My first appointment is at 8.30. Our daily meeting is also at 8.30, despite my protestations at the obvious scheduling conflict. There is no room in which to hold it, so we gather in the waiting room. One of the partners begins the meeting by running through staff absences: one doctor is off with stress, another must look after their child, who has Covid. There is a massive backlog of patients waiting to be seen, despite the fact the practice is offering a record number of face-to-face and telephone appointments. It can’t keep up with demand. The days are long and frequently tough; a colleague cracks a quick joke to lighten the mood. The patients already waiting watch us laughing and glance pointedly at the clock.
I hurry to my consulting room and briefly go over my schedule for the day — one morning clinic from 8.30 to 12, an afternoon telephone clinic from 2 to 5, and an hour for admin from 1 to 2. I have two scheduled coffee breaks as well, which I won’t use for coffee: I always try to schedule them after my trickier patients, so that when they inevitably overrun, it is not into another patient’s time. I am a trainee doctor, having qualified from medical school two years ago, so my appointments are 15 minutes long rather than 10 minutes, and I have time at the end of my day to debrief with a supervisor.
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At 8.45, I go to the waiting room to call my first patient, Mrs Smith. She is hard of hearing and I don’t know what she looks like, so it takes a minute for her to acknowledge me. It takes a further two minutes for her to walk to the consultation room, because her ankles are swollen and she walks with a stick. By the time she has managed to sit down in the chair and remove her coat, nearly half of the appointment time has gone.
Mrs Smith starts to talk about the weather. I interrupt and remind her we need to keep on topic. As a medical student, I watched qualified doctors talk over patients in this way and thought naively that I would never be so rude. But it only took a few weeks of working in General Practice to realise that being brusque and firm is essential, unless you have hour-long appointment slots. Mrs Smith looks crushed. I suddenly remember that she recently had an appointment with my colleague following a bereavement, and that I am perhaps the only person she will speak to today. I constantly feel pulled in two different directions — forced to choose between doing the best for the patient in front of me, and doing the best for the patients waiting for me.
She eventually tells me that she has come to see me about breathlessness. When I hear that word, a list of potential diagnoses pops into my head: infection, lung disease, fluid overload, cancer, or perhaps a more niche disorder I’ve only seen in a medical school textbook. To determine which seemed more likely would require me, at the very least, to take a 20-minute “history”, but if I want to examine her, that would leave us with around three minutes, not including the time required to write out any prescriptions and refer Mrs Smith, if necessary.
Mrs Smith seems slightly annoyed when I ask about her medical history: “Isn’t it in my notes?” She’s right — it probably is somewhere in her electronic record, but I haven’t had a chance to click through its entirety, and long gone are the days when GPs know each individual patient. On average, there is one qualified GP for every 2087 patients.
This ratio is worsening year on year, partly because the population is increasing, but also because the pool of full-time GPs is shrinking. It’s not surprising. In the UK, the average full-time employee works 35.7 hours a week; 48 is the statutory maximum. General Practice is often seen, even among doctors, as the ‘easy’ way to practice medicine: the equivalent of a 9 to 5. But full-time GPs work 48 hours a week, while “part-time” GPs work 35, not including the unpaid hours when clinics overrun, or the time spent on admin at home.
No amount of time ever seems to be enough, though. I was reluctant, for instance, to examine Mrs Smith on the bed, rather than letting her remain in the chair, because I knew it would take at least five minutes to get her on and off it. But my conscience got the better of me. As I assisted her onto the trolley, I mentally readied myself for complaints about waiting times later in the day. I can deal with angry patients; Mrs Smith’s health cannot deal with a misdiagnosis.
Mrs Smith’s breathlessness, I decide, is most likely related to her heart failure, and that the best course of action would be to increase her diuretic dose to try and get some of the fluid off her lungs. But Mrs Smith has chronic kidney disease — which is common in the elderly — and increasing the diuretic dose might exacerbate it; I want to schedule her a blood test for the next week, to check. She takes out her diary, which I cross check with the phlebotomist’s diary — which feels like a bad use of my time. I find myself becoming frustrated.
As I begin teeing Mrs Smith up to leave, she bursts into tears and says it’s just so hard without her husband. Perhaps, I think guiltily, the breathlessness was just an excuse to talk about her bereavement. But I have seen one patient and I am already running 30 minutes late: I cannot comfort her now but offer a follow-up appointment to talk about how she’s coping generally. I have a free slot in 2 weeks. At the end of this consultation, I don’t feel like a good doctor; I feel like I rushed a grieving old lady with complex health issues. I tell myself to think about it later, when I have time.
By the time Mrs Smith leaves the room, my next three patients are already waiting, but I need to wipe down the chairs, bed and door handle: Covid is still with us after all. My next patient is Luke, a young man I have been seeing regularly due to his deteriorating mental health. He is unemployed, in serious debt and has recently split up with his girlfriend and moved in with his alcoholic father. We are both aware that his low mood and anxiety are mainly down to these circumstances — but I cannot fix them, so I have prescribed him an antidepressant and referred him for counselling.
Today, Luke is agitated. He tells me he is having serious thoughts about driving his car off a bridge. I screen for protective factors — a support network, a hobby, any hope for the future — but find none. Luke accepts my concern and agrees to be referred to the mental health crisis team. The person who answers my call is a trainee and wants to discuss the case with her boss. I am aware that the mental health team is as stretched as we are, but I can’t help but feel frustrated: it takes thirty minutes for her to call back. During this time, I do not feel comfortable asking Luke to leave my room, so we make awkward conversation as my patient list builds up.
When the phone eventually does ring, I speak to a mental health nurse who insists that, because Luke has had previous suicidal ideation that he has not acted on, his latest symptoms don’t constitute an acute change. Luke does not need to be reviewed by their team, she tells me. I need to take responsibility for discharging him. I don’t feel comfortable doing this, so we go back and forth until she eventually agrees to contact Luke later that afternoon. As Luke grunts a thank you and leaves the room with his head down, I am not sure that I have helped him at all.
There is no time to dwell, however: I need to write a detailed entry in Luke’s notes. In theory I am doing this to provide an accurate history of his condition to help him get the best treatment possible from subsequent professionals. In reality, I am doing it to protect myself in court should harm come to him.
Fortunately, the rest of the morning’s cases are simpler: a child with a urine infection, a man with a fungal rash, a woman who wants a repeat prescription of her contraceptive pill. I rush through them, grateful both that I have a chance to catch up and that, if the patients are angry about their wait, they do not show it.
I finish my morning surgery at 1.15, over an hour late. As usual, I will have to eat as I go through my admin. Patients often wonder what I do when I am not actively seeing them. They don’t realise that I have to sign every repeat prescription request, even if the patient has been on the medication for years. I can do this well, or I can do it badly.
If I do it well, I will read through their entire list of repeat medications, making sure that another doctor hasn’t started them on any drugs that might inadvertently interact with the ones they’re already taking. I will check that they haven’t been on a medication for years that should have been stopped after a certain period of time. I will see if any checks are overdue. If any of those things are the case, I need to ‘action’ them — by sending a letter to the patient to ask them to come in for a check-up, or by writing to their specialist consultant about changing their medication.
If I did it badly, I would just sign.
Next on my admin to-do list is to read through letters sent from secondary care. Today, I note that Mrs Jones, who I referred a few weeks ago with a breast lump, has been diagnosed with cancer. I call her to schedule an appointment to talk through everything. Finally, I catch up with my admin from the morning clinic that I didn’t have time to do during the appointment — like sending Mrs Smith’s referral.
The afternoon clinic is a telephone surgery, for which I am grateful. It means that patients won’t be getting agitated in the waiting room if I have another Luke or Mrs Smith, but can instead get on with their days as they wait for my call. I can also choose the order in which I call patients: I scan the afternoon’s list, scheduling simple prescriptions for acne and leaving a young woman with a recurrent sore throat until later in the day. I know that she is becoming fed up with the GP management of her condition and that the phone call is likely to be a difficult one.
Because it’s easier to read the guidelines for a condition during telephone surgery, by the time I phone her I am able to apologetically inform her that she does not meet the referral criteria for a tonsillectomy. The patient is angry. Her affliction is interfering with her job and private life; I know she cannot understand why the people who are meant to help her will not. I understand, but I am also affronted. It would be much easier if I could pass her on to the hospital, instead of prescribing another packet of throat lozenges, but I know that the referral will be instantly rejected. Of course, this is as much to do with the risks of surgery as the pressures on secondary care, but the patient does not care about that. As her anger dies down and she says goodbye, I find myself hoping she will eventually get fed up of calling. I admonish myself and decide to refer the patient anyway. At least then I can tell her I tried my best.
My final phone call of the day is with a patient who has some sort of pain somewhere, but it’s hard to work out where because there is a significant language barrier. I get put on to someone — a nephew, I think — who tries to explain, in slightly less broken English. In the end, I make the patient a face-to-face out-of-hours appointment with a colleague, and add a warning in her notes that it is not suitable to offer her a telephone appointment in the future.
Before I leave, I have a debrief with one of the GP partners. I hover outside his door, listening for a gap between his phone patients. When I eventually enter, he has his head in his hands, but quickly springs to attention when he sees me — he is keen to train more doctors after all, and tries his best to shield me from the pressures, and focus on the positive aspects of a job he once loved.
But I know that he has stayed late each night this week and that in his spare time he obsesses over the — increasingly negative — Google reviews of the practice. I don’t want to take up his time, but if something goes wrong with one of my patients after I had chosen not to discuss their case with a senior, I could end up in hot water legally. So I rattle through my day while he nods and occasionally interjects with suggestions.
Once I get home, I try to relax, but thoughts continually flash into my head: didn’t you rush those “easy” patients a bit? Are you sure the diagnoses weren’t actually urosepsis and a malignant rash? If harm comes to them, they will blame me, and I will blame myself.
My phone buzzes with messages from colleagues from my previous rotation, a surgical job. They joke that I am living the dream, working 9 to 5 — that I spend most of my time sitting down and refer any real problems onto the hospital. I turn off my phone and head to bed. I have decided not to apply for GP training.