Day in the life of a General Practitioner

The saying ‘no two days are the same’ could not apply more to general practice, in fact no two half days are the same!

I work as a GP partner in a suburban practice with 15,000 patients 2 days a week. We split each day in half, so 2 sessions a day. For me, these sessions will vary between:

• clinic - where patients have rung and booked an appointment in advance or on the day, some of these include baby checks where we review all newborn babies at the practice at around 8 weeks of age!
• an on-call session – where all appointments are emergency only and can not wait to the next available appointment.
• teaching session – delivering undergraduate clinical training to medical students
• mentoring session – delivering one to one training with one of our GP trainees.

The practice is open from 8am and closes at 6.30pm. Between these times, the multidisciplinary team and I will work clinical sessions with appointments booked from 8.30am to 12.00pm and from 2.30pm to 5.10pm.

Whilst the appointments are booked for 10 minutes the content of them is unpredictable, a lot of the patients I see will be concerned about a potential diagnosis of cancer. Patients will have been made aware of a sign to look out for and are now worried that they themselves have an undiagnosed cancer.

There are always waves of public worry after difficult high profile cancer diagnoses, where we will see many patients worried about the same cancer.

In terms of assessing the patient the traditional thorough history and examination can help us reassure the patient in a lot of cases. Where more information is needed, I have a number of possible next steps:

• Admission – for someone who is very unwell. For example if they have a twisted bowel or are losing a lot of blood. I will ring my hospital colleagues and send the patient straight to hospital.
• Urgent suspected cancer referral – for patients where I am worried too that it could be cancer. I will refer on agreed pathways to designated specialist hospital teams who aim to see them within a few working days or weeks.
• Rapid diagnostic clinic (RDC) - for patients who do not fit into standardised referral pathways because their symptoms are non-specific. The RDC allows rapid review by a hospital specialist with access to on the day investigations like scans.
• Investigations in the community – I can arrange bloods, heart tracings (ECGs), urine and stool testing, x-rays (including some scans) from my desk. The patient attends these appointments and we will review them back with the results to decide on the next appropriate step. The next steps could be any of the 3 above, or simple reassurance and when to worry advice.

You may also be interested in: Rapid Referral Guidelines for suspected cancer

Between 12pm and 2.30pm I may visit the homes of our most frail and poorly patients who can not get to the surgery. We have the oldest demographic of patients in Wales and a fair number are over 100!

With my trainees and colleagues, I will advocate trying to gently open conversations about advance care planning and end of life care, where possible. If we do not record these conversations and wishes when the patients are able to, we will not be able to deliver the care that they hoped for.

I have a close working relationship with our community hospice colleagues, who may well also be seeing these patients regularly. For cancer patients who no longer are on active treatment, they are grateful for the continued care from the surgery. We may have supported them at all times of their cancer journey and before. We are the only clinical speciality to support our patients from the cradle to the grave.

There will also be an electronic inbox full of results to sign off. These may contain unexpected bad news like a very high cancer marker making it highly likely this patient does have an undiagnosed cancer. So these people need contacting immediately and advised of this.

I would encourage them to come into a face-to-face appointment that day, but often they know something is wrong and would just prefer the information straight away, over the phone. It is important to offer follow up and a plan for what to expect next with these patients.

I will also have letters to read. These may be about patients who have been in hospital for a while, and we need to update their records and prescriptions. They could be about patients who have been seen in clinics and there is update about their care. There are also prescription requests which must be manually signed off and issued for patients.

Once a month I will chair a clinical meeting from 1pm to 2pm with our palliative team and our practice team. We will review our palliative care patients, all deaths, and all new cancer patients. My minutes will contain an update to the whole practice with advice and requests to my colleagues. For example, I will ask the clinician who referred the patient with a new cancer diagnosis, to make contact with them for a review.

If there is any spare time, I keep a list of patients who I have been recently involved with and may call them to touch base and see how they are doing. These are often cancer patients on active treatment who are often too unwell or too busy with other appointments to come to see me regularly. I am grateful to be able to keep in touch and to support them in their illness. However, I am always conscious that if they are not expecting the call, to check that it is at a time that is suitable to them.

We have a dedicated team of secretaries who will take calls, send referral letters and contact hospital teams on our behalf. I pop into their office when I can to offer advice and support. Sometimes they will come straight to us in an on-call session when an abnormal hospital result is rung through to them so we can arrange ongoing care for the patient.

As a clinical team we do try and meet for coffee pre afternoon surgery, but not all of us make it every time due to the volume of work. Lunch is often eaten in a hurry. Once the practice doors shut at 6.30pm the work may not always be done. We may be in the building till after 7pm sending referrals from the day or completing other tasks. We may also catch up with each other and debrief patients that each other has seen.

The job is amazingly rewarding but an enormous challenge, our team, and the camaraderie within it make the job a lot more bearable! We do look at each other’s clinical screens and step in if they are running very late and we have capacity to help.

Through the winter months this is always worse, with a very heavy burden of demand and at times we all struggle to deliver optimum care in a stretched system.

We never run late out of choice and are always conscious that people have sat and waited for us, but we will try and provide empathy and solutions to the very varied physical and mental health problems that patients bring to us. Primary care remains the first point-of-call for a lot of clinical issues and the only holder of a patient’s complete healthcare record, and we are proud to be so.

The doctor will see you now…