My First Exposure to General Practice.
Introduction
I had to explore how a general practice ran as a primary health care and its management to the doctors and the delivering of care. I had to talk about how the doctors went about their days, their communication, their body language, the pharmaceutical care plan that was chosen and how to have a successful consultation. A successful consultation is challenging and it is highly rewarding as it increases patient adherence, improves prognosis and builds trust between patients and their doctors.
Part 1 – The general practice setting
How it looked and how it worked
The clinic contained both appointment style where patients could phone to make a booking or patients could walk-in and see if there was an available slot with the doctors. It was very well organized as the doctors could see updated schedules on their computer with a description of the patient. They could see their files and see their history if they have been here before. The patient demographic ranged from; young age such as children to geriatric patients, all ethnicity was included, man and women, all education level and occupation and all income level. The main demographics were middle-aged and older patients with type 2 diabetes mellitus. Clinical problems ranged from acute conditions such as giving an injection, stitching up a wound and acute constipation to chronic conditions where patients had depression, hypertension, diabetes type 1 and 2, erection problems and drug addiction.
So who's there and what they offered?
The clinic contained at least three doctors, one nurse and once a week there is one dietician, one psychologist specialised in diabetes and one podiatrist. The provision of treatment on-site were wound dressings, sutures, investigation and follow up on anomalies, blood pressure check-ups, blood sugar check-ups with a glucometers, immunisation update chart, eyes check-ups for the diabetic patients by using photography, history follow up on the current and past disease and a pharmaceutical care plan that is greatly emphasised for diabetic patients. Provision of medicines included samples, scripts for repeats or new ones and there is a supply from the stock cabinet or fridge for the vaccines. Both primary and secondary prevention were included such as immunization for flu vaccines to screening blood sugar and seeing if it is normal or staying in the normal range without causing further damages. There were posters and how to recognize diabetes and a poster illustrating “the wheel of diabetes” depicting different stages of diabetes and there were also immunization programs.
Part 2 – Role of the GP
At the clinic, my expectations of the doctors were definitely met and the way they worked was higher in the quality of medical practice. The quality of communication, knowledge of pathologies and medications and patient-centeredness was outstanding.
The subject material covered that was present at the clinic was endocrinology with patients arriving with diabetes mellitus both type 1 and type 2. This was very interesting as I had a profound knowledge of the pathology and its complications that arise such as neuropathy, retinopathy, foot damage and even the socio-economic determinants that have a huge impact on the patient. Relating more to Ecology of Health 1 there was a vaccine health chart where it indicated when the patient had to take their vaccines which also indicated how these vaccination policies are set to cover and protect the health of future patients. These policies were mentioned during EH1 on how they came about and implemented so it is interesting to see policies being set up.
What did I focus on?
Communication and the position of doctor was one of the aspects I focused on such as noticing the tone of voice that was used, the posture, the distance between the doctor and the patient was comfortable, the amount of touch, the hand gestures and how the doctor went on to find out everything about his patients. All of these were done in such a way to maximize patient’s comfort and get the best out of the consultation. The practice gave away samples and I asked about how it impacted the doctor’s behaviour about giving away samples given from the pharmaceutical companies. The doctor described that they try as much not to be influenced when prescribing these products and when they did give samples, it seemed very justifiable. I also noticed the bulk billing on some patients and understood the importance of it as after the consultation I could get a better understanding that some patient cannot afford the life-saving medications.
Part 3 – Communication techniques
The consultation started by a welcoming greeting already making the patient feel comfortable as the whole purpose is to establish a purposeful relationship with the patient. Instilling warmth and making the patient confident is significant for a stronger patient-centeredness relation. This will improve the willingness of patients to tell their agenda. The factors to make a patient comfortable were: the GP posture was upright but relaxed, a calm tone of voice was used for patients that needed a calmer tone as it was different to the patients he knew very well, the space between them was good and the direction which was about 45 degrees so that it did not feel like an interview. All of these made the patient feel very comfortable. Thus, information gathering, history taking, exploring fears and the examination was smooth and enjoyable. The goal was to find out the concern, instilling a plan of management and sharing thoughts and information. In all cases, this was achieved.
The information-sharing process within the consultation was talking about the patient issues, listening to those issues and reassuring the listeners by nodding or agreeing, to raising any concerns they may have. Then seeking the information and sharing views such as finding the right pathology and using SOCRATES to find out exactly what is going on with the patient. Most of the time the patient themselves would say what they thought it was and the doctor always listen attentively as listening to their concerns could give the doctors more clues - it is their body after all.
Trust, flexibility and satisfaction
The management of decision went impeccable and I was really impressed by how the doctors went on about it. The doctors explained fully the disease they thought it was and demonstrated the best outcome with a medication plan but not just one but with several medication plans which could suit the patient best. The patient can choose but generally put a lot of trust within the doctors and went on with their first medication plan of treatment. After demonstrating the medication plan including dosage route, adverse effects and indication the doctors always presented the patient with a scheduling plan that suited them best as to see them again and do follow-ups to see if everything is going fine. Giving all this freedom and decisions really impacts the patient in terms of trust, flexibility, their satisfaction with the consultation and their confidence in their relationship.
What surprised me about consultations is that there is a lot of calculating guessing and unknown. Many pathologies cross each other in terms of symptoms and most of the time it is really difficult to pinpoint the right cause. The doctors generally gave their best diagnosis but sometimes they also stipulated it could be something else and that they need to be checked up again. That was very interesting as medicine is like detective work and that small details can be immensely impactful if not picked up. I learned that communication is an ongoing skill and that it affected immensely on the outcome of the consultation and definitely plays a role in prognosis and adherence to medication. I noticed that each consultation is tailored to all the factors the patient have in terms of flexibility and their socio-economical status.
Part 4 – The physical environment
The practice is laid out as an open plan where it feels comfortable and not crowded as some practice may feel like it. There is the secretary desk with information about billing and scheduling, the desk is not too high and the counter not too separating as to create barriers. The waiting area is open and big with couches and chairs and toys for the kids, a big TV lies on the wall for patients to relax before being consulted. The consultation rooms are private as well as the treatment room. The toilets are discreet and there is lots of space to do urine sampling or changing infants. The computers and record keeping are in the consultation room, the schedule gets updated from the secretary’s desk. The record-keeping is very useful as it has all previous history typed out with future schedules and important notes. The clinical equipment and emergency equipment are in the treatment room that can be easily be accessed by any health care professional but not too easy for the patients to reach. The break room is out of sight to give privacy. Overall the practice is comfortable and private and emergency situations can be done swiftly.
The clinic is designed that it has a large parking space and contains reserved parking for those who need it. There are no stairs so that people in wheelchairs can access it as I have seen patients with amputated limbs due to diabetes mellitus. I find that there is plenty of room inside the practice to move about and a playing area for children that contains an iPad. No options were available for man and woman toilet, but the toilet is large and spacious for people in wheelchairs or if children need to be changed or urine samples to be taken.
Overall
Overall, I had a very fulfilling and enjoyable time. I had the pleasure to experience and work where I could with the health professionals at the clinic. I was able to take a history, blood pressure and follow up questions during consultations. I assisted where I could and learned as much as I could. This was a wonderful experience and exposed me more to general medicine and how the health care system works in Australia.
Published 10th September 2018. Last reviewed 30th December 2021.
