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The future for our students

Coalface tales

James Booth

Monday, 20 May 2019

AdobeStock_151243289_student_blog.jpgLast week, we said goodbye to the two medical students who’ve been on placement with us this year. The newest medical school in the UK is just down the road, and as part of their declared ethos around GP training, two of their undergraduates have been visiting us every few weeks for a day. As a surgery, we’ve loved this; they are keen, enthusiastic and clearly delighted to be starting their journeys through a medical career. Having never formally taught before, I’ve rather liked going through history taking and clinical examination and twenty years fell away as I remembered being taught the clinical signs left behind by childhood rheumatic fever in much the same way I was at the Middlesex (far fewer patients with those signs around now, though).   

This enthusiasm has been rather thrown into contrast, this week, by the frankly gloomy news that has emerged about what is starting to seem like nothing less than a developing crisis in primary care. It has, frankly, made me fear for the future we are going to be offering in general practice for students like the two we have come to know this year. The BBC coverage can’t have been missed. It was headlined by the disturbing news that we have just seen the first sustained drop in GP numbers in fifty years; and this is at a time where we are grappling with an ageing population, ever increased demand on our services, and an increasing expansion of our roles within the health service. As GP Online points out, our very sustainability is under threat now. I work in probably the most deprived area in town and I absolutely recognise the increase both in consultation rates and missed appointments this brings, compounded by the difficulty we all face in recruitment. I’d like to think that my patients still have good access to our services, but I utterly sympathise with those practices in which a third of their patients cannot get same day access. 

I am currently the only partner for 7,750 patients. I am very lucky to have some excellent salaried colleagues and a wonderful team about me. There are, however, far too many days in which I feel overworked and exhausted – just this week, one day began at 7am, and proceeded to finish at 9:30pm. Over eight hours of face-face contacts, 40 phone contacts to sort between three of us, home visits, and a meeting about our PCN. I’ve been in the position of having to leave results at the end of the day as I was only too conscious that my concentration was such that I was going to miss something.

Reflecting on this over the last few days, I have feared that perhaps there has been an unwitting dishonesty in how we have given our students their first experiences at the coalface. They certainly can’t have missed that we all start earlier and finish later than they do. They have seen the sheer unpredictability of GP life: the surgery interrupted by the patient who had collapsed in the loo, the acutely ill baby rushed into us, the carefully planned schedule that lies in tatters by lunchtime. They have seen the rate at which we need to sometimes work; although the surgeries they observe have breaks for teaching and cross cover arranged. They have had the luxury we only get as students, of being able to spend over an hour with a single patient, examining from top to toe and taking the kind of history we – ahem – stopped doing after finals. I’ve wondered if we have, with the best of intentions, shielded them from some of the harsher realities of life in primary care. I didn’t take them to the visit to an elderly man, stricken with paranoia borne of dementia, in a house filled with his hoardings, and let them see how this led to the usual grappling with an equally stretched social care system to get him help that he would try and refuse. They weren’t with my colleague or me when I had to intervene for a patient bellowing in anger following a – completely correct - refusal of a CD prescription. They’ve not needed to sit and listen in my latest meeting with NHS Property Services. 

What I have hoped to do, though, is still get across the parts of this job that I still love, and which are still there, even in the most frantic of days. After they clerked my patient and listened to the clicking of the artificial heart valve that has fixed the damage of the rheumatic fever that she vividly recalled, they got to see that through looking after this lady for over a decade, I have seen her through her widowhood, through the difficult complications she had after hip surgery, and have helped arrange the support she needs to stay independent at home. They have also seen how we talk about the members of her family who I look after, and indeed met one of those people on a different day. They have seen how the whole practice team has pulled together at busy times, and how vital everyone is to the service we deliver. Together, we have talked to patients with conditions as trivial as nits and as life-altering as Huntington’s disease. Through that, they have actually done me a great service; I have seen my job anew and have been able to remember why at its core, I still wouldn’t do anything else. 

The challenges ahead of us cannot be overstated; I am very lucky to still be able to experience some of these positives and I’m only too aware that there are colleagues who face far greater problems than me. I don’t deny the cost of my chosen job in terms of my family life, and I’m grateful that my wife and daughters show such understanding at frequent late nights and weekend afternoons spent kipping in a chair. I hope, though, that solutions are found, so that this unique, challenging, unpredictable but rewarding job of ours can continue to be done as we would wish it.

Oh – and before I go – a small footnote. I don’t doubt that all of us face that perennial grumble from patients about the late-running surgery. Well, my colleague Elena had to visit a government office this week to be fingerprinted. She’s Romanian, and this is part of her visa requirements. It seems something of an effrontery to me, given that she went there after a morning surgery caring for her patients, but there you go, that’s the UK today. Anyway; she was one of three people having it done, it took seconds…and they still made her wait over an hour, despite her paying a fair sum for the privilege. I’m going to remember that next time I’m thirty minutes behind.

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James Booth

James qualified from UCL in 2002 and has been a GP partner in Chelmsford since 2006. He is also the named GP for Safeguarding Children locally. All views expressed are his own.
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