Abstract
Although most GP trainees look forward ardently to their general practice placement, it can raise anxiety levels for some registrars. The reasons for the latter are many; most can however be grouped into the category of the fear of the unknown. In the following article, Dr Chawathey, discusses various aspects related to settling in to a new practice, and provides practical tips for trainees who are about to commence their GP placement.
The GP training programme includes a 6 month primary care placement during the second year of training. This is the first placement in primary care for many trainees. Some schemes may offer a 4 month experience during the ST1 year as well, while some trainees may have obtained primary care exposure in their foundation training. As registrars move out of the cocoon of the hospital environment into community practice, it is not surprising that some will experience more than a blip on their anxiety meters. Addressing trainees’ concerns at the outset can help trainers foster a healthy relationship with trainees and ensure that the general practice placement is enjoyable.
Preparation for your GP placement
It is imperative that you contact your clinical supervisor or the practice manager a few weeks prior to commencement of your post. This will allow you to get acquainted with the practice and ensure that you complete the relevant paperwork in time. Various issues (such as occupational health checks, medical defence insurance certificates, linking NHS smart cards to practices, etc.) need to be sorted before you start consulting with patients. You will certainly not make a good impression if the practice team has to cancel or move your appointments because paperwork is incomplete. GP surgeries organise a robust induction to help trainees to settle into their new practices. If your trainer is aware of your past experience, he/she can adjust your induction schedule to get the most benefit out of it.
From hospital to general practice
The work day in general practice can be quite different to a hospital placement. The hospital morning ward round with its list of jobs and the drudgery of ward duties in the middle of an afternoon clinic (re-siting cannulas and completing discharge summaries) get replaced by morning and afternoon clinics (and/or home visits) with plenty of paperwork to fill any gaps in the day. General practice is busy – those trainees (thankfully, a very small number in my experience!) who wish to ‘have an easy time in GP land’ are likely to have their dreams shattered. Climbing the training ladder into ST2 or ST3 means increased autonomy and increased responsibility. As a trainee, you may sit in with your trainer and other GPs during the first couple of weeks of your placement, but soon you will have your own booked surgeries and work independently – with help close at hand whenever required.
Working with the team
As you settle in your practice, you will realise that many of the GPs and nurses have special interests and run additional clinics, such as baby clinics, diabetes clinics, anti-coagulation clinics, minor surgery and joint injection clinics. Some practices may have consultant-led specialty services. There is much to learn from attending these sessions. This experience can reduce your secondary care referral rates when you practice as a GP.
The practice team is not confined to GPs and nurses, but includes practice secretaries, administrative staff, reception staff and, most important, the practice manager. Some practices may have an in-house pharmacy, while others will have close working relationships with local community pharmacies. As a part of your daily work, you can liaise with community teams, such as community physiotherapy, social services, Macmillan teams, home treatment teams, etc. Ask your trainer for a tutorial on community services – it will help you understand the role of the GP as sometime conductor of the primary care orchestra.
Calibrations for primary care
Knowing when to escalate treatment and arrange further investigations are important skills that a junior doctor develops during his or her training. The triggers for these are different in general practice as compared to hospital. For example, in a patient admitted with pneumonia to the acute medical unit, investigation of incidental mild anaemia will be low on the priority list and can be managed at a later stage. However, as a GP when you see this patient post-discharge, it is important to investigate further. I can recall a trainee fresh from an intensive care placement, who marked a new rise in ALT (Alanine transaminase) to 150 mmol/mol as ‘Satisfactory – no action needed’, reasoning that ‘it’s not dangerously high and is likely due to fatty liver disease’. It prompted a tutorial on when and how to action slightly abnormal blood tests in asymptomatic patients.
Fear of the unknown
Having spent the majority of time in hospital settings, some trainees find the move to general practice unnerving. There are many reasons for this, but fear of the unknown is a common thread.
The most common cause of a spike in the anxiety meter is uncertainty about support from the in-house clinicians. With patients in hospital, a clinical query can often wait for the next registrar or consultant ward round; in a GP setting queries are usually dealt with during the appointments. Your clinical supervisor/trainer will be a lifeline during your GP placement. They will be the first point of contact when you need advice about a patient. It is therefore useful to know their preferred means of contact when help is needed. Some GPs prefer use of the internal computer messaging system, some a telephone call, others a knock on their door. If you establish preferences at the outset it may reduce miscommunication and help things flow more smoothly. If your supervisor is busy, try asking your patient to sit in the waiting room while you see the next patient. This can avoid awkward small talk with the patient and stress about running late! Some supervisors may prefer to discuss non-urgent queries at the end of the clinic or during your tutorial.
Some trainees worry that they are being ‘made to work more than they should’. This is often a combination of misplaced expectations, time management skills and misinformed comparison with other trainees’ timetables. I remember a trainee’s concerns that 15 minute appointment slots might be unreasonable given that his friend at another practice was seeing patients at 20 minute intervals. On further discussion, he realised that his friend’s practice had clinician-led triage, and only complex patients were seen by GPs, with others managed over the phone or by nurse practitioners. However, if you strongly feel that your work schedule is beyond the recommendations of your lead employer or if you are struggling with the workload, discuss it with your trainer. In most cases, these problems can easily be remedied with minor adjustments to your work schedule.
A third important cause of anxiety for trainees is management of clinical uncertainty and patient expectations. Patients have expectations of a formal diagnosis and cure, but a high degree of overlap between symptoms of common trivial conditions and uncommon serious diseases, alongside a high prevalence of medically unexplained symptoms that lack an identifiable organic cause can make consultations challenging, even for experienced GPs. It is therefore natural to feel that you are out of your comfort zone in a GP placement. Many trainees confess that the first few weeks in general practice were a humbling experience – yet the most useful one at the same time! Remember to practice safely, refrain from intrepid decision making and when in doubt ask for help.
Practising self awareness
As a doctor, it is important to be aware of your own core beliefs that can negatively affect your stress levels. Common ‘should and must’ beliefs that can lead to stress include: I must run on time, all patients must be happy with my advice, only patients with genuine problems should book appointments with their doctor, etc. Most experienced trainers will explore these during tutorials or sometimes in an informal chat. There are formal exercises, such as the Johari’s window, which will not only improve self-awareness, but also help to develop a better rapport with your trainer.
Top tips from the trainer
Contact your clinical supervisor or practice manager a few weeks prior to your placement Ensure you have your paperwork completed by the time you start your placement Inform the practice well in advance of any individual requirements Ask your supervisor and other GPs how they would prefer to be contacted for advice during clinic times Get to know your practice staff and treat them with respect and dignity Be methodical with your day-to-day working life during your placement – this can help ease any time pressures you may feel Remember that you learn much more from challenging cases than from easy ones Realise you that you will feel out of your depth and that such feelings are expected; if in doubt always ask for help
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