Traditionally, general practice has been community family medicine. The ‘Doc Martin’ model of the local GP—working in a small practice, caring for the day-to-day health issues of a known population, often a pillar of the community, mostly dealing with day-to-day minor ailments but also acting as advocate, counsellor, family therapist, and taking care of families from cradle to grave. General practice and the role of a GP have changed enormously over the last 10–20 years. Elements of this kind of practice remain but the speciality has developed rapidly and modern-day GPs deal with far more complex problems in the community than in the past.
GPs work at the absolute coal face of medicine. We are the first port of call for everything from chest pain to cancer symptoms, from a student with suicidal feelings to a child with a snotty nose and a fever. We support individuals and families through acute illnesses, making decisions on treatment and deciding if and when a specialty opinion is needed. We look after people through chronic illness, managing symptoms when a cure is not possible, weighing up risks and benefits of different treatments, and providing palliative care to those at the end of life. We change lives through lifestyle advice as well as saving lives through identifying and providing timely treatments or referrals.
GPs have to know something about everything, but we also need to know when to ask for more help, and where to go for that help. A good GP has an enormous breadth of knowledge and skill but also has an ability to pick out the needle in the haystack—the febrile child developing meningococcal sepsis, the one person with palpitations who has a phaeochromocytoma, or the one with headaches who has a brain tumour. We have to do all this while being aware of the limitations to NHS resources, and of the harm that can occur from over-referral or over-investigation; while also keeping up to date with ever changing evidence and best practice guidelines.
Public perception, even among medical students and hospital specialists, of what a GP does every day is poor. Well people tend to only see their GP once in a blue moon, and for something fairly straightforward. The reality of a typical GP surgery is far from this. An average GP day might include some of the following examples:
Of about 240,000 GMC registered doctors in the UK, about 25% are GPs, 29% are hospital specialists, 25% are in training, and 20% are not in training and not on either the speciality or the GP registers. 54% of GPs are female, compared to 35% of specialists and 18% of surgeons (GMC report 2017).
The numbers of GPs per population is decreasing due to some taking early retirement and the numbers of new GPs being trained not keeping pace with population growth. The NHS needs to attract increasing numbers of newly qualified doctors into GP training if we are to retain our current model of asking people to make their GP the first port of call with any health complaint that is not an emergency. In 2012, 24.2% of doctors entering speciality training went onto a GP vocational training scheme.
It helps to be interested in everything! If you get bored easily, you like variety and change and enjoy being challenged academically on a daily basis then it could suit you. A bit like EM, literally any clinical presentation can walk in your door at any time. Sometimes it may not even be a clinical problem—but a question about benefits, or someone asking advice on something you never heard about at medical school, such as when to start going to the gym again after having a baby, or how to get your child to eat fish! Unlike EM, no one will ever expect you to perform an open thoracotomy.
You need to like and be interested in people and their lives. This may sound silly but do not all doctors care for their patients? In fact, there is a range in medical specialities of how much direct patient contact you will have and how much you will have to listen to people tell you about their lives and their concerns. If you do not like talking to people, then general practice probably is not for you.
GPs also develop a skill for reading between the lines of what people say and accessing the hidden agenda as to what might be really going on or causing the problems they are talking to you about. What might be underlying someone’s headaches or back pain? Excellent communication skills, a good rapport, and an ongoing relationship with your patient may allow them to open up about hidden anxieties or past traumas that are causing physical manifestations that could be superficially investigated with a radiograph but will not be cured until you have addressed the underlying concerns or problems. A robust communication model includes the Calgary–Cambridge model (see Fig. 15.1).
A willingness to continue learning throughout your career is essential. Primary care research is a broad and growing specialty but you are unlikely to become the forefront expert in something niche. As most doctor–patient consultations take place in primary care, any advances in how to be effective in the consultation and in primary care treatments may have the widest impact on morbidity and mortality of all.
Fig. 15.1 The Calgary–Cambridge model. Reproduced with permission from Kurtz S et al. ‘Marrying Content and Process in Clinical Method Teaching: Enhancing the Calgary-Cambridge Guides’, Academic Medicine, 78:8, pp. 802–809, 2003: Wolters Kluwer Health.
• Clinical audit or quality improvement project.
• Assessment of prescribing and delivering of urgent medications.
• OSCEs to assess communication and diagnostic skills.
• Logbook of cases, and clinical skills.
Matching the breadth of clinical acumen needed in a good GP is the breadth of potential for career development in general practice. The ways in which you might use a GP qualification are limited only by your own imagination. It is becoming increasingly popular and mainstream now to have a portfolio of different specialist interests—and these can even change over the course of your career. Many choose to train to be educators, teaching medical students or training junior doctors. Trainers get extra time when supervising students or trainees, they plan and run tutorials or may lecture at medical schools. Others have a specialist interest—many spend a day a week in a specialist hospital service, such as a cardiology clinic, conducting cardiac echocardiograms and assessing cardiac patients, or palliative care, endoscopy, dermatology, gynaecology, family planning, respiratory medicine, prison medicine, urgent care centres, or EM, etc. These skills are then brought back into the practice where they work, allowing GPs to internally refer patients with suitable issues to their own colleagues.
GPs’ common-sense approach and breadth of knowledge, if supplemented with the right training, can make them useful event doctors, working on expeditions, cruise ships, or sporting events. You can travel abroad, work for international organizations, or international clinics. Some even choose to go into private practice. The growing demand for telemedicine and online app-based consultations has been largely met by GPs. Or there is also medical journalism, writing, politics, or working for the local commissioning group. It is completely up to you!
• This is a chapter about general practice—of course the answer has to be YES!
• This is even more important for those of you who do not want to be GPs.
It is essential that hospital doctors have some concept of what GPs do—what the difficulties are and what the limits are. Maintaining professional and collegiate relationships between primary and secondary care avoids a lot of angst and stress for both. Medical school training entails spending a great deal of time learning about hospital medicine and very little about community medical practice. How else will you learn about what >25% of medical doctors do all day? And if you are considering a career in general practice it gives you a chance to see what it is really like. And the on-call rota is pretty good!
Firstly, leave any preconceptions and prejudices at the front door and go in with a willingness to learn from the subtleties as well as maybe a new syndrome or a new clinical sign. Remember that there is no such thing as a typical GP. Your experience will vary enormously from the next student’s depending on the individual trainers you are exposed to, the setting of the practice—rural or urban, wealthy or deprived, small or a large practice?
As with any medical training setting try to get as much first-hand experience and exposure to as many patients as possible. If it has not been set up for you already, ask if you can see your own patients—you will be given plenty of time for this—find out why they have come and listen to what they are telling you verbally as well as looking for the in-between information—why are they really there? What are they most worried about? Find out about their ideas, concerns, and expectations (ICE). Your patients will also be seen by their GP and you will have a chance to discuss each one with the trainer. Use this as an opportunity to find out what skills you can learn from your trainer, particularly in communication, as well as finding out how they approach not missing that seriously ill person.
Zola (1973)1 suggested that patients do not seek help at their sickest point, but when they can no longer accommodate the changes they are experiencing with five ‘triggers’ for help-seeking:
1. Interpersonal crisis (e.g. death in the family), which may call attention to a person’s bodily changes 
prompting them to do seek help.
2. Perceived interference with relations: a bodily change interferes with relationships and daily life prompting action.
3. Sanctioning: family, friends, or partners encourage help-seeking.
4. Perceived interference with vocational or physical activity: changes stop someone carrying out their job or other physical activity.
5. Temporalizing of symptomatology: people place a time limit on their changes, and consult if they have not resolved by that time.
Learn about risk and safety-netting. GPs are good at managing risk and at knowing how to safety-net with their patient—explaining which serious things to look out for and being clear on how they might seek further help if needed.
Go out with all the members of the GP team. Spend time with the practice nurses, the midwife, and the receptionist. Sit in on minor surgery if your practice offers it. Take any chance of doing a home visit. You learn an enormous amount about patients when you see them in a home environment. You will realize how hard it is to assess a sick, frail, elderly person who has had a collapse or a fall at home when you are not in a bright, exposed hospital setting. Think about the GP lifestyle and the practice/small business management aspects of the job. All senior jobs have admin and management responsibilities—might you like the relative freedom that comes with being contracted to the NHS?
Reference
1. Zola IK. Pathways to the doctor — from person to patient. Soc Sci Med 1973;7:677–89.