How to work in… general practice
Dr Katie MacLaren, chairman of the BMA GP Trainees Subcommittee, is about to complete her GP training. She describes how it has carved her impression of general practice
What is it?
General practice is the first port of call for anyone in the health service. People visit their GP to be diagnosed and treated, or to be referred to a specialist in hospital. The role of a GP is hard to define; they are often described as the gatekeepers of the NHS and are true generalists.
GPs diagnose and treat both complex and minor illness, monitor chronic disease, educate and prevent disease, and foster better healthcare; and, as the patient’s advocate, we often get involved in the social aspects of patients’ lives and help their families help themselves. We help patients deal with the impact of a condition on their life, no matter how trivial it may seem.
Training
We help patients deal with the impact of a condition on their life, no matter how trivial it may seem
GP training is what trainees make of it – you have to be incredibly proactive, and get the best out of it as soon as you start. Currently it is a three-year scheme that you enter into after foundation years.
The training is split between time in general practice and time in hospital posts. Working in general practice early in your training as a trainee helps to identify what needs to be learned when you are in your hospital training components, and gives you a greater appreciation of the social context of illness. The training programmes all finish with a full year in general practice.
The particular uniqueness of GP training is your trainer: they are in your designated practice and primarily mentor and monitor you. If you weren’t happy with your training, I’d recommend speaking to your clinical trainer or supervisor; if you still weren’t happy I’d suggest speaking to your deanery. Alongside two exams (one a multiple choice exam – the AKT, and one an OSCE – the CSA), GPs are assessed through their e-portfolio, so trainees should keep it up-to-date and perform the required workplace-based assessments.
If you do this you will have no difficulties with the final year. I’m nearing the end of my training and there are certain specialties that I haven’t done a specific rotation in. Sadly, nobody gets to do everything; however, I have made up for it by doing extra training days and courses – so I’ve managed to pick up the necessary skills and knowledge. This has been supported by the deanery and I would encourage anyone in this position to do the same.
Changes to GP training are being proposed for the future: the biggest change, if it is introduced, will extend GP training to five years. If it is a well-managed curriculum and the conditions are right, aspiring GPs shouldn’t be put off; it will hopefully mean more time training in general practice placements and a more self-directed curriculum.
Working as a GP
I work in a practice in Scotland. I usually arrive around 8am and do paperwork, then spend two hours seeing patients (every ten minutes): this usually amounts to around 12 patients, before setting off on home visits. The afternoons are very similar, with longer surgeries.
No two days are the same; in between patients and surgeries you find yourself following up on enquiries, checking prescriptions and checking results that have arrived for your patients, and often dealing with emergencies. Practice schedules are often staggered so that while one GP is going on home visits, another is seeing patients and hence a wide range of contact opportunities are available for patients at all times.
One thing that struck me when moving into general practice from hospital is that, as trainees, you are used to being with colleagues of a similar age and ability, who share their interests. So starting to work on your own can initially feel quite isolating and you feel very pressured to suddenly have to see, diagnose and treat all on your own.
You take home a lot of emotional weight, but you have to learn to trust your instincts and safety net
This doesn’t last long and you soon settle into the general practice team and learn to use time as a great ally. I chose general practice over hospital medicine because I enjoy the challenges of diagnosis, but also feel the value in helping a patient cope with illness over a variety of timelines. GPs see patients over their lifetime and hence they can pinpoint the different factors that are contributing to a particular ailment, as they have got to know the patient over several years. In hospital you only get snapshots of people’s lives.
However, a consequence of this is that you take home a lot of emotional weight. A patient places their trust in their GP, and if you make a wrong call it can be disastrous. There is always the fear whether you’ve diagnosed the right thing, or prescribed the right medicine, but you have to learn to trust your instincts and safety net.
The patients I particularly worry about are the ones with the unknown diagnosis that you just aren’t sure about, but know there is something wrong. Talking with colleagues is a great way of helping calm anxieties and getting suggestions as to what to do next. Exploring alternatives and finding individual solutions is part of being a GP, as is helping patients through difficult periods.
Palliative care, where you make sure that a patient will die comfortably in a way that they want, is very rewarding, but still incredibly difficult to do. The patients often write you nice letters and come back; more often than not, they are the ones you wouldn’t expect to. You hear of other stories such as being given freshly caught fish: patients never stop surprising you.
Career prospects
Once you have qualified as a GP you have a huge number of opportunities. You can follow the traditional route and become a partner in a practice, or you can become salaried, which means that you don’t have as many business responsibilities. Increasingly, people are opting for “portfolio” careers where they divide their time between clinical and other interests, such as medical politics and teaching.
Another consideration is what sort of practice you want to work in; whether it is in a city, semi-rural, rural or remote. I worked for six months at a city practice, but I’m now completing my GP training in a rural practice. I have enjoyed both immensely, but there are definite differences in working patterns and patient expectation. I would advise every trainee to try and experience a variety of practices prior to choosing which suits them.
The future
The future of general practice is constantly changing, especially with regards to private practice and GP-led health centres. It is hard to identify exactly what it will look like.
BOX 1: The skills you'll need...
Personality: Good communicator, adaptable, committed, good at listening, driven in every specialty, well-rounded.
Best bit: Seeing success of prolonged therapy/contact, exciting, rewarding.
Worst bits: Dealing with uncertainty, constant paperwork, the complexity.
Hurdles: Perceived lack of partnership opportunities, getting enough training.
Stress: Moderate.
Salary: Trainee similar to hospital trainee. Salaried GPs earn between £53,249 to £80,354. Partners’ pay varies (more information about partners' pay).
Competition: Competitive.
Useful information
Dr Katie MacLaren is a GP trainee in Scotland.