After the first 2020 lockdown, a duo of Auckland GPs hit the road as locums. They had sold their practice the previous year and wanted to get back into the workforce. The couple’s ideal destination, Dr N* writes, is “a town that’s big enough for a small hospital, has a few restaurants and is close to the best of the great outdoors”. Over the past three years, they have taken up the patient load all over the motu: Motueka, Rotorua and Invercargill have been some of their favourite stops. Here, Dr N writes of a recent day on the general practice frontline in another small centre.
The job of caring for people’s health is a privilege and a responsibility, but it’s also stressful and unrewarding at times. Let me share a morning from last week.
We arrive at 8am, deposit last night’s left-overs into the fridge for lunch and grab a coffee. Someone has made a carrot cake for morning tea, so it’s going to be a good day.
I make a start on the inbox letters and lab results before the patients start arriving. The first is a well-dressed woman who states she has insurance and wants three referrals. Please. She knows the names of the specialists she wants to see. A dermatologist for mild eczema, a urologist because she’s had two urinary tract infections, and a neurologist because she gets headaches. And isn’t it ridiculous, she says, that the insurance company insists she gets a GP referral.
I try offering her advice and explain that specialists are for problems that can’t be managed in primary care. She starts getting loud, so I do what I’m told and tell myself that specialist visits might relieve her anxiety, even though it will result in increased insurance premiums for everyone else.
The referrals take me 17 minutes, according to the little timer pop-up on the computer (appointments are 15 minutes) and the patient and I are irritated. Not a great start to the day.
Patient No 2 is here for a blood pressure review. He has waited three weeks for the appointment and wonders why he has to see me rather than his regular doctor (she is booked out six weeks in advance).
He ran out of his pills a week ago, so his readings are sky high and I explain he will need to take his medications regularly and come back in a few weeks. And could I look at the mole on his back … which looks suspicious and he can’t afford our excision fee. I take a photo, upload it to his notes and write a referral to the minor surgery team at the hospital. 16 minutes.
The next young woman needs a review of her mental health. She is withdrawn and unhappy. She needs gentle encouragement to talk about how she’s getting on.
We decide to increase her medicines and refer her to see a counsellor. I give her the phone number for the on-call crisis team. She also has an infected earlobe and I prescribe antibiotics.
And please could I look at her shoulder that she hurt at work last week. It’s been 27 minutes already. I explain I don’t have time for a shoulder examination and the required ACC paperwork and that she will need a separate appointment for this.
I give her a website to look at for shoulder exercises and add some anti-inflammatories and paracetamol to her prescription. 32 minutes.
Now I see an elderly woman with her worried daughter. She was discharged from hospital last week after a 10-day stay with pneumonia and heart failure. She is breathless and feverish and I think she needs to be readmitted. I phone the hospital, get put on hold, wait for three minutes, get cut off and phone again. The registrar is not answering, so I write a letter and send her to the emergency department. 25 minutes.
The nurse pops in and asks if I could see a mother without an appointment who has brought in her three kids for their overdue vaccinations. She has mentioned she has a breast lump. She is 27 years old and it doesn’t look good. I refer her for an urgent mammogram, ultrasound-guided biopsy and review at the breast clinic. 18 minutes.
The practice manager comes in to talk to me. She has had an irate phone call from the mother of the depressed girl who is upset I didn’t examine her shoulder.
I explain that even a double appointment wouldn’t have given me enough time to manage her shoulder and her depression and her infected ear. The practice manager agrees and goes off to placate the mother. Seven minutes.
I’m running behind and the next patient has two crutches and walks painfully to my room. It’s four minutes before he sits down. He has seen the orthopaedic surgeon, who has recommended a hip replacement. The X-ray report says “severe end-stage osteoarthritis”.
He has had a recent letter from the hospital saying that, unfortunately, due to demand, they won’t be able to offer him surgery and to return to his GP for ongoing care. He needs more pain-relief tablets and tells me he is asking his family for help to raise money to pay for private surgery.
My job today is to complete his Work and Income certificate, because he can no longer do his job at the sawmill. He thanks me and tells me to have a good day. 14 minutes.
Time for a quick toilet stop and another coffee. Of course the carrot cake is finished and it’s not even 10 o’clock.
Our observations
We have worked in more than a dozen different practices and had a pretty good look at the state of general practice over the past three years and, yes, you should be worried about whether your doctor will be available when you need her or him most. Often, we have worked in practices where one of the regular doctors is on stress leave.
Nearly two-thirds of New Zealand GPs plan to retire in the next 10 years and there aren’t enough younger ones to take our place. They don’t want to run a business on top of the demands of the job, so many of the practices are being bought by overseas corporates.
The staff at these places are the same, but they are bewildered by their new overlords and the pressures to meet financial targets. The doctors are frazzled and the patients are grumpy. We’ve chosen to stop working for those.
We’re on our last week for this practice. Next stop, Ashburton. I can feel the agates waiting to be found on the beach and I’ll have to remember to pack my togs.
*Dr N and her partner have not been named for privacy reasons. Read more about general practice problems here.
