Welcome to My working day. I’m a GP working in the United Kingdom. I have 10 minutes to call a patient to my consultation room, gather information, examine the patient, diagnose, explain, create a management plan, prescribe and type up my notes. I like every other GP would love to offer an appointment on the same day to everybody (both urgent and more routine medical problems). I have decided to give an account of my typical day which will hopefully go some way towards explaining why we cannot do this and have to prioritise those with pressing medical needs and see them first. This means that those with more routine matters are required to wait for another day. I hope that along the way it will also dispel some myths about GPs and our working day. Every GP works slightly differently in how they manage their workload but all are equally busy.
“Medicine is a science of uncertainty and an art of probability”.
That is a quote from William Osler a physician in the Nineteenth Century and this sums up the daily work of a GP quite nicely.
I’m in work at 0730. I catch up on some paperwork before starting at 0800. I’m the on-call doctor for the surgery today. This means it is my responsibility to deal with all emergencies and urgent requests today. I have to triage and prioritise all telephone calls and urgent appointment requests. I also have to see all of the unwell patients if there are no appointments left. “I have 10 mins to ask, examine, diagnose and treat”Even before my computer has had a chance to start up there are 10 patients waiting to be called back. The receptionist takes calls and for those who are unwell and requesting an urgent appointment or a home visit (or have a question) a call back is requested from me. The call list is rising by the minute 11, 12, 13…. I can make upwards of 150 telephone calls in the day. When you count the number of telephone consultations during the day and use a crude measurement to divide the time I have by the number of consultations that’s 4 minutes per patient working non-stop! That’s even before accounting for paperwork, referring patients to hospital, speaking to hospital colleagues, home visits. It can be soul-destroying looking at the telephone list and seeing it build up. I am never able to keep up despite how quickly I work.
Quickly scanning some of the call backs – An elderly gentleman is requesting a house visit because he is breathless, a middle aged woman has a severe headache, a young lady thinks she is having a miscarriage, a young man is feeling depressed and someone is asking for a sick note for work. By 0830 most of the ‘on the day appointment slots’ reserved for emergencies have already been used. Once these emergency slots with my colleagues are full it is completely up to me to both call and see all patients requiring same day appointments. I worry how I will see all the unwell patients today. As the day goes on the list of telephone calls rises as does the request for house visits (someone concerned about the mobility of their mother, a wife worried her husband is dizzy and falling, an elderly lady with vomiting and abdominal pain). Some patients, especially children, I know that 9/10 times with that fever and cold type symptoms that they will be okay. However I can’t get an accurate picture of how unwell the child is over the phone so I end up giving them an appointment and seeing them.
One of the district nurses calls me to ask about the syringe driver for a patient with cancer that they are dealing with. They too are on the front line in people’s homes and have a very difficult job especially with the resources available to them. I receive a call from a pharmacist querying a prescription. The pharmacy seems to call on a daily basis asking for me to prescribe alternatives for medications that are having a manufacturing problem.
Then suddenly I’m told there is someone at the reception desk who has arrived stating he has chest pain. I try to see him as quickly as possible in case he is having a heart attack. After seeing and examining him I feel that he may be having a heart attack. I contact the hospital and arrange for an ambulance for him to be urgently assessed in hospital. I don’t have immediate access to ECGs, blood tests, x-rays and continual monitoring for acutely unwell patients.
Throughout my day I have to go through hospital letters the GP surgery has received about patients, and alter management accordingly. I also have to read the GP Out-of-Hours notes for patients who were seen by their service overnight. This can amount to more than 50 documents I have to read carefully and action. Most days I struggle to do this (and have to put it last on my list) simply because of all the other urgent work during the day.
I leave to do house visits early afternoon knowing that there will be another 20 or so phone calls building up on my return. I can’t find the house and it’s only a 5 minute delay but it stresses me out as that is 5 minutes less to deal with patients during my day. On my return from a house visit the family of a cancer patient who died left me a thank-you note for the care he had received. It puts a smile on my face and keeps me going through the afternoon. I briefly forget the cynicism and anti-GP sentiment flowing around in newspapers and society.
Its 1500 and I’ve had no lunch or water so far in the day. Unfortunately I remember I have no food with me today. Oh well it will need to be another day with no lunch but at least I’ve saved 4 minutes that it would have taken me to eat a sandwich. “It’s 15.00 and i’ve had no food or water. The calls keep coming”I can call one extra patient in this time. I do manage to get lunch most days. With a dictation machine in one hand – sandwich in another, or going through blood results, or reading the latest developments in, for example, kidney disease.
The calls keep coming. It feels like everyone wants some of my limited time today. A relative calls about his wife who sounds like she is having a stroke. She is refusing an urgent assessment in hospital because she wants me to visit her at home first. Someone calls late in the day to ask for a home visit for their mother who is unwell. I decide to do this on the way home as I have too many other urgent tasks requiring my attention just now so schedule it for then. Mr Jones with metastatic lung cancer is in severe pain with breathing problems, the practice nurse has asked a patient to call the on call doctor because his Blood Pressure has been very high, Mrs Smith wants a sick line today and her employer can’t wait, Mrs Brown is in my consultation but needs to provide a urine sample as part of the diagnosis. It’s been 10 minutes and she still hasn’t returned. Mr Taylor missed his recent hospital clinic appointment and is asking to be re-referred. The practice nurse is requesting antibiotics for a foot infection for a patient she has just seen. The list goes on.
I need to assess a leg wound in a young man but need to remove the dressing first. There is no-one in the treatment room this late in the day so I have to muddle on and try to redress it the best I can. There is a patient calling who forgot to order his medications on time and is now requesting an urgent prescription.
My printer is out of prescription paper and it really annoys me that it is precious time I could be using to see another patient. I have a mild headache and severe heartburn. Can I take a minute to catch my breath? No. There is another telephone call to make, another patient to see, another blood result to look at, another prescription to sign.
I feel I’m firefighting with the resources I have. I’m adding people in at the end of my surgeries later in the week for people who don’t need seen today but refuse to wait for a routine appointment. So we reach a compromise and I slot them in for an appointment later in the week. However this just puts even more pressure for the on call doctor that day.
Am I perfect? No. But I do what I can within the constraints of the system and resources. But what can I do? I feel for my patients and that I am not able to provide a perfect service. But I am struggling and I can’t see light at the end of the tunnel. So next time you look at the newspapers and think your GP does nothing. Cut them some slack. Or if you see your GP is on-call for the day, understand why he/she does not have a little more time during the consultation or to discuss more routine matters at this appointment.
It would be great if patients were aware of everything we are trying to juggle on a daily basis. But this is not convenient for the government to convey. We don’t blame patients but if they saw everything we have to deal with it would be clearer to them where the problems in the system lay. When you call about something that could wait although it may only feel like 10 minutes of my time to you, lots of these 10 minutes add up to make hours and days. I try to be compassionate but time is not compassions friend.
During my working day, other than patients, I routinely receive calls from solicitors, social workers, practice nurses, colleagues in hospital, social work, district nurses, care homes, nursing homes, health visitors, midwives, and pharmacists. I have to attend meetings for child protection, palliative care and significant events (where we learn from near-misses or mistakes). All the while I have all the administration that goes along with running a business. I also have to keep my medical knowledge up to date.
So it’s not all just about sitting behind a desk. And just because there may be no patients sitting in front of me that doesn’t mean I’m not working or we are closed.
Could we open longer in the evenings? Could we be open at weekends? Say I saw an extra 2 hours of patients’ every evening. That will generate at least an extra hour’s additional administration work. That’s 3 hours extra. So you want me to work 14 hours every day and every weekend for the rest of my life? No Thanks.
I understand patients concerns regarding appointment times and access to see a GP. However I don’t even get 5 minutes in the day to think about it. I’m working flat out. Do I feel sorry for the 76 year old who lives alone and is in severe pain and I have just had to tell her she has lung cancer? Do I feel for the fact that from a humanity point of view I should be able to spend 30 minutes discussing her concerns and expectations for the future? Yes I do. I feel bad for only being able to take 15 minutes to talk to her. I don’t get a chance to think about it during the rest of the day. “It’s not all sitting behind a desk. I make phone calls, see patients, do house visits”However in the evening I think about her diagnosis, her living alone, the tear in her eye when she heard the news – the fear. I wish I had more time. The lady who has just become pregnant for the first time after trying for years and now bleeding? The man who I had been seeing over the last few months who’s blood results I got late in the day and rather than calling him I went to his house on the way home to arrange for him to go to hospital and explain why. He shook my hand with genuine warmth and I really appreciated this. He looked so well. I never saw him again. He died in hospital 4 weeks later. The immobile elderly man who needed antibiotics, it was 17.30 and no way he could get them. The wife was vulnerable and could not get to the pharmacy. I went with the prescription to the pharmacy and delivered the medications to them on the way home. If you are nice to me it is more likely I will be nice back. Its human nature.
I wish I could offer more, but I’m just human like everyone else. I have thoughts, emotions, and feelings. You quite rightly are only worried about your own health when you call me. But I have to look after the needs of 10, 000 people and prioritise. But I don’t blame patients for this and neither do most GPs.
Should people wait 2 weeks, 1 week, or even 2 days for an appointment to be seen by their GP? No. I feel they shouldn’t even have to wait a day in an ideal world with unlimited resources. Unfortunately everything in life has an opportunity cost and we can only work with the resources we are given.
I have 10 minutes to call a patient to my consultation room, gather information, examine the patient, diagnose, explain, create a management plan, prescribe and type up my notes. I would like longer appointment times with my patients but that would mean less patients seen in the day.
The patient who I have asked to return and wish to refresh my knowledge about his/her condition. I will take a mental note of this and remember to read up on this before the next visit. When do I do this? Weekends and evenings. Do I sometimes feel lost? Yes. We are doctors and generalists but I can’t know everything about everything. It’s always the non-critical things questions that can catch us out. Questions that have no answer and that medical school or on the job learning hasn’t prepared us for. Such as “Why do I shiver for a few seconds every day at the same time?” or “Why have my dreams changed recently?” However I always remember to find out as much information as I can in case another patient attends with the same or the same patient returns for follow up.
Its 18.15 and I still haven’t called back the patient who called in the morning about her routine fertility blood test results. Should I have called her earlier? Yes. But I had to prioritise all my other tasks. I call her back. Thankfully she isn’t annoyed that I called her back so late.
If I haven’t managed to call you back or see you it’s not because I’m sitting on my computer playing solitaire or internet shopping. I may be calling someone else, seeing someone else, arranging emergency admission to hospital, giving bad news to a patient, actioning abnormal blood results, discussing a patients with my colleagues in secondary care.
Its 18.45 and I realise I’m delaying the cleaners again. So I decide to leave and come in early tomorrow.
There is a sense of relief with bag in hand on leaving the doors to the practice. Glad I got through another day.
On the car journey on the way home I am either content that things have gone well in my working day or annoyed mainly at myself (if a patient has been angry, upset, or if I have a feeling that maybe I could have managed the situation better)
On a weekly basis I see a range of emotions from happiness, sadness, self-doubt, feeling low, anger, aggression, amazement, indifference, fear, loneliness. I am the first port of call for many of my patients even for non-medical issues. I go through similar emotions though I have to try and hide them. I’m supposed to be professional. Don’t forget though I’m human too. I try to do my part. I could do better but I’m trying as hard as I can. I’m no magician. I have an understanding of health based on current evidence. This changes over time with new evidence and advancements. The emotions don’t.
Which brings us back nicely to William Osler and the work of a GP:
“Medicine is a science of uncertainty and an art of probability”.
This is my day as a GP. Welcome to the world of GP – and tomorrow will be no different. In fact it seems that currently things are getting busier every week.
Thank-you for taking the time to read about my day.
Please note all names used in this article are not the real names of anyone involved.
By TheGPDoctor (thegpdoc.com)