General practice – the ‘easy’ specialty?

I often hear from medical students and junior doctors that having a good work-life balance is a good reason to become a general practitioner (GP). This makes me question what’s actually defined as good work-life balance. Are we achieving this in our clinical practice as GPs?

Other than having a supposed good work-life balance, are there ‘qualities’ which we are respected for by our colleagues, medical students and junior doctors? Office-based general practice is becoming more and more unattractive to medical students. As one of my students said, procedural specialties are much more “exciting”, and they pay better.

To do well in general practice, we need an all-encompassing skill set that includes not only clinical skills, but clinical reasoning, organisation, clinical prioritisation capability, procedural and communication skills. Yet, general practice is still viewed as the ‘lesser specialty’ by many junior doctors, despite the complex skill set and breadth of knowledge required. So, why is this?

Most established GPs are booked ahead by about a week to 10 days, which means patients have already formulated their ‘problem list’ by the time they see their GP.

For example, a patient of mine who booked two weeks ahead of his appointment came in telling me so much had happened in the six months since I saw him last.

“My wife’s health has been deteriorating with the onset of memory issues, she really needs to see you. I’ve become her sole carer, and I need help getting carers’ allowances from Centrelink.

“I’m struggling to look after my health, work commitments and the home. My sugar levels are high, and I’ve been self-adjusting my insulin levels as I’ve been too scared to get my Hba1c done.

“My mental health is worsening; I’ve put on weight; sleep is poor; and I really don’t want you to check my blood pressure."

“And before I forget, I need all my scripts renewed. One of the diabetes injection medications was recently unavailable, so I need a substitute. I haven’t had my flu shot yet, but I did get my COVID-19 jabs.”

And so began a multifaceted consult that called on the need for longitudinal coordinated care for this patient.

Training to be a GP includes broad knowledge and several years of experience to become proficient in managing patients of different ages, races, ethnicity, and socio-economic backgrounds; and building the capability to switch between various ‘organ’ related or unrelated problems. This enables a GP to manage uncertainty with a level of comfort and responsibility. While this may look easy from the outset, it’s not a skill set to be taken for granted.

As a citizen of this country, and a daughter and wife, I do recognise that access to health care is an essential component of our country. But access to good health care delivered by appropriately trained health professionals is key.

The current Medicare system is under significant strain, with funding cuts and a growing number of patients presenting with complex and multiple health problems. This is compounded by the fragmentation of patient care, with some allied health sectors basing their care on tunnel-visioned clinical reasoning, rather than a holistic approach to patient care. While allied health professionals play a vital role in the healthcare system and have a significant impact on patient outcomes, GPs need to be the stewards leading the coordination of care for patients.

Complexity in health is not pre-announced as a patient walks in through the doors. I recently saw a 40-year-old gentleman, previously fit and well, who presented to see me with tiredness, abdominal bloating, a few cervical lymph nodes that were raised and tender, and symptoms of anxiety. He and his wife (also a patient of mine) were expecting a baby. This seemingly unrelated group of symptoms has since been diagnosed as lymphoma, which completely changed his world within a span of two weeks.

This is the invisible work that is done in general practice. Common things are common, and protocols will work within reason – but there will be outliers in patient presentations which, if not carefully worked up, will lead to poorer outcomes.

Early exposure to general practice enables positive role models and experience building for junior doctors. I am an alumnus of the Prevocational General Practice Placements Program (PGPPP) that gave me the opportunity to ‘trial general practice’ as a resident medical officer (PGY3). This provided experience in continuity of care, importance of preventative care, chronic disease management, treatment of acute illness and injuries, care coordination, and small procedural skills.

The loss of funding for PGPPP has certainly played a role in the decline of junior doctors considering general practice as a specialty. Reinstating programs like the PGPPP will give junior doctors the opportunity to experience the true essence of working as a GP.

We need to teach our junior colleagues the importance of long-term care and management of patients in office-based general practice. But, to complement this, we need better investment in general practice which has not kept pace with the cost of providing care, including the Medicare rebate freeze that has impacted significantly on general practice remuneration.

We need to rebuild the foundations of our healthcare system and address the impending issues around workforce in general practice. Part of this is to prioritise investing in general practice in a sustainable manner that makes it an attractive profession – not necessarily the ‘easy’ option.

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