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The diverse world of general practice

General practice in South Africa is a specialty of contrasts, say Professor Julia Blitz and Dr Zandy Rosochacki

The different strands of public and private sector and rural and urban practice come together under the term general practice.

Public sector

Following community service, many doctors start to look for a registrar post in their chosen speciality. Others choose the route of general practice, where there is no need to embark on the rigours of postgraduate training.

In the public service, this is not a restrictive choice at all. It can allow you the freedom to move between different disciplines (this might be in the process of deciding which one you might like to specialise in at a later date), or to remain in one discipline developing the practical knowledge, wisdom and experience which make you a very dependable member of the healthcare team (the so-called career medical officer).

You can choose to work in any of the full range of public healthcare facilities – large urban hospitals, small rural district hospitals, community health centres (CHCs), or disease specific clinics (eg, HIV), or a non-governmental organisation (NGO).

Depending where you choose to work, you may end up using and developing different skill sets – the NGO may require you to develop project management or grant writing skills; the CHC may require you to develop expertise in ambulatory care of patients with chronic diseases and the skill to help people make healthier lifestyle choices; the district hospital may require a skill set that encompasses procedural skills and emergency care; the large urban hospital may require a skill set restricted to a specific discipline, but including outpatient, ward and theatre work. You could also pursue a career as a member of a research team.

One of the options for general practitioners who develop a particular interest in a discipline is to pursue a Diploma through the Colleges of Medicine of South Africa. Almost every constituent College (including the College of Family Physicians) offers a Diploma, which does not require the candidate to be in a registrar position in order to be eligible for the exam. This does give the general practitioner certification of a nationally recognised level of skill in the particular discipline.

Working as a general practitioner in the public sector in South Africa does mean that your potential career and pay progression is capped at a level lower than a specialist might reach

Working as a general practitioner in the public sector in South Africa does mean that your potential career and pay progression is capped at a level lower than a specialist might reach, but deciding to pursue this path needs to be weighed up against other choices that you are confronted with about how you want to live life outside work. At least your working hours are set, and you will have a fixed income at the end of each month.

However, conditions can be quite difficult if the staff complement is not filled, there is inadequate maintenance of infrastructure, and inconsistent supplies of consumables. There are opportunities to build well-working teams (both inside the hospital and with the community-based healthcare providers) and to improve systems to provide more efficient care, so jobs in the public sector can provide both interesting challenges and chances to problem-solve in unique ways, to really make you feel that you are contributing to improvements in patient care.

Pursuit of a postgraduate qualification is not an essential requirement for a very fulfilling career in general practice in the public sector.

Private sector

Working as a GP in private practice, you have a smaller pool of patients you care for than in the public sector, but you have to work very intensively. You are able to provide continuity of care: covering conditions from the cradle to the grave by practising at the level of competence that befits your skill and the needs of your community.

So, if you are a rural GP, you may well perform caesarean sections or general anaesthesia as part of your routine workload. In an urban setting, you will more likely become an expert in palliative care, or sports medicine. If you have a gift to teach, there are several family medicine departments to link you to students.

Do you have power over your workload anywhere? Well, here you certainly can set the pace for good quality consultations you and your patients can be proud of. This alone is worth a lot! There are often complaints about third party payers (medical aids that broker the fee for service arrangements), but if you knuckle down and practise good medicine, patients will want your care and the income will take care of itself.

Can it get boring? If you want action work in the country, if you love human interaction and can see a preventive opportunity in a seemingly trivial presentation, there will be endless anecdotes to feed on. Good medicine means treating any patient, any time, with any problem. You embrace them all. Can it frustrate you? Yes, there is a weakness in the current system in that you intellectually know you are only looking after a chosen (their choice and yours) selection of patients in your community. Certain common diseases (eg, HIV, TB) may pass you by unless you make a specific effort to remain competent in these spheres.

You certainly can set the pace for good quality consultations you and your patients can be proud of. This alone is worth a lot
The good news is that NHI will open the playing fields and though private, your work is now likely to open up. This is one more important skill to retain: remain competent to work in a public sector primary health clinic. Does it get lonely? Yes, but if you position yourself in long-term real relationships you will be buoyed up. Remarkably, you will always have someone who will happily accept a patient you refer. This is not true for the public sector GP, who may be pushed deep into levels of clinical dissonance and discomfort. One of the great joys of being a GP is assisting good surgeons.

You will remain privy to high-end medicine where all current diagnostic and treatment modalities are at hand. You will see a range of pathology you do not see in the public sector. You may assist your own patient with colon cancer resection, or a hysterectomy, or even a kyphoplasty for a fractured thoracic vertebrae. Assisting in a knee replacement remains a treat. You are paid well for the work and it allows a break from consulting.

Is there a downside? Make sure you keep yourself intellectually and physically involved. Dream up new challenges each year and build on your practice team. This is where negativity and rot can set in and demoralise good work. In public GP work, ever younger and sharper colleagues enter the fray. In private GP work, you all grow old and wrinkled together, patients and staff included!

Can the two roles of public and private sector GP be compared? They are, in many senses very different. In the public sector, you must grow in your supervisory and leadership capacity; in private practice, you must remain faithful to your patient following and your comfortable position in the hierarchy of fellow doctors.

Whatever the differences, both public and private sector GPs are generalists, and both want to practise good medicine.

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