In this fly-on-the-wall feature, we speak with Dr. Clare Anderson, a part-time locum general practitioner in the United Kingdom. She covers a number of practices in Worthing and Shoreham on the blustery south coast of England.
The alarm shakes her into action at 6:30 a.m., and a sense of nervous anticipation replaces the calm of sleep.
She takes the opportunity to fuel up on caffeine before heading to her car for the 45-minute commute through Sussex. Her journey includes glimpses of the choppy, grayish-blue English Channel and the imposing grandeur of Lancing College.
Upon arrival at the office, Dr. Anderson logs in and discovers where she will be working for the rest of the day.
The role of a general practitioner (GP) - the equivalent of a primary care physician - is arguably one of the most varied in medicine.
Dr. Anderson ended up as a GP almost through a process of elimination.
"There wasn't one specialty that excited me enough to do it," she said, adding that as a GP, you get to "do a bit of everything."
In this article, we follow Dr. Anderson through a standard day and ask about the challenges, the highs and lows, and what it is like to be a GP in the U.K. in 2017.
Arriving at work
Depending on which practice Dr. Anderson has been assigned to, the morning clinic will last between 2 and 4 hours. She will be required to consult with one patient every 10 minutes without a break.
Both the joy and the challenge of a GP's clinic is the variety. Facing anything from a newborn with Mongolian spots to a suspected heart attack, and from an octogenarian experiencing little but loneliness to a woman with a sore throat, time is always of the essence, but so is empathy - a difficult juggling act.
GPs are often referred to as "gatekeepers of the NHS [National Health Service]," because they are tasked with referring patients to the appropriate secondary care. Although many patients attending clinic will have relatively mild conditions, being on the alert for serious conditions is paramount.
As Dr. Anderson said, "A patient's presentation is a complex interaction between physical, psychological, and social factors." A GP must combine these factors and render a coherent picture - all within a 10-minute appointment slot.
We asked whether hitting the 10-minute target per patient was a tough feat, and unsurprisingly, it is. Multiple factors can slow a consultation down, none of which are avoidable. These include the, "I rarely see a doctor so I've brought a list" patients, language barriers, complex presentations, and frailty.
Additionally, if a patient needs emergency care or admission, there is little chance of completing the meeting within 10 minutes; medical admissions to hospitals in the U.K. go through a call center and can sometimes take 30 minutes or more to arrange.
In a survey of GPs by the British Medical Association in 2015, two of the top three reported factors that most negatively impact GPs' personal commitment to a career in general practice were workload (71 percent) and insufficient time with patients (43 percent).
However, it is this contact with the patients and the constant variety that keeps Dr. Anderson passionate about her role.
Although she said that she joined the medical field with her "eyes wide shut" (no one in her family was in the medical field), over the years, she has retained her passion for human biology and interacting with the public.
Switching to a locum life
Dr. Anderson has been a practicing GP for more than 20 years. Around 9 years ago, she switched from a role as partner at a busy practice in the center of Worthing, to that of a part-time locum.
Her decision to switch gears came after a battle with breast cancer. Following her recovery, assessing her work/life balance became a priority.
"Being a partner involves many management duties as you are running a business," she said. "Many GP partners work 14-hour days. My children were young then and, during my recovery phase, uppermost in my mind was the thought that if the cancer recurred, I would regret the impact that working long days would have on me and my young family," she said.
Becoming a locum GP comes with a range of pros and cons. The hours are more flexible, but holiday and sick pay vanish, along with the security of familiarity. Also, as Dr. Anderson explained, there are other frustrations. "[Although] as a locum, I can work to suit me, it is not ideal; there is a lack of continuity of care with patients. But, to get over that, I try and do blocks of work or maternity cover in one practice."
Perhaps bizarrely, nobody knows exactly how many GP locums there are in the U.K. However, there may be as many as 17,000, and this number is thought to be rising.
Admin, phone calls, and a little more admin
If Dr. Anderson is assigned the role of duty doctor for the day instead of running a clinic, her first stop is to "speak with the on-call team and get a general overview of the session holders and plan the next few hours."
Most general practices in the U.K. run a telephone triage service to manage patients' concerns when there are no routine appointments left for that day. Coping with demand is an ever-increasing challenge.
With an aging population, the unprecedented rise in patient numbers, and the growing complexity of health needs, GPs are engaged in a constant firefight. The U.K.'s 9,458 GP practices are all creaking under the strain.
Dr. Anderson speaks with patients on the phone and, if she feels that the case is urgent, an appointment is arranged.
"The phone lines open at 8 a.m. and shut at 6.30 p.m., when the out-of-hours service takes over." Dr. Anderson admitted that when the clock finally hits 6.30 p.m., it is the "highlight" of her day. "Even though I may have calls still to make and patients to see, it is a relief that the tide of demand has ceased."
According to Dr. Anderson, days as a duty doctor are "quite stressful" because the "demand on the day is unpredictable and, if it is very busy, it can be very overwhelming with pressure of time."
Lunch is, at best, a sandwich wolfed down while battling with paperwork. General administration is a huge, time-consuming challenge for general practice; this includes referral letters, requests for scans, X-rays or blood tests, and ensuring that every symptom and detail given by the patient is entered into their medical records.
The associated admin certainly adds to GPs' overall burden, perhaps contributing to the fact that around 1 in 6 GPs consider their workload as unmanageable.
Home visit drama
In the afternoon or across lunchtime, home visits to patients who are unable to come into the doctor's office might be scheduled in. These are Dr. Anderson's pet hate, comprising a range of difficulties - they are "time-consuming" and it is a "challenge to examine, treat, and arrange care at home."
We asked whether she had any particularly memorable home visits.
"My worst experience on a home visit was visiting an elderly patient who was 'dizzy.' She had left the gas cooker on and was very unwell. The fire brigade arrived with the ambulance and I was criticized for using my mobile phone, which could have ignited the gas.
The only reason I didn't end up under a pile of rubble was that the concentration of the gas was so high it didn't ignite."
Dr. Clare Anderson
Normally, Dr. Anderson has another fully booked clinic in the afternoon, again seeing patients every 10 minutes, and she may even do an evening "extended hours" clinic, which finishes at 8 p.m.
Arriving home exhausted at the end of the day, a bite to eat and an early night is the extent of the evening's entertainment.
We asked Dr. Anderson whether she thinks about work when she gets home - the cases she has seen or the inevitable onslaught of her next shift. She told us about a piece of advice she received during her GP training:
"Think of a patient's problem as a balloon that they bring into the consultation room, you may share the balloon during the consultation, but ultimately you must hand it back to the patient to take with them when they go. If you don't your room will be so full of 'balloons' that you will be unable to breathe. This analogy has stood me in good stead over the years."
As for the transition from a full-time to part-time GP, she felt that she made the right choice, saying, "I have achieved a good work/life balance. I don't think I could be the GP I want to be if I worked full-time. I would run out of mental energy in a flash."
With changeable shifts, the full gamut of medical conditions, and a pile of paperwork, a GP locum's life is as challenging as it is varied.