During my 5 years at medical school I spent 4 weeks in general practice
We had a general practice attachment in the penultimate year of medical school. There was some classroom teaching to prepare us, which I don’t remember much about. Then there were two weeks in a practice in London and two somewhere else in the country, which involved staying with a GP and family. The time devoted to general practice (primary care) in the curriculum was short (4-8 weeks in the 3 years of clinical rotations) compared to hospital-based practice (secondary care) even though the majority of people in most jurisdictions received and continue to receive most of their health care in the community. General practice teaching in the 1970s was not prioritised. Departments of General Practice in universities were still rare though the number had grown from one in 1965 to eleven by 1972,[i] and there was one at UCL when I was at medical school.
By this point I think I had been to consult with a GP no more than about 10 times in my life. And even though I had had nearly two years of learning in different hospitals, I had no great understanding of how the NHS worked. Patients moved in and out of secondary care (hospitals) and were registered in the community with one GP. But how this happened wasn’t clear. At least with the NHS (free at the point of care delivery) we didn’t consider costs – to patients or indeed to the taxpayer. I don’t think we had any lectures about expense. I didn’t realise until a lot later that GPs were technically self-employed in the NHS, whereas hospital doctors were salaried (and there was some private practice but very little that was seen by students).
The London practice was quite close to the medical school and had some famous media doctors working there. I had no way of knowing whether it was a typical general practice, or even if such a thing existed. At that time GPs were moving into health centres and group practices but there were still some single-handed doctors around. The student’s role in the practice was mainly to sit in with whichever GP was available and willing and observe consultations. On my first day I was asked to take a patient’s blood pressure with the fairly frightening GP watching. I did so and then he said something along the lines of – they never teach medical students to take blood pressures properly at medical school. It appeared that I was doing it too quickly and therefore wasn’t accurate enough. The patient had to put up with me repeating the reading a few times until I let the mercury slide down the tube slow enough (there were only the old type of mercury sphygnomanometers available). Blood pressures are frequently written with the figures rounded off to the nearest 0 or 5 (for example 120/80; 145/95) but the GP wanted the number not to be rounded off – so 142/84 or 118/62… It wasn’t that obvious what difference this made at the time – now of course we use electronic sphygs that are much more accurate. And take a lot more readings before diagnosing that someone has hypertension (raised blood pressure).
Sitting in on many GP consultations I noticed that the interactions between the patient and the doctor were quite different to those I was used to in hospital. They were shorter (at this time I think GP consultations in England would be booked to last about 7- 10 minutes) and GPs had no time to take a long medical student-type 40-minute comprehensive history – there were shortcuts and quick decision making. I did realise that this was partly due to many patients being well-known to the doctor. For me, it was like listening to a story from the middle; for the GP more similar to picking up a book put down a few weeks ago. I didn’t have a framework with which to analyse what was and wasn’t being said. If a diagnosis were made (and this was rare – it didn’t seem to be the main task of the consultation), it was quick and then a prescription was issued, or advice given. What was happening? There were some similarities to out-patient clinics but those were segregated into specialties and patients came with a referral letter outlining some of the history. The description I heard used later was that GP consultations are undifferentiated. A GP is a generalist, as implied by the title ‘general practitioner’. The person is not labelled as surgical or neurological or with a heart problem before they enter the room. The variety of problems was vast. And often there appeared to be no ‘presenting complaint’ at all – the GP seemed to know what the patient wanted.
My ‘away’ practice was in Devon, and I was asked to see patients prior to the GP consultation if a patient agreed, and there was time. I still felt the need to go through the whole history, but patients didn’t always seem comfortable spending half an hour doing this. General practice was more about a focussed history on the backdrop of a knowledge of the patient, and was short even if the patient was ‘new’ and unknown to the GP. There seemed less need to do tests if there was no diagnosis – ‘wait and see’ was a management plan for many patients. ‘Wait and see’ was a difficult strategy when someone was lying in a hospital bed – things had to be done to justify the bed occupancy. ‘Wait and see’ was also difficult for me as a student as I wouldn’t be waiting around to see what happened to the person with diarrhoea or headaches (which to me needed investigation in case of all sorts of serious pathologies, but which the GP seemed to be less concerned about).
In Devon I first experienced home visits – people who were too ill or disabled to attend the surgery. Home visits were an important part of a GP’s day and, in a country practice where there was no easy access to an A&E department and homes were scattered over a wide area, took up several hours each day between morning and evening clinics. The GP I was with emphasised the need to observe the home conditions as these gave insight into the patient’s life that histories only touched on. Some patients obviously tidied up for the doctor’s visit and put the kettle on when they say the car approaching. Others lived more chaotic lives with pets and pills scattered about, and where it was difficult to know where to sit safely to avoid contamination: sticky floors and seats, cats climbing into the doctor’s bag… Interactions in the home were even more difficult to understand as a novice and patients more difficult to examine. I saw a few people with home oxygen cylinders and overflowing ash trays, seemingly oblivious to the danger of setting fire to themselves and their houses.
In most general practice consultations, the patient-doctor relationship appeared strong and both parties seemed satisfied with outcomes as far as I could tell. In a morning clinic the GP might see a small child with a fever, a teenager with acne, a couple wanting to get pregnant, a woman not wanting to get pregnant, an old farmer with a sore leg and a worry about his sheep, a new mum with depression and an old lady with heart failure. It was hard to keep up.
I absorbed some of the ethos of general practice during the two weeks but, still being rather shy, I found living with the family difficult. One of the GP partners remarked that considering I was interested in becoming a GP, I didn’t ask a lot of questions. True – but I observed and took mental notes. Primary care had a breadth of conditions whereas specialties were concerned with a few in depth. I wondered how could you ever know enough about all of human life and how it could go wrong?
[i] Patrick Sarsfield Byrne, ‘University Departments of General Practice and the Undergraduate Teaching of General Practice in the United Kingdom in 1972’, The Journal of the Royal College of General Practitioners, 23, suppl. 1 (1973), 1–12.