I often get asked ‘what’s it like to be a GP?’
Well sometimes it’s great. Sometimes it’s not so great. Sometimes it’s a bit of a rollercoaster.
Let’s reflect on a day I had recently. It was a fairly typical day. I’ll walk you through it. Some may be surprised to read what we do in an average day, but still I’m sure the intro will certainly resonate with many.
It’s midnight and I’m awake. My 2 year old daughter has decided it’s fun to not sleep tonight (again). She wants to come play. Jumps in to bed. Refuses to sleep. Despite popular belief doctors’ kids are no different to anyone else’s and they play up, don’t sleep, generally misbehave. She gets put back to bed. I go to sleep.
It’s now 4am. It’s been 4 hours of my 2 year old jumping on me whilst I’m trying to sleep. She’s finally decided she’s tired and settles down and allows me some peace and quiet to sleep.
My wife’s alarm goes off at 5.15am. She’s doing a surgical rotation at the hospital in the city and has to get up early. I get back to sleep. My alarm goes off at 6.30am. Thankfully because my youngest daughter didn’t sleep much she’s still soundly asleep, and my eldest is fairly self sufficient now in the mornings. I lazily head to the kitchen rubbing my eyes and happily see that my wife has made a coffee. It’s now lukewarm but I’ll take it. Thankfully the microwave can work miracles.
Eventually I saunter back to the kitchen, make my breakfast, curse the world for making me get up so early, and proceed to feed and clothe my eldest daughter. The youngest remains asleep for all this thankfully and so just before it’s time to leave I wake her up, change her nappy, dress her and bundle them both in to the car for the day care drop off.
I breathe a sigh of relief. The kids are in the car. Everybody is dressed. Bags are packed. It’s school holidays so thankfully little traffic. I feel like I’m winning. This might just be a good day.
“Elsa plait! I want an Elsa plait! Daddy you forgot to my hair!” come screams from the back of the car en route to drop off… So now daddy has to do a plait, with no hair brush and no hair ties…maybe I’m not winning any more.
I arrive at work. On time. Somehow I just always seem to make it in on time. Even with time to spare! I make my second coffee of the day [btw it definitely does not look like this picture] Now I probably drink too much coffee, so this is definitely a ‘do as I say not as I do’ story. Of note the WHO recommends 400mg max caffeine per day for most people, and an average cup of coffee has around 100mg in it so that’s max 4 coffees a day.
My first patient is late. Not a brilliant start to the working day. Eventually they make it in 10 minutes late. New patient. Need to register. That takes another 10 minutes. So now they have run over their start time by a full 20 minutes. Being the dutiful GP I am though I still see them. Thankfully something quite benign and relatively brief.
I do skin checks for a couple and unfortunately find a skin cancer on both of them. I now have the unpleasant task for telling them they have cancer. The word nobody ever wants to hear. Thankfully they are Basal Cell Carcinomas (BCC) and as far as skin cancers go, pretty low risk. Now most Australians reading this will say ‘well it’s only a BCC what’s the issue?’, and to be fair the couple took it very well and weren’t really that bothered, but it’s never nice to tell someone they have a cancer.
A few coughs and colds, and then the next challenging case of the day. A minor. Comes in with a grandparent. They want a mental health care plan. They are seeing the psychologist that day so need it now.
Why do they need it? Well they have some marked anxiety and depression symptoms. More accurately they likely have an ‘adjustment disorder with features of anxiety and depression’. I listen to the story. What unfolds makes me angry, but not surprised. I’ll leave out the details due to patient confidentiality, but basically they report that their parents regularly abandon them to go on jaunts away, sometimes in the middle of the night. Sometimes for days on end. They regularly get drunk in the house whilst looking after them and their siblings. There is verbal aggression in the household. We spent over an hour (in a 15 minute appointment) going through everything. It’s the first time I’ve met this child and they are being an absolute superstar discussing it all with me.
We talk. Lots. About lots of stuff. Thankfully nothing more serious is reported, but due to the issues raised I’m duty bound to report to the child services team as their safety is in question. Not immediate safety so police are not needed, but still it’s not an easy thing to say to someone who has just confided such secrets to you. Thankfully both the child and grandparent are ok with it and understand the need so no arguments from them.
I call child services, report the issues. ‘Ok thanks. I’ll make a note…oh no there won’t be any investigation in to it. A report will be made that probably nobody will read’. That was the answer from child services. So this child has been failed by their parents and now by the system designed to protect them…
My patients are angry. They have been patiently sat waiting for me through all this, not knowing why on earth I’m running so late. Blissfully unaware of the difficult conversation I’ve just been having with this child.
I make my apologies and ask for forgiveness. Some are ok with it, others are angry. I try my best to catch up but it’s difficult. Some more skin checks, more diagnosis of skin cancer, more bad news to give to patients.
A few coughs and colds. Thankfully I’m able to catch up a little.
I remember back to my number one rule : look after myself. I have a break. My patients are waiting, but I need a few minutes to unwind. There’s another GP doing the same.
yeah it wasn’t like this
It’s more like this
Ok i’m hydrated-ish. Well at least I’m caffeinated. For those counting we are now on coffee 3.
Back to work. It’s only 11am. 1.5 hours to go until lunch break. Thankfully I have some skin checks and I can catch up a little. I usually book them slightly longer than I really need, mostly for time to do a good thorough check, but it also gives time to either do a biopsy or 2 at the end (happens most checks) or simply catch up a little. Thankfully no biopsies needed, no signs of skin cancer. They are happy.
I’ve caught up. I’m happy.
I’ve caught up. My patients are happy.
Next patient, persistent debilitating back pain. With no clear cause. Taking opiates. Requests a repeat script. No clear diagnosis. Getting side effects of the medication. Wants to stop them, yet simultaenously can’t do without them. Unfortunately an all too familiar story. In some of our patients, especially the elderly, we just never really find the cause of their chronic pain, yet chronic pain they have. Their symptoms are real. They are struggling. But the very medications meant to be helping them are probably making it worse. Opiate induced hyperalgesia – the opiates actually making the pain worse. They are getting side effects. Yet they just can’t bear the idea of stopping them. Fear that they will be incapacitated. Fear that the pain will get worse.
So the opiates are probably making it worse. They aren’t good in the long term. They are addictive, dangerous medications. The other problem is though, we just don’t have a suitable alternative. They aren’t suitable to take any other medications.
Queue a very difficult discussion, with a patient I’ve never met before.
I’m running late again.
I don’t like running late. I think it’s unfair to patients who have appointments booked and have their own things to do, their own timetables to keep.Dr Suresh Khirwadkar
A few wound dressings. Simple right? Wrong. These are chronic, non healing, deep wounds, on elderly frail patients with high risk of infections. One requires debdriding – removing all the gunk and debris and crap from the wound so it can heal better. The practice nurse is dealing with other patients so I’m doing the debriding, dressings and cleanup. I don’t mind this, it’s a good way to both connect with patients and keep up to date with wound care principles, but it makes me even later. I’m still only about 15 minutes late but I dislike being late for my patients. They have appointment times and I like to stick to them.
Last patient of the morning. I’m already in to my lunch break. A chest infection. In a child. They are unwell and their parents are worried. They’ve had multiple admissions before. Thankfully not this time. They aren’t unwell enough to need an admission, and antibiotics should suffice.
It’s lunch time. late. But better late than never. I’m starved. There’s a rep from the local private hospital along with a specialist that wants to talk to us. They have brought some food (yay). It actually was sushi although it didn’t quite look like the picture above.
We talk about work stuff. Not hugely relaxing but it’s nice to grab a bite and talk to my colleagues. It rarely happens so when it does it’s nice, reminds us we are part of a team.
The afternoon session starts. My first patient is a minor. She’s unwell, bloated, crampy pains. Vague symptoms…she’s pregnant and she didn’t know. Her parents don’t know. She doesn’t want them to know. She doesn’t know what to do. She’s in distress. She might want a termination, she’s not sure.
Now this conversation is not going to be quick, so yep you guess it, I’m running a little late again.
Next up some kids are in for vaccinations. I’ve gone straight from discussing termination of pregnancy to seeing a baby. I have to mentally reset. Detach myself from one consultation into the next.
I don’t like doing the actual vaccinations, thankfully our nurses are great at doing those, but I do like these consults. It’s a great way to bond with the child and the families. Cradle to grave care is what we do. We discuss vaccines, do their health checks, have a general chat about life as a parent (there’s nothing parents like more than moaning to each other about life as a parent)
I have a break. Coffee #5. Yes I’m now above the WHO recommendations.
Afternoon session I have some skin cancer excisions booked in. I love doing these. I find it quite relaxing actually. I can unwind and just focus on what I’m doing.
Following the surgeries I have a few more patients. A few coughs and colds, fairly standard stuff. But then a patient who wants to lose weight. These are always very difficult consultations. Weight loss is not easy, everybody knows that, but unfortunately there’s just no magic answers. There’s some medications that can help but nothing that has shown that much evidence. We talk about the issues but unfortunately they don’t want to really discuss things, they just wanted a prescription, which I declined to write them. Patient is unhappy, they leave but not before giving the reception staff get an ear bashing.
Next patient is new and wants opiates. Yes that’s basically what they said. They give a story of some back pain, not very convincing though. I examine them, they complain of pain when examined but again not very convincing. I explain what I think is the issue and decline to issue the opiates because it’s not indicated, and we have a practice policy that I follow. They were aware of it (there’s signs all over the front doors and reception) but they claim they weren’t. They shout and swear and get angry. I try to discuss with them, they seem like they might be addicted to opiates, that they have an issue with them. I offer help. They aren’t interested. The storm out, slam the door, run off without paying, but again not before abusing the practice staff.
So that’s 2 patients back to back that have been angry and abusive. Great. Not only that one of them ran off without paying, effectively stealing from me. Now we can’t just bill medicare for it. That money is gone. So me and my practice staff got abused for trying to help. All for free.
Some consults for repeat scripts. These are not always easy, but these ones are fairly straight forward. They are repeat scripts, long standing meds, well controlled conditions, bloods up to date, etc.
Finally I’m on the last patient of the day. Guess what, they are late. Not just late, but late and a new patient. They arrive at the end of their appointment time, not the start. They have chest pain. They need to be seen to rule out anything serious, but they spend 10 minutes filling out the new patient form.
So the day ends as it begins.
Late. Over 30 minutes late home. It happens, but it’s frustrating. I miss time with my kids, but you can’t just up and leave when a patient needs to be seen.
Dinner, bath, bedtime time stories.
KIDS ARE IN BED, TIME TO READ
…my material for my skin cancer courses. Yep it just doesn’t stop.
Eventually I’m finished for the evening, turn in and prepare for the next day.
I just hope my daughter sleeps tonight.
Dr Suresh is a GP and skin cancer doctor in Brisbane, and patients can book with him at this link