I want to be a general surgeon. I love surgery. I love the theatre environment, the strong team set up, the buzz of hospital, and most of all, I love being involved in and performing surgical procedures. So what does 4 months of working in a primary care setting as a GP have to offer me? At the start of the placement I was sceptical if it would have anything to offer me at all.
During those months as an FY2 GP I performed no surgical procedure. I rarely saw patients with surgical problems and I didn't admit anyone directly to a general surgical ward. So what did I do? I developed communication skills. I improved my general medical knowledge. I learnt about cardiovascular risk and prevention. I learnt how to better communicate with patients and other healthcare professionals. I developed an appreciation for management techniques I'd not used previously such as watch, wait, and review. I even enjoyed it!
In primary care I had more time to discuss problems, medical, psychological and emotional, with patients than before. Having a quiet room and time allotted to that patient without the call of nurses, other patients to attend to and a pager meant I could focus on the patient and listen to them. I remembered the ‘ICE’ technique was taught as a student and hadn't used since. I've never attempted to elicit these issues let alone address them before working in primary care. This is now an important aspect of my practice when taking a history or communicating with patients and relatives.
Negotiating skills were added to my repertoire of communication methods. I'd suggest to a patient that their blood pressure wasn't well controlled, blood sugars were too high, I'd like them to take a statin and while we were doing all this, could they please stop smoking? The patient would happily (and retrospectively unsurprisingly) refuse my advice! This wasn't something I'd come across before and opened up new challenges. I learnt the importance of explaining why I felt these changes were necessary and the benefits this had to offer. Allowing the patient time in attempting lifestyle and dietary changes was not only sensible management but also good for the patient's understanding of their influence over their own health. Mutual agreement also strengthened the doctor–patient relationship I was developing with them and made future consultations easier.
I discovered how little patients understand about their hospital experience. Patients recently discharged came to see me for an explanation of what the hospital team had inflicted upon them. The only information I had was an illegible, incomplete TTO letter containing very little description of investigation, procedures, or management. Why had the patient's medication been stopped? Was it deliberate, an error or simply omitted on the TTO letter? When I reflect upon some of the patients I've managed within secondary care I realise how little time is spent explaining what operation was done, why and what implications this has for the future. A cursory ‘we'll see you in 6 weeks’ may have been all that was given. Since returning to surgery as an ST1, I have been mindful of this and place more emphasis on explaining procedures. Discussing the operation, the benefits, disadvantages, and need for new medications post-procedure is essential information that can easily be forgone in secondary care.
An audit of my caseload found that I was seeing much larger numbers of minor illness and injury compared with the average partner (50% versus 29%) and a relatively unbalanced share of gynaecological and contraceptive problems (21% versus 9%). The likely reason for this being that I, a temporary member of the team with no fixed, regular caseload often had appointments available at short notice. Weekly shared surgeries were of great value when the balance of case mix was much more typically representative of that of a GP and gave me greater insight as to the work of a partner. Without this, my time as an FY2 could have been very biased toward minor injury and illness.
In conclusion, I learnt much from my time as an FY2 in primary care. I may have seen a relatively unbalanced caseload compared with an experienced partner but I now feel better prepared for life as a hospital practitioner and have become a more balanced, well-rounded doctor. The most valuable learning experience was that of communication: to listen and explain more carefully, to communicate more effectively with team members including the primary care physician and to value doing so. I would recommend 4 months of primary care experience to any future surgeon.
- © British Journal of General Practice, 2008.
