interesting aspect about this calling was that whilst I felt called to Palliative Care, I had countless friends and colleagues who felt the same calling to General Practice!
Clinical General Practice was their fuel and fire, their significant contribution to the world and their absolute delight and love.
There is a place for us all to operate in our calling in medicine.
Making a difference in General Practice
So let’s talk about the truth in making a difference in General Practice.
As a General Practitioner, you can actually change lives and help people re-write their medical life story.
Now “actually” is a powerful word because it is within reach of every GP.
The wisdom in General Practice is knowing that the ripples or the butterfly effect of your attention to your patient’s problems, is vast and far-reaching.
By listening attentively to a young mum’s concerns about herself as a mother, you kindly encourage her and allow her to truly see her value. This ripples as confidence and helps her to negate her self-doubt — her child thrives, she has someone who cares about her mental health and physical wellbeing.
The word “breathless” catches your attention in a middle-aged woman who tells you it’s “just a little gastro”. Your gut feeling leads you to find a large myocardial infarction on her ECG which helps you to save her life and that of her families — her children still have a mum and possibly a grandma one day.
Your attention and care to a simple request for a repeat prescription brings a worried single-mum back to see you with her suicidal son. He’s lost, he’s questioning his sexuality, he doesn’t know who to talk to. You listen. Your voice cracks with emotion, “I’ll help you”. One simple smile and care for his mother’s cardiovascular risk brought this young legend in. He’s found another adult who believes in him. He’s not weird, he’s going to be okay.
Your attention and care for a longterm patient who dies of metastatic cancer with great suffering, despite the very best of specialist care, catches the attention of her grandson. He wants to do more. He wants to help. He believes that there has to be another way to deal with pain in cancer. Your care inspires him.
The ripples of your care and attention in General Practice can be wide — more than you could ever ask, think or imagine.
That is the truth about General Practice and “actually” helping in this space.
We are the best bits of the best doctors
My registrar understood me as I told him about the truth and nature of General Practice.
He was excited and like every good doctor, he understands that his career trajectory and the story that he writes will be unique and up to how he responds to the challenge General Practice.
See I think that we as human beings we are the “best bits” of those people who we’ve met, who have impressed us, believed in us and taught us important lessons. Similarly, as doctors, we are the amalgamation of the very best and wisest doctors that we’ve had the pleasure of meeting, working with or have inspired us from afar. I still use phrases during a crisis that I learnt as a second-year resident from a group of very cool, calm and collected Emergency Physician’s in Tamworth! I learned from these wonderful doctors that it is all about your self-talk in a crisis — be calm and work out your plan.
General Practice is a wonderful and honourable speciality where a difference can be made with every patient, every day. Health care in Australia should not be measured by Emergency Department wait times or Surgical waitlist reduction nor should it EVER be measured by bulk-billing numbers in any way.
The true measure of a healthcare system is well-funded and considered General Practice and its impact on local communities.
This is because, within General Practice, the formation of a wonderful therapeutic relationship and the right people finding their way to becoming General Practitioners, makes an actual difference in the community in many vast ways.
Enjoy your health — find a good GP!
Dr. Jonathan Ramachenderan.