What does my GP do all day?


As a GP I understand that, for the majority of people, the prospect of having to visit me is only slightly more welcome than a visit to the dentist. You want to get in and out with as little hassle as possible, explain your problem and leave with a solution.
For many of my patients, that's the service I provide.
As a result, you might believe that my area of expertise is limited to the last medical problem that you asked for my help to solve.

So too do all the other patients that you shared a waiting room with on that day.......

As a GP I understand that, for the majority of people, the prospect of having to visit me is only slightly more welcome than a visit to the dentist. You want to get in and out with as little hassle as possible, explain your problem and leave with a solution.
For many of my patients, that's the service I provide.
As a result, you might believe that my area of expertise is limited to the last medical problem that you asked for my help to solve. So too do all the other patients that you shared a waiting room with on that day.

I am a highly-trained specialist in the speciality of Generalism, which is a wordy way of saying that I know a lot about all medical specialities without being an expert in any one in particular. Juggling multiple problems is the norm.

With this in mind, I thought it might be interesting to publish a snapshot of a typical day in my consultation room.

 

It is reckoned that the Irish GP deals with 2.5 problems per consultation, on average, a trend you will see from the list below.
Our patient demographic is different to many other practices in that we have quite a young population and don't have that many older patients with multi-morbidity (more than one disease).
The grammatically unorthodox use of the '?' in the list is my GP shorthand for 'query' and denotes an issue that the patient and I are trying to rule in or out.

Each number represents a scheduled 15 minute consultation or an emergency consultation. Very few were completed inside 15 minutes.

Welcome to a typical day in a GP surgery.

1. Pregnant, feeling less movements, + soreness in pelvis, ?baby ok
2. Headache right side + sleepy when driving + sweating profusely
3. Pain in right leg few days ?clot + ongoing pain in knee (3 months into 9-mth wait for free physiotherapy)
4. Monitor antidepressant treatment + family stress + wants to conceive
5. Chronic back pain, on waiting list for physiotherapy, can't afford MRI scan, ?fit for back to work
6. Confirm pregnancy 8 weeks, traumatised by last delivery, counselled
7. Pre-employment medical, protein in urine ?relevance + ankle pain ?fracture
8. Newly diagnosed diabetes + obese ?refer hosp clinic for structured care
9. Pain x few months in site of an operation years ago + sore throat
10. Itch and rash hands and knees ?cause + renew pill script
11. Bleeding from back passage + perianal pain at times
12. Stomach cramps + diarrhoea + stress + short of breath ?clot ?pneumothorax ?anxiety
13. Chest pain + palpitations + not sleeping well + stress at work
14. Stomach pains + obesity + poor diet + public HSE dietitian refuses to see unless diabetic (not yet) ?go private
15. Face pain + congestion + headache + lump on leg
16. STI screen + check genital 'growth' ?wart ?herpes ?contagious
17. Pain in one eye + rash on foot + toenail problem
18. Smear + tired all the time + stress at work/being bullied
19. No energy + low mood + suicidal thoughts
20. Renew script lithium + others + do bloods
21. ?continue bisphosphonate, has had 10 years + breastcheck + refer mammogram
22. 3rd rabies and 3rd hepatitis B vaccine + malaria script ?which one, going to South America + pill script
23. Baby chesty cough + fever 3 days + new rash ?meningitis
24. Feeling cold + difficulty concentrating + tired all the time
25. Renew pill script + check changing mole ?cancer ?refer
26. Confirm pregnancy 5 weeks, cramps, previous ectopic at 6 weeks, anxious ?another ectopic. ?safe to run
27. Not sleeping well + head racing + anxious about everything + suicidal thoughts x few weeks

Outcomes:

Number of patients sent to the local over-crowded A&E today: 0 of 27
Number of patients referred for consultant opinion: 2 of 27
Number of patients fixed in-house: 25 of 27


In between these consultations, I also need to deal with the paperwork generated by consultations of previous days, including blood results. I also have patients phoning to speak to me, email queries from various sources and all the paperwork generated by today's appointments too.

Phone-calls:

11 people phoned with queries for the doctor. It is just not possible for me to deal with them all so they are triaged by my secretary. Urgent queries are prioritised for appointments or a phone-call (see below).

Others go on a waiting list for whenever I have time (next week. maybe).

Hopefully, I haven't missed one that turns out to be more serious than presumed.


1. Phone-call: mid-pregnancy, wants to go on hols 6-hr flight, previous DVT, ?safe to fly
2. Phone-call: surgeon recommended urgent surgery, insurance won't cover, long public waiting list, what to do?
3. Phone-call: patient I sent to A/E for admission yesterday sent home after 10 hours. What to do now?

Today's post:

I read 17 letters from consultants and others prior to my admin staff scanning them into patient files; entered notes in files of 3 patients regarding new diagnoses made by a third party.

Blood results from previous week:

Check results of 23 lab results regarding 14 patients. There is often a backlog of results to process as I have no time to get them checked daily.
Sent a text to 10 patients regarding normal results.
1. Phoned regarding positive chlamydia and arrange contact tracing;
2. Phoned regarding TSH 9 start eltroxin;
3. Phoned regarding anaemia Hb 10.2 + renal impairment GFR 58 arrange follow-up + answer queries about what this means.
4. Phoned regarding cholesterol of 8.1.

Forms, Letters, Reports and random paperwork:

1. Sign Medical card application forms.
2. Fit for work letter – redirect for appointment and examination.
3. Write Social welfare report.
4. Amend staff payroll based on change in tax credits.
5. Update online log of continuing professional development hours for the meeting later this evening.
6. Review and sign off on purchase of a new computer for our Nurse room.
7. Block out time on my schedule for the Admin meeting next week.

Prescriptions:

1. Renew medications for 4 patients by phone request – check files first.
2. Redirect another 2 for appointments as overdue check-up and unsafe to prescribe without seeing them.
3. Renew complex medications list for cancer patient (list of 13 medications), ensure safety and no interactions, check hospital   letters for any changes to these medications since I last saw this patient.

Emails:

Only 2 patient email queries which can't be sorted by reception staff, must be a quiet day or maybe the Internet is broken.


1. Wanting lab results sent to specialist – are they all back and ok to send on?
2. Enquiring about getting fertility tests and what day to come in.

Referrals:

I write referral letters for 3 of 11 patients on my 'to do' list since last week.
No time to do the other 8 or the 2 new referrals from consultations today. I may get to finish these at the weekend.

Breaks?

2 x 5 minute coffee breaks including discussal of a physiotherapy problem of a shared patient with the physiotherapist in kitchen.

I got a 25 minute lunch break, during which I read letters.

The typical day outlined above dealt with about 64 clinical problems, 5 of which were potentially life-threatening.

11 were primarily mental health issues which often take 20-30 minutes to deal with safely.

Time for anything else?

No. Keep meaning to tidy my desk.

Stress levels:

Moderate to high.

 

In my role as GP/Detective I have to ask the correct questions (but not too many), consider the likely differential diagnoses, possibly carry out a physical examination, blood tests or other investigation to confirm the diagnosis if required, advise the patient of diagnosis and plan, prescribe medications if necessary and arrange follow-up if the problem doesn't resolve.

I then have to write up detailed notes for each consultation or other interaction, to form an accurate entry in the patient's permanent medical records. Bearing in mind that the most important problem is often the one the patient doesn't mention until they got the minor stuff out of the way, you can see how it is sometimes difficult to fit all of this into a 30-minute appointment, never mind a 15 minute slot.

Scheduled work day:

8.30am – 5pm.Finally left at 6.40pm. Got home for short visit in case my 2 year old forgets who I am. It's just as well that my husband works in the surgery or I'd never see him either.
Grab food before attending a medical education meeting from 8-10pm.
Come home. Catch up briefly with GP social media to see what is new in the wider GP world.
Go to bed. Aim to wake refreshed for more of the same tomorrow, but with 30 different patients and 70 different new problems.

There's very little time left for being a mother, wife, daughter or a friend.
No time for any of the regular exercise I advise but don't do.
You would need to really love this kind of work to keep up with the pace, and still make safe decisions.
Thankfully I do.
I just wish there was more time.

 

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