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“Entry into the profession is a voluntary act, and most people who perform it are disposed to learn its ways and take its ideology seriously. They need only to be told how.”

J.Kultgen

Medicine was not my first choice as a career and I am pretty sure that my 20 year old self, knowing what would result out of my naïve choice to become a doctor, would have probably abandoned the thought of ever becoming a doctor and rather become a lawyer or a programmer instead. Nevertheless, naïve or not, the choice I made has made an enormous impact on my life and my personality, something I am sure I am sharing with every other colleague out there. None of us can grasp the enormity of the decision we take when we decide to study medicine.

My glide into a career as a General Practitioner was a gradual one: neither did I set up from the start to become a doctor nor did I plan to be a GP by the time I had reached Medical School. My initial career choices were always rather abstract: before studying medicine, it was Statistics, Computer Science or even Genetics. 2 years as a paramedic in the German Air Force gave me some insight into the work of a physician, and as I was quite impressed by all the trappings and the status that came with a career in medicine, I tried applying to Med school.

Especially Dermatology seemed an interesting specialty, for the chaps working there never seemed to do any work. When I had finally reached Med School, it was clear to me that I had to become a Dermatologist: One of the purest and most academic of all subspecialties, I liked Dermatology for its reliance on good history, meticulous diagnostics and an abundance of weird sounding diagnoses, not to mention the promise of being stuck in a lab using molecular biological methods on cell surface receptors on Keratinocytes.

Patient contact was a rather abstract concept for me, with the rest of the annoying human always attached to a particularly interesting rash. So I started working on my doctorate thesis while still at Uni, started publishing and spent research semesters in the U.S. to build up a relevant CV.

After graduating, I was offered exactly what I wanted: a research post at the most prestigious and best funded dermatological University department in Germany. Funnily enough, I didn’t take up the post: after working my back off to become an academic orientated Dermatologist, I hesitated and decided to give “real medicine” at least a chance. As medicine in Germany (in all areas) was pretty de-humanised (as I preferred it then), I decided to go directly to the coalface and sign up for a 6 month contract as a JHO in a District General Hospital in post-industrial Middle England hell: The town west of Birmingham was (and mostly still is) the epitomy of what happens when a whole manufacturing sector is put to death: mass-unemployment, struggling communities, social deprivation with all its impacts and effects on peoples health: High incidence of alcoholism, COPD, malnourishment and mental illness. The Black Country, as the region West of Birmingham is known, has been in a structural and economical turmoil ever since Margaret Thatcher celebrated her victory over the unions. The Landscape is bleak: industrial ruins mingle with sprawling social housing estates and rundown towns. My hospital fitted perfectly into the ambience: a grey, sixties concrete bunker with dirty windows and scores of pregnant mothers standing in front of the doors - smoking. Inside sickening yellow plastic walls, understaffed wards sporting rooms stuffed with patients (8 male and female patients stuffed into one room was not uncommon: sure a change from the aseptic atmosphere of German Hospitals, were patient rooms have a maximal 2 same sex patients lying in one room): this was the coalface all right. The medical department had 31 junior doctors from 14 countries (one Englishman between them) and the gastroenterological team I was working with was staffed with one Iraqi, one Indian, one Pakistani, one Greek, the Englishman and myself. The two Consultants were of course English.

An on-call rota that would have been unheard-of in Germany and up to 40 inpatients would have made this the job from hell, but funnily enough, days after starting to work in this semi-organised chaos I knew that I would never go back to the way medicine was practised on the other side of the channel. Not only did my consultants make sure that my non-existent clinical skills were brought up to scratch (Before I started working in England, everything under the skin was regarded as pretty much superfluous by myself. ECG’s were for cardiologists) by taking me on twice weekly, very entertaining but also gruelling 5 hour ward rounds, but I started noticing that I enjoyed the daily contact with my patients: there were personalities hidden away between all the malaena, diarrhoea and haematemesis, and it was a joy to discover them. So these first 6 months as a doctor triggered the wish to become what Kleinman probably would call a “healer”: to become involved in people’s lives and share their triumphs and disasters and on the way try to help solving their big and small health problems. In my first years as a doctor, I was nevertheless far too busy to try to come to terms with the basic tools of the trade then to actually actively think about the mechanics of the Patient – Doctor encounter or holistic approaches to medicine: a central line, a temporary pacemaker or a Sengstaken Tube were pretty much the answer to all the roots of patients suffering, but while still in the mechanistic phase of “healing”, I already (unconsciously, I believe) tried to at least have a friendly bedside manner and be more than a pill-giving machine.

The Royal Colleges much maligned emphasis on patient orientated consultation models a la Roger Neighbour and David Pendleton that I was taught during my GP- registrar training actually helped me to further focus on the expectations that patients have about their contacts with a physician: the question “What do you think I can do for you?” opened up a whole new dimension within my consultations, as patients suddenly (at least at times) started to share their true agendas which at times were astonishing moments.

Today, after moving around the world a couple of times, I have found my place in a large group practice on the South Island of New Zealand: With a list size of ca 7000 and patients distributed in a triangle between the adjacent communities this is a busy place: during peak times, each of the doctors will see around 40-45 patients between 9 and 5pm. The on-call rota is (at least compared to the rural practices I have worked in Scotland) manageable, with ca 5 weekends per year and a weekday on-call ca every two weeks. The patients who choose to see me tell me that they find it easy to talk to me: there are issues that my patients perceive are easier to discuss with me than with other doctors, so I see a fair share of patients with psychosexual and emotional problems and a lot of teenagers. Most days I have Jazz softly playing in my consultation room, which tends to put my patients at ease. My dress code is casual: I always found it harder to relate to someone wearing a jacket and tie during a consultation, so I think my clothing style can contribute to a relaxed atmosphere within the consultation. I am fortunate that the partners at my practice have a similar approach to work as well, so I am not the only one working in Jeans and T-shirts.

When it comes to identifying myself with any of the classic doctor’s personalities (as defined by Kleinman), I think that there is something of all of these colleagues inside of me: Although most days enthusiastic about my work, there are dark moments when I am cynical and disillusioned about my profession and when I feel that all that humanity and the expectations are just too much for me. The last time I started to feel that I was getting grumpy and overworked (after one of my colleagues had to leave the practice because of a serious illness and our individual patient load suddenly ballooned) I discussed this with the partners in the surgery (which I fortunately can call friends) and arranged to have every Tuesday off. This one day off during the week is the ideal antidote to getting too overwhelmed with medicine: I tend to use the day to read up on the BMJ, BJGP and the NZ Doctor, potter around the house and try to catch up on my emails. The rest of the week then just flies by.

After 10 years being a doctor, I now see myself as a mixture between friendly lifestyle adviser, counsellor and classic family doctor: this will surely change, as the role of the General Practitioner is an ever evolving one.


Sources:
Kultgen J. Ethics and professionalism Philadelphia: University of Pennsylvania Press, 1988.
Kleinmann, A. The healers: varieties of experience in doctoring. In: The illness narratives: suffering, healing, and the human condition. New York: Basic Books; 1988; p 209-26
Neighbour, R. The Inner Consultation: How to Develop an Effective and Intuitive and Consulting Style. MTP Press; 1998
Pendleton, D. The Consultation: An Approach to Learning and Teaching. Oxford University Press, 1984
Kleinmann, A. The healers: varieties of experience in doctoring. In: The illness narratives: suffering, healing, and the human condition. New York: Basic Books; 1988; p 209-26

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