Some interactions really bring out those skills unique to general practitioners. Like not throwing equipment at the wall.
My 56-year-old patient with worsening lumbar back pain, sharp shooting electric pain radiating down the left leg and left sided parasthesia comes to ask for a medical certificate for a couple of weeks.
He works on his feet and was struggling with the sciatica. “Are you still seeing the physio?” I ask. No, he explains. He has already used up his five subsidised physio sessions through the GP management plan, and can’t afford to pay privately for physio, although he is still doing his back exercises at home.
I suggest a CT lumbar spine to look at the anatomy and check if there is a suitable target for a steroid injection. Unfortunately, the out-of-pocket costs for both spinal imaging and interventional treatment is not feasible for him right now.
“It’s OK,” I reassure him, “It’s clinically worsening sciatica and it’s impacting your daily life and ability to work. We can get you seen by public neurosurgery, and they should be able to organise the imaging or steroid injection for you”.
I submit the referral, and by the end of the day get a prompt rejection citing that the patient hasn’t had spinal imaging ($) or physiotherapy for over six months ($$) or trialled interventional treatment like steroid injections ($$$).
I call my patient and offer to refer him to a private neurosurgeon instead, who might be able to refer for a bulk billed MRI. “Doc, come on.” ($$$$).
I rage at the public hospitals for their ridiculous protocol-driven referral criteria and desk-rejections, rage a little at private radiology for their interventional fees, then send some frustrated texts to a neurosurgeon colleague for good measure.
My 63-year-old patient is a few months post an aortic dissection repair, and doing very well other than worsening palpitations.
“I can’t sleep at night because of the pounding in my chest, doc,” he explains worriedly, “but the cardiologist last week said she was going to send me for a test”.
All of the above is new to me. I sit my patient in the waiting room while reception calls the hospital to chase the cardiology outpatient notes. Twenty minutes later, I have very polite and respectful notes (‘unsigned but sighted and sent to avoid delays’) from his cardiologist;
“The plan today is as follows:
GP to kindly organise a Holter monitor and commence rate control such as metoprolol 25mg BD.”
I stare at the patient a short while.
“You saw the cardiologist about these palpitations?” “Yes.”
“At the public hospital?” “Yes.”
“And she wanted you do a Holter?” “Yes.”
“And she wanted you to start medication?” “Yes.”
“But she, the cardiologist, didn’t organise for you to have a Holter, being a cardiology test that she, the cardiologist, wanted, for free, at the hospital where you were already seeing her, for free? And she also didn’t give you a script for a cardiac medication that she, the cardiologist, recommended to treat your cardiac condition?” “That’s right.”
I arrange his Holter, give him a script for metoprolol, then send him to reception to pay the bill for the appointment today. I figure there’s a reasonable explanation for the cardiologist’s difficulties in arranging her own Holter, like the computer system was broken at the hospital that day, and the Holter department had sadly closed down, and the paper prescription pads had all been stolen.
A lovely 20-year-old patient who I’ve been looking after since she started high school has just been diagnosed with idiopathic intracranial hypertension. She saw the neurologist yesterday and has come to debrief the appointment.
The specialist suggested a specific medication that is unfamiliar and intimidating to this woman. In response to this, my patient has said “OK, I’ll talk to my GP and make sure she’s happy for me to take that”. This is unsurprising to those who understand the trust that comes with family medicine. This was, however, both surprising and offensive to the neurologist, who snapped back with “Well, I’m the specialist and I know more than your GP.”
Consequently, the patient tells me she doesn’t want to go back to this neurologist. I am inwardly and outwardly pleased by the strong therapeutic relationships that we grow in general practice. I am also inwardly and despite my best efforts outwardly annoyed at this specialist. I think it’s clear to all that I, the GP, am not a specialist in the brain, but I, after treating this family for years, am a specialist in this patient.
Saying “Yes, that’s a great idea to talk to your GP. I’ll send her a letter outlining what I’ve suggested, and happy for her to call me if she has any concerns” might have caught more flies than this current vinegar approach.
But, I dutifully accept my place in the medical hierarchy, and inwardly and outwardly gaze with adoration at the neurologists above.
My 38-year-old patient with advanced metastatic colorectal cancer attends for pain management. She has rapidly increasing spinal metastases and is getting quite cachectic. She has just seen her oncologist and wants to discuss a new clinical trial. Her several rounds of chemotherapy regimes have not made much meaningful difference, and she is rapidly deteriorating.
I am a little taken aback by the explanatory statement she produces about the trial. She doesn’t look like she’ll survive another month. I gently explore her understanding about the prognosis; she doesn’t realise she’s dying.
This conversation needs to happen right now, today, at this moment. My morning, obviously, is going to run an hour late, but I explain to this patient her level of disease. I explain the prognosis. I explain the goals for her care. We complete an advanced care directive for her and link her in with the palliative care unit. I reassure her that I provide palliative care through a shared model, and can continue to help until the end, should this be her wish.
It was a crap consult and I feel crap, and really wish the specialist hadn’t left this conversation to me.
“I’m really glad you’ve come into my life, Pallavi,” she says as her mother pushes the wheelchair out of my room. I have a quiet little cry alone in my room. She dies a month later.
An 8-year-old girl comes in for review of an extremely unusual looking facial rash. I’ve seen her four times in the last fortnight, tried multiple treatments that have not helped, and feeling quite stumped, sent her to a skin clinic with a referral that essentially said, ‘help me I have absolutely no idea what to do’. The child comes in today, rash completely resolved, and very happy parents. Mum gives me a letter from the dermatologist;
“Many thanks for your referral of this lovely child. I agree with your provisional diagnosis and think you have tried many reasonable management options, which unfortunately have not worked. I do see this quite often, and have suggested a fourth line treatment. I have also taken a biopsy for confirmation and will call the family early next week to follow up on the results, which I have also cc’ed to you for your own records.”
I turn the letter over, looking for the list of tasks he would like me to do (nil). I check with the family if they need to debrief or have any follow up questions after the appointment with the specialist (no). I ask if there are any specific concerns or issues that need addressing today (no), complications with the biopsy (nil), issues with specialist fees (no), bedside manner (no), or suggested treatment plan (no).
I finish the day as happy and satisfied as this family and add the specialist to our “favourites” list in the clinic address book. I have dinner with my specialist friends and tell them about the joys of general practice, and the exciting case of the Holter that the cardiologist let me organise! All! By! Myself!
Dr Pallavi Prathivadi is a Melbourne GP and an adjunct senior lecturer at Monash University, with a PhD in safe opioid prescribing. She was a Fulbright Scholar at the Stanford University School of Medicine in 2020-2021 and the 2019 RACGP National Registrar of the Year.