Personal views: Starting back at the bottom

Ihave lost count of the times that people have told me that I must have been upset to give up surgery. It seemed that everyone who interviewed me thought that the surgical bug would eventually pull me back. I think after four years in general practice I can safely say that the move was one of the best decisions I have made. I had always aimed at doing surgery, and three and a half years into senior house officer posts I was on a good rotation and had achieved the fellowship of the Royal College of Surgeons. But osteogenesis was winning. In the days of open cholecystectomies we used to guess the patient’s weight by how many fingers I broke holding the liver retractor. I was furious on one occasion during my accident and emergency job when my boss sent me home after I broke my toe, in my view a minor injury. The final straw was a fracture round my elbow early in a three day weekend on call. Over a cup of coffee with my consultant the next day I talked myself round to the idea that the part of surgery that I found most fulfilling if I could not operate was talking to patients and their long term care, and so general practice was the right way to go. I wonder how many juniors are put off a major career change by a feeling of failure in their previous specialty I decided to do a complete training scheme partly because I did not think that I had enough experience of other areas of medicine, and partly because none of my surgical jobs was recognised for vocational training. Vocational training held many surprises, not least that my surgical experience was far better preparation for general practice than any of the training scheme posts. I was used to coping with uncertainty. The medical problems I saw in surgery were far more akin to general practice than were those in general medicine, where by definition we saw the problems that GPs could not sort out. Also, with a background in neurosurgery I had plenty of experience of and training in breaking bad news. It came as quite a shock on a new trainers’ course earlier this year to find that out of 10 prospective trainers I was the only one with any training in this skill. The hospital jobs were hard; suddenly I was back to being at the bottom of the pile. It came as a blow the first time in gynaecology when I was timetabled to be in theatre and was sent away to find a proper gynaecological senior house officer. Surgical problems were another bone of contention. It seemed a daft system that someone with non-gynaecological pain was sent home even if it was a barn door appendix. On one occasion a registrar did relent and let me relieve a patient of an inflamed appendix as he wanted to learn how to do it. In care of the elderly the consultant seemed willing to let me decide whether we could deal with a situation rather than call on a surgical senior house officer probably less experienced than I was. But a lot of the hospital time and teaching was unhelpful. Making prospective GPs attend tutorials for higher professional exams and then calling this appropriate in-service training is far from adequate. Some posts were good at recognising the different needs; others definitely were not. At the end assessment of one post the only comment I got from the consultant was that my writing was awful. Consultants’ attitudes to GPs vary dramatically, and this has an effect on the juniors’ willingness to accept referrals. I was impressed with one who told us senior house officers never to refuse an admission as the GP was always more experienced than us. The GP can also see the home situation, but may not be able to tell you on the phone in front of the patient. I have since made a very dodgy referral because I did not dare do a repeat home visit to a man in a house with pornographic pictures all round and a six inch knife under the bed. You can always ring back later if you do not understand a referral. It would be good for all doctors, no matter what specialty—even surgeons—to spend time as GP registrars. Having reassured my trainer that I really did want to be a GP, I finally made it to a training practice and have never looked back. But I wonder how many juniors are put off a major career change by a feeling of failure in their previous specialty or because they had less sympathetic seniors than I had. It is easy not to realise what a specialty involves until you try it; even preregistration house jobs do not really give you a clear idea. At a time when doctors’ stress levels are a major problem we should be making every effort to let juniors find the right area, even if it does mean a few false starts. Forty years in the wrong specialty is bound to lead to sick doctors.