My Job

I thought it would be an idea to provide an update on ‘My Job’ – I have been working in this role for almost five months and it has gotten to the point where my children have begun asking me, ‘Dad, what are you?’ Not in the sense, ‘Are you from around here?’ (Although I am sure this is an occasional consideration), but, ‘What sort of doctor are you?’

You see, it used to be straightforward; back in the day I was either (in my kid’s eyes) a doctor who worked in hospital or a doctor who cared for older people or, even, at times, a doctor who had a special skill supporting people living with dementia.

Now I am an enigma.

I don’t work in hospital (at all), I do still support older people although I see younger patients too (What is ‘older’ anyway?) (I always did care for younger people) and although I have (I think anyway) a skill that helps me engage with people living with dementia and their carers, this is only a small part of what I now do.

Oh, yes, also, I am not a GP.

Sounds like that game, ‘I am weightless, but you can see me. Put me in a bucket, and I’ll make it lighter. What am I?’*

In June I joined Manor Field Surgery in Maltby (South Yorkshire) as a partner, working in my specialist field (which is, (officially) Geriatrics and General Internal Medicine) – I am OK with the GIM as it is often called, but hate the geriatrics and usually say, ‘Specialist in the Care of Older People’ – I know that we will change the official name of our discipline one day, I just wish it would happen sooner.

I mean, come on, ‘Geriatrics’? Over 65? So last millennium.

I work in the surgery two and a half days a week; Monday, Thursday and Friday. Seeing older people (not geriatrics!) and those living with long-term conditions. Most people reading this blog will know what I mean by these terms; to be explicit, here is a variety of the patients I see –

60-odd residents of our nearby care home

People living with dementia

People who have significant frailty

Older people (for arguments sake and to draw a line under things, over 65) who have two or more falls

People who have Parkinson’s disease

Those who are housebound (another term I don’t like) 😄

People with a combination of long-term conditions – stroke, COPD, arthritis, cancer and so on.

There are more, although that might give you a flavour.

Oh, and the very old which used to be people over 85 although I am finding that even that extended benchmark is meaningless.

I also support the running of the practice, working with nurses and the reception and admin staff to operate as a happy, healthy, effective team, supporting our patients and each other as best we can.

To provide a little more detail, I have 20 minutes per patient compared to a standard 10 minute GP slot (although I have worked-out how to reduce 20 to 10 if it is just to quickly check on someone) (I have 40 minute home slots for new people) (although, as I am my own boss – these timings are subject to change and subject to what I and the other partners agree is appropriate and in the best interests of patients (and me) and, I have my own room with computer, photo of dog, etc.

I do my best to address patient concerns, I prescribe and de-prescribe, I discuss end of life care and avoidance of admission (formerly called my ‘Sherlock Letter’ although currently, in combination with colleagues, a combined Advance Care Plan), I review blood results and medicines, I speak with patients, often on the phone which is something I never did much of previously.

There is more to my role than this – essentially I work with the GPs and the nurses and all the staff in the practice to support our patients and provide the best care we are able, although my focus is narrower than the others, it is, possibly a little deeper. And that is how it’s meant to be.

I have gone-on a little about my job as, to the best of my knowledge, I am the only physician working this way in the UK and given that we have a unique health-service, the world.

It can be lonely at times, and isolating, which I suspect anyone who is doing something new or uncharted experiences, although it is rewarding;

Getting to know the first names of some of my patients (and they, getting to know me), even knowing how to drive to their houses without Sat Nav is for me, profound.

There is more to do, and my hope is that I will be able to work with other practices around the area to provide the same level of support and care that doesn’t have the hospital or some form of NHS call-handling service as an intermediary.

On this, I will keep you all posted.

And yet, I have only described half of my job – no wonder my children are confused.

The other half of the week I work as a Community Physician specialising in the Care of Older People; again, a bit of a mouthful, but still better than, ‘Community Geriatrician.’

In this, Tuesday, Wednesday and Thursday morning I travel across Rotherham (which is quite a large town) seeing people in their homes and in care homes.

In essence, the role is very similar to the one I do in Maltby although, you might call it, watered-down as I tend to break-off my connection with the patients after I have seen them, it is more a see, review and sort as best I can and hand back care or treatment to the GP.

This is more a traditional model of medicine and albeit very rewarding, doesn’t have the same depth as my surgery role.

In this job, I see the same cohort of patients as I described above, although I suspect I meet a far narrower proportion of those who might benefit from my intervention;

I also work with other teams across Rotherham, these are social workers, physiotherapists and OTs, hospital doctors and staff, speech and language therapists, nurses, matrons and support workers; I link with GPs – I get to live the interconnected web that is community care in the NHS.

It is great fun although there is more I can do and have plans for the future! Mostly, my approach is to consider that we, that is the community services (those outside the acute hospital), can and do support a far broader range of patients than people realise and, when working well together, can care for a significant proportion of the people who otherwise arrive at the door of A&E.

Sure, it will be a few years before we are diagnosing and treating people with strokes, broken hips and heart attacks, but, when you look at the data, you will find that most people don’t have these conditions (at least in their acute form) and much of the treatment that happens either in A&E or on hospital wards or outpatients can happen either in community clinics or patients’ own homes.

I know I must sound like a Gimp of the NHS Long Term Plan, yet, it is true; we just haven’t worked out how to balance the over-medicalisation and hospitalisation of care with the real needs of patients and the abilities and functions of the health service outside hospital wards and operating theatres.

I will stop there as I have exceeded my idealised 800 words; I suspect this has something to do with my writing about me and what I am doing, which is yes, me.

Uncertainties still exist.

There have been questions as to whether I am ‘pretending’ to be a GP – or I might be best placed back in the hospital; to the former, I will quote the Podcaster Dan Carlin, who describes himself as, ‘Not a historian but a fan of history’ –

I see the roles as both being distinct (no babies, pregnancy, working-age people with anxiety and depression or rashes, lumps and bumps for me) (yes, GPs do much more than that) – equally, there is an overlap.

A 70 year old who is immobile in bed with pneumonia seen by me and given antibiotics is the same patients as is seen by a GP in the same role; Sure, I might have more time to spend looking peripherally, planning ahead and so on, less focused on the moment, although many GPs do this, just in a very compressed timescale.

It is still the same patient, the same bacteria and the same antibiotic.

The two roles potentially overlap – a patient in Maltby who I see as a community physician; what of them? I do my best to separate the two lives I lead. Logging into different computer accounts and making it explicit to patients who I am and what I am doing.

There is much more going-on here and it is probably the complexity that has stopped my fully explaining to son and daughter what it is I do.

Maybe someday they will read this and become enlightened.

The picture is evolving as is society; I don’t expect to be doing the same thing in five years as I am doing now. Care in the community is growing – every day there is more we can do and achieve outside of hospital (where the car parking is free and the smell less ‘hospital’)

I promise to keep you updated.

*A hole