It’s fair to say that no day is ever the same in general practice. I keep thinking it is exactly like Forrest Gump’s mama said – it is “like a box of chocolates. You never know what you’re gonna get”. Let me show you what I mean. While the patients described are all fictitious, they represent compilations of the incredible variety of stories and personalities seen over the course of my GP training.
It’s 7.40 am and I’m sitting in my room nursing a cup of tea. The practice doesn’t open until 8am, but I am hoping for a few quiet moments to catch up. I check through my list of electronic results that have come through. Normal. Positive urine Chlamydia PCR. Recall. An obstetric ultrasound with findings of a persistent subchorionic haemorrhage. I call the patient’s obstetrician to get their opinion on whether I should be concerned with this result. HbA1c 7.2%. Stable. A total cholesterol level of 9.6 mmol/L. Is that Familial hypercholesterolaemia? As I ponder about this patient’s Dutch Lipid Score, I hear loud knocking on the door outside.
There’s an anxious mum outside with her young daughter in tow. I recognise them; it is young Lily who I had seen last week for her four-year check-up. She is visibly distressed.
I bring them to the treatment room.
She’s alert, but tachypnoeic with increased work of breathing. She’s trying to stand tall and brave. She says “Dr Vicky, can I… have… lollipop?” because that’s what she got after her immunisations. Her saturations are 93% with widespread polyphonic wheeze. It looks like acute asthma.
I grab the oxygen and the ventolin nebuliser. After I’ve given her back to back nebs, she’s looking better, and saturations have improved. I let mum know that we will need to get her to hospital for further monitoring and ventolin stretching. I reassure mum. She is going to be okay, and we’ll review her again after discharge because we’ll probably need to consider a preventer. I hand Lily the sweets jar and she excitedly grabs a cola-flavoured lollipop. I chuckle to myself, thinking about what my dentist would say.
I look at the time. It’s 8.39 am and I’m already two patients behind. Groan. I apologise to my first patient, secretly hoping it’s going to be a routine presentation!
It is Jeff who is under immense stress at work. He’s being bullied by his new manager, and has been having these troubling thoughts about not wanting to exist anymore. I take a deep breath; I tell him that we have plenty of time to talk. I make a quick call the front desk, hoping they can reschedule some of the other patients for the morning. It is definitely “one of those days” where 15-minute appointments can be so unforgiving.
My second patient is Bin, he’s a 65-year-old businessman who has not come in for a while. He says “Doc, I need antibiotics.” I chuckle. This is not the first time I have heard this. I ask him why, pause and watch him expectantly. He becomes nervous with avoidant gaze, and then concedes that he had recently come back from Vietnam, and now has had copious amounts of urethral discharge after a visit to a local brothel. Bingo! We discuss the empirical treatment for gonorrhoea – a single dose of antibiotics; two tablets and an injection. I inform him that the laboratory will notify the Public Health Unit if there is a positive result, and that we need to contact trace and perform a complete STI check. He is relieved by the simple treatment. I also note that his blood pressure is 165/100 mmHg, and ask him to come back next week to discuss his cardiovascular risk, as well as discuss the results and confirm symptom resolution.
Next up is a travel consult for a family of four going back to India to visit grandma. They were told by some friends they should come in but are not exactly sure why they needed to come. They go back every year and have “always been fine”. I spend the next 15 minutes chatting to the family about why visiting friends and relatives puts them in a high-risk group.
Following this, I see a few patients with viral URTIs, then complete a wound review for dear Mrs Jones, who sustained a skin tear while doing her groceries.
Eighteen-month-old Charlie comes tottering in pulling his mother’s hand. Dad is carrying his younger sister, who is screeching after being woken up from her nap. They are here for Charlie’s developmental check & immunisations. After plotting height and weight, I observe him for some time and notice that he can only say “Ma” and that he has a history of recurrent otitis media with effusions in the past eight months. I say “I think your son may have a speech delay”, but his parents aren’t convinced. They go on to say that they speak to him in 3 languages at home, and that he’s just being shy and he actually has at least 10 words. They could be right. I gently suggest starting with a hearing assessment first, then bringing him back for a review.
My stomach growls and I am thinking about lunch. The next patient is a new patient to the practice, Greg, he’s a 68-year-old who hobbles into my room. He has recently moved here from QLD and has recently been discharged from hospital after having spinal surgery … how did they let this man on the plane? There are a few red flags here … could he possibly be drug-seeking?
Then Jenny comes in for a “routine pap smear”, or a cervical screening test as we refer to the new test. Jenny is extremely nervous, because she had a terrible experience last time. As I am reassuring her that we will take it slowly, the phone rings. I apologise and explain it might be urgent. Our practice nurse asks me to assist with a difficult cannulation for an iron infusion. She’s an ex-ICU nurse and has tried twice! I say I will come in shortly. We finish the procedure and Jenny says that it was not as bad as she remembered, and I am relieved.
I knock on the treatment room, hoping the patient does not have chemotherapy-battered veins. I’m feeling rusty, but I grin when I am successful after the first attempt while masking my inner spirit fingers.
I then take a phone call from our local radiology centre. What is with the flurry of phone calls all of a sudden? It must be lunch time. Dr Clark has a sombre voice – the breast biopsy for one of my patients looks suspicious for breast cancer. It is beautiful Leanne who is only 32 years old. I think about her young children and start to feel quite emotional. I take a moment and regather my composure before slowly walking down the corridor. I feel like my emotional compass is being particularly tested today.
Next up is widowed 78-year-old Franca, who always brings us the most delicious Lebanese sweets. She is always 10 minutes late for a 15-minute appointment, and just loves to chat! She is wondering why her BSLs are constantly over 14 mmol/L, and I don’t have the heart to mention the baklava in her hand.
Feeling mentally drained, I am just about done for the morning. Then “just” one more phone call from front desk. A heavily pregnant patient has just walked in asking if she can be squeezed in. She is complaining of increasing headaches over the past week. Her blood pressure is 146/85 mmHg. I repeat it manually, again and again, and it’s the same. I am now worried about pre-eclampsia and call the liaison midwife at our local hospital. I send her in to the day stay unit for some investigations and some monitoring.
I take a breath. I am desperate to empty my bladder and fix my hypoglycaemia. That was just the morning session – all before 12.30 pm.
I debrief with my supervisor over lunch, and we discuss some of the challenging and interesting cases we have seen. We discuss the place of genomics and prenatal genetic testing, and the best part of my day – dinner plans!
My afternoon looks like I might have a bit of time to call a few patients and finalise that paperwork. I reflect on how far I’ve come in the last couple of years – shedding that anxiety of seeing unwell patients as an intern to coming to terms with the uncertainty of General Practice. In a few hours, I would have seen people from all ages, backgrounds, and different walks of life. I would have reviewed a two-year history of toe pain, right up to a suspected acute stroke.
Perhaps the best part of general practice for me is building long-term relationships with patients and families. It’s incredible that I’ve known some of my patients their whole lives. Personally, there is nothing more rewarding than confirming a woman’s pregnancy, supporting her through the months of self-doubt about her parenting skills, and then looking after her baby and watching them grow up. That real sense of family is unique to general practice and what I believe is truly the essence of “continuity of care.”