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A DAY IN THE LIFE OF A KIWI GP


The photos used in this publication illustrate general practice and do not relate to any of the consultations described.

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A DAY IN THE LIFE OF A KIWI GP

Foreword In the lead-up to World Family Doctor Day 2018, we asked our members to tell us what a typical working day is like for them. It was heartening to see such a huge response from members across the country. The comments that follow are a selection of the contributions we received. They show the broad range of conditions and patients our GPs treat, non-stop, all day, every day across the country. There is no better way of recognising or appreciating the work our GPs do than by letting them share their experiences in their own words. Having read these comments, there is no doubt GPs are caring, compassionate, hard-working and dedicated. We are immensely proud of our members’ work and we thank them for their huge contribution to New Zealand society.

Dr Tim Malloy Helen Morgan-Banda President Chief Executive

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A DAY IN THE LIFE OF A KIWI GP

T

here is no way you could adequately put it into words. Our job is so complex and the variables are infinite.

I have been a qualified GP for 20 years, and almost every day I see something I have never seen before. We never know what problems we will have to manage on a daily basis, and with the constantly changing demographics in society – ageing population, poverty, increasing drug use, family breakdown, social media use, internet use, changing medications and updates in medical knowledge, financial restraints in secondary care – the job becomes more complex by the day! General practice thrives on continuity of care – this is one thing that has not changed and needs to be protected wherever possible.

Waikato GP

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I

’m a GP in skin cancer medicine. So usually in the morning I see people for skin checks or those who have skin

lesions that concern them. In the afternoon I operate on people to remove skin cancers, I do biopsies and sometimes I remove benign but bothersome lesions like cysts and lipomas. General practitioners don’t always do traditional general practice!

Wellington GP

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A

rrived early to work to clear my inbox and follow up any results that need my attention. Then spent the

first half of the morning visiting rest home residents to ensure their health is taken care of. Rest of the day was GP consults seeing anyone and everything. I work in a rural practice so have to be a bit flexible to fit in urgent patients in between my booked patients, while still ensuring every patient gets the attention they deserve. Lunch was a great catch-up with the practice team, where we all sit around a shared meal every day and catch up with each other and talk through any cases that need discussion. We were also joined today by the Rural Mental Health team to maintain connections to our secondary services and get an update on what’s happening currently in that sector. Canterbury GP

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I

saw patients the whole day while teaching a second-year medical student. I was able to teach her a range of topics from child

health/women’s health/antenatal care and how to assess elderly. Also able to discuss with her preventive care and immunisation. It was a challenging day with having to manage possible DVT and fractures.

Overseas-based College Fellow

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S

tarted at 8.00am with drop-in clinic patients waiting from two minutes past the clock, so not a lot of time to review

overnight results. Not a busy drop-in, but so much variety – from a nine-week-old well baby with strep throat contact to reassure, to an 80-year-old with shortness of breath, and everything in between! Spent lunchtime driving across town to visit a long-term patient, now on palliative care and bed bound – lovely to see him and his family and discuss his end-of-life care (can still see the spark within). What an honour to be involved at this stage of his journey. Rushed back through all the traffic lights to start on afternoon appointments – caught in the corridor by a colleague when calling in my first patient to run something past each other, fitted in a quick ‘acute’, then spent 30 minutes with a dementia patient and her long-term caregiver (wheels seem to be falling off and

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sad to see the grief). Luckily the caregiver is strong and dedicated. Then post-op review of a patient who has just had aortic stenosis surgery sorting some fast atrial fibrillation; squeeze in my lovely, sprightly Māori patient just needing meds, and glad that she is fast as my next is to discuss the hospital decision not to operate on my 88-year-old gent with critical aortic stenosis – struggling a bit. Getting tired towards the end, so luckily my next few are fairly quick, and big sigh of relief when my last patient booked just needs a contraceptive script. Almost done – then I check on my list of tasks and it looks like I am in for a late night of paperwork (again). Better grab the cuppa I missed at 3.00pm. Need to beat the paperwork into submission before starting again on drop-in at 8.00am tomorrow! Bay of Plenty GP

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I

started work at 7.30am, and before seeing my first patient at 8.30am I sorted out eight other patients over the phone – only

two of them needed to come in to see me. I then saw 15 patients before heading off to meetings to help with integration of health and social services with GPs, to implement e-Shared Care and to better integrate primary and secondary IT systems. I’ve now been at work 10 hours but have two hours of paperwork to get through before having a quiet beer. This is a usual day for me.

Northland GP

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S

tarted 8.30am by giving intranasal sedation to an IHC patient prior to blood tests – who struggled to tolerate

this. Injected acneiform cysts with steroid after aspiration. Home visit for completion of death certificate and cremation for a very well-known patient. Cut out two or three skin cancers in theatre. Supervised a few sixthyear medical students. Now on-call overnight for PRIME emergencies and general on-call duties. It is 5.00pm, I still need to complete a supervision report for these students and catch up with a doctor from overseas for supervision purposes.

North Island GP

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P

ut in a MirenaÂŽ, saw a transgender

patient for mental health and hormonal treatment; counselled a

woman wanting to leave her marriage and did her smear; teen STI check and mental health advice; saw a patient with mania and arranged respite, family support and medication advice; saw a very difficult chronic pain patient with new symptoms of flank pain; adult ADHD medication review; mother with panic symptoms and grief post foetal demise at 28/40; patient with GAD who needed medication and to check some symptoms; refugee with socioeconomic needs and MH symptoms for medication and referral to counselling; mother with infant with new diagnosis of ataxia and ID. That was only the morning! Then paperwork and scripts and staff issues and business issues! THEN more patients.

Canterbury GP

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D

iagnosed a young woman with diabetes, counselled an accused sex offender, plastered a broken arm,

argued with an ACC case manager, medically assessed immigrants to New Zealand, gave 20 flu shots to local primary school teachers in their staffroom, treated three UTIs, arranged a PEG tube for an ALS patient.

Otago GP

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T

oday I spoke with my staff about the upcoming initiatives in general practice, drained an abscess on a

lady’s finger, inserted an IUD for a patient who has just had her sixth child and discussed the importance of immunisation for her six-week-old, visited a dying 92-year-old at her home and helped her relatives provide her care along with the district nurse, taught a fifth-year medical student about peripheral neuropathy, carried out an annual performance review on my receptionist, carried out a driver’s medical on a man with poorly controlled diabetes and visited the rest home to see an elderly lady who recently fractured her hip. I performed a pipelle biopsy on a lady with postmenopausal bleeding, referred a paranoid patient to the mental health service, followed up a lady six weeks post-partum with postnatal depression, saw a lady with bilateral knee injuries and chronic pain to improve

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her medication regime, removed a pigmented skin lesion from a lady’s upper back, assessed and treated a patient with campylobacter gastroenteritis, adjusted a man’s blood pressure medication, changed a warfarin dose on a patient with atrial fibrillation, provided repeat prescriptions and phoned patients with their results, arranged travel advice for a man to travel to Vietnam and immunised him, performed a cervical smear and STI check on a young lady, spoke to my practice manager about a new IT purchase, treated a young man with a depigmenting skin lesion, and documented all my consultations and interactions. A typical busy rural GP day! Otago GP

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W

oke up at 5.30am, was at work by 6.15am hoping to catch up on paperwork. Unable to get

Medtech working as having issues recently, finally managed to log on, started clinic at 7.15am – complex patients with mental health issues, highlighting the inadequate resources and financial constraints to deal with mental health problems in the country. Had medical student sit in as well. Also saw the common coughs and colds, abdominal pains, rashes, young child with difficult parent consultation, heart failure, etc. Left work at 2.45pm for school pick-up and other afterschool activities for my daughter, picked up other daughter from day care at 5.00pm, then regular routine of dinner prep, baths etc for the kids and, of course, I have the notes from work to catch up on. This is what my routine day is like, although I start a bit later on two days. Wellington GP

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I

n the morning I held a clinic at a local high school with the school nurse; this is a PHO-funded clinic due to being a

decile 9 school. The clinic also serves the teen parent unit. We had a young person with a skin infection, someone with uncontrolled asthma, a teen in late pregnancy with unexplained breathlessness, a young mum with weight loss due to newly diagnosed coeliac disease, a young person starting her journey through the mental health service due to anxiety, self-harm, disordered eating and alcohol bingeing, and spoke with the counsellor and alternative education support worker about troubled young people from hugely difficult social backgrounds. Then, I went back to my main clinic to catch up on paperwork and attended a research meeting. This is my easiest day of the week! Wellington GP

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D

iagnosed a fractured wrist, concussion, glandular fever and appendicitis. Pretended to be

astronaut (teaching a child to use a spacer). Incised and drained a large abscess. Congratulated a patient on becoming pregnant. Wrote out over 15 prescriptions, read over 15 clinic letters and checked more than 50 blood test results. Gave out lots of stamps smiles and reassurance and went home feeling I’d been useful today! Waikato GP

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A DAY IN THE LIFE OF A KIWI GP

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I

sub-specialise in skin cancer, so I saw a number of patients in the morning for skin consultations. I picked up a number

of skin cancers that I booked in for surgery. In the afternoon I had a surgical list and removed a number of skin cancers including an early invasive melanoma from the thigh of a 32-year-old woman and removed a large basal cell carcinoma from the nose of an elderly gent, with a skin graft taken from in front of his ear. All in all, a very satisfying and enjoyable day helping people. I love my job! Auckland GP

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S

tarted the day at 7.00am with an hour of paperwork – referral letters and form filling. First patient at 8.00am

was a 24-year-old vet. She had an unusual rash – I think most likely a bullous impetigo with the blisters having burst and gone. I mention her because my last patient at 6.45pm was another 24-year-old vet wanting to discuss the option of a Mirena®. In between, a typical variety that makes up general practice: a grieving mum who lost her son to metastatic melanoma and the difficulties of her relationship with his widow. A middle-aged market gardener who bought in a bag of produce – mainly tomatoes – organically grown! He had bilateral hearing loss both in the low and the high frequencies but had lost the bone conduction on the left. Not sure how that works but necessitated a referral to the ENT.

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An older woman who I think has gout in the left knee. Another elderly woman who I think may have fractured her right fibula, etc, etc. But a good day overall. Finished up at 8.15pm after another hour of filing results and telephone calls. Auckland GP

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T

his morning I worked in my GP liaison role, attending a session with the team I work in who are

implementing a set of shared care plans across the South Island, then met with some representatives of private allied health interests who are trying to connect to HealthOne to help them with their project. Then I did an afternoon clinic where I saw three people with seasonal sinusitis or bronchitis, two children with ear infections, one young man with complex anxiety and somatisation, a woman with a probable ankle fracture after a fit/faint, a woman with unstable bipolar disorder who was having some borderline psychotic symptoms which were distressing her, a four-yearold child who sleeps four hours a night and is excessively violent towards all other household members, his mum who needed a

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sickness benefit form (and a holiday), a young woman with a sexually transmitted disease, a boy with newly diagnosed asthma, a woman with a knee sprain, and did an hour of paper work at the end of the session. South Island GP

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W

as a reasonably typical, but busy day in rural general practice today. The day began with ward

round at our local hospital, where I saw a range of patients in acute GP beds, long-term, elderly hospital-level care and palliative care. After huddle, began seeing patients at the practice, including people needing med reviews, shoulder issues, abdo pain, followup bowel cancer consult, acute abdo, exacerbation of CHF, LRTI and further med review. Across the morning was contacted by a hospice nurse concerned about a palliative patient, so had to duck out to check on her, which led to many phone calls to family and other docs, eventually settled on a plan ‌ in time for lunch, where I had a teaching session with our (excellent) GPEP1 registrar. In the afternoon I saw a few more patients, including a depressed male post-CVA (and very stressed partner), follow-up frank

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haematurua patient with extensive cardiac history, COPD exacerbation, child with persistent eosinophilia (parasitic infection?), infected ingrown toenail kid wanting wedge resection, follow-up with male with likely IBS but had weight loss and poor response to treatment thus far. In between patients, checked inbox and tasks, and sorted repeat scripts. Responded to several emails and at day’s end, popped in to see the palliative care lady (who is fast asleep, so chatted with her grandson instead), then called in on newly admitted, long-term patient who is approaching endstage CHF and has been admitted to local hospital to treat and give family a well-earned break! Caught up with him and his wife and daughter before heading home. Pretty standard stuff! Waikato GP

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I

arrived at the practice at about 9.30am to complete administration before my rest home visit later that morning. This

included checking results and completing referrals. I also used the time to research two problems I was going to review at the rest home, and discussed potential drug effects with a local pharmacist. I saw five patients at the rest home – a mixture of three-monthly reviews and more acute problems. One was a potential SCC requiring excision biopsy at the surgery, to be arranged by the family. My afternoon’s consultations were fully booked, with a mixture of my own and colleagues’ patients. This included a potential measles presentation, which required a great deal of work in consultation, lab work, notification and then further discussion with the local MOH. I then ran very behind! A few

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more straightforward consults helped me catch up. One was a discussion with an elderly patient stressed about caring for her husband with dementia. After patients all seen, there was more administrative work. Left for home at 5.30pm. Nelson/Marlborough GP

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I

provided terminal care for an elderly woman and mother of eight and grandmother to many. She had been

discharged from our local hospital, having been there for two months after abdominal surgery for bowel cancer, and unfortunately had complications. She had been sent to a rest home with hospital-level facilities, which was a big upheaval for her. She died tonight and I went back in to see her and her family. Amongst other consultations I saw a small boy with a temperature of 40°C who had a viral pneumonia. Paracetamol had little impact on this and his rapid respiratory rate, so I sent him through to hospital as I could see he was getting tired and could deteriorate. I sutured a laceration on a young builder’s leg, saw more people with bugs, listened as a son talked to me about his concerns re his elderly mother who has been accusing her husband of dementia but has cognitive issues herself and gets angry ‌ I saw another older woman 28


A DAY IN THE LIFE OF A KIWI GP

with hypertension and intermittent chest pain. Another older woman had fallen and sustained a large haematoma on her hand, as well as a painful swollen wrist, so she went to hospital. We had to organise a driver for her as the ambulance was delayed and, in any case, she’d have no way of getting home (hospital 50km away) if she went via ambulance. A small boy had run into another and sustained bruising round his eye and perhaps a concussion. Unusually, no one came with a complex case history, which is pretty much the norm at present (multi-condition assessments; 30 percent population over 65). After work I drove into the city, 50km away, to get printing ink for my printer at home, shopped for tea, visited a friend who has chronic pain, certified the elderly woman (as mentioned, had died), cooked dinner, and have started on an assignment for a postgraduate course in pain management. Canterbury GP

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B

RCA1-positive female needing to change to non-hormonal contraception, reluctant. Also

chat about prophylactic mastectomy and oophorectomy. A one-year-old baby with high fevers. A depressed 42-year-old male; started antidepressants. A 14-year-old girl with ongoing cough after pertussis. A skin lesion removed. A beneficiary needing a W&I certificate with several other problems (knee pain and back pain). A new diagnosis of gout, started on allopurinol. An elderly 80-year-old woman asked me to check her vulva for CA as her mother died of this. A teenage girl with an eating disorder. Nelson/Marlborough GP

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S

aw a dozen patients, ages ranging from three to 94 years, covering a variety of problems: respiratory, heart, dressings

to lacerations, broken toe, cyst in mouth. Admitted one older lady after laboratory advised some very abnormal results, which meant liaising with family, hospital and ambulance. Several hours spent looking at results, writing referral letters and discussing clinical issues with nurses and staff. A busy but rewarding day!

Auckland GP

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I

began by calling a very agitated patient to explain the meaning of a referral under section 91 of the Vulnerable Children

Act made by Oranga Tamariki. She was really angry as she thought the referral had come from me – it hadn't. I then saw a depressed 17-year-old who is self harming. She has involved her sister in the appointments I set up through the child mental health service because she did not want to involve her parents yet, but the sister is so scared she's threatening to tell the parents. Not a 15-minute consultation. Thirty minutes behind already. Saw an 87-year-old with her niece (all other supporting family are dead and gone) to tell her that while the huge rectal polyp she had removed was benign, the lump in her breast was malignant. Not a 15-minute consultation. Forty minutes behind. A smorgasbord of tired parents with screaming children holding ears and throats

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ensue, and then the lovely 80 plus brigade with their list of 12 chronic diagnoses and 15 medications. I struggle with myself not to add to their pharmaceutical stew. Fortyfive minutes late by ‘lunchtime’ and I'm glad I brought something to eat with me because leaving the desk isn't an option. Twenty minutes chasing the right worker in Oranga Tamariki to make sure I'm clear what's going on for my family, and then another call to the case worker at Child Mental Health to see if I can get the latest assessment of the child which is absent from my inbox. The case worker is out at lunch. Of course she is. Ten minutes eating, and we're under starters orders; then we're off again. I opt to give the husband–wife team first up their flu and shingles vaccines rather than let them wait for the nurses because their waiting room is jammed with agitated pre- and post-vaccine gold carders hoping they’ll be back on the

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bus home before 3.00pm for free once they're done. Ten minutes late already. Uncontrolled hypertension, ‘I think I need to look at a rest home’, recurrent Candida and ‘my wife's left me, taken my boy and is accusing me of being a meth-head’ takes me to 3.15pm. And I'm gagging for a cup of coffee, but I better lead by example, and collect a refreshing cup of water from the cooler in the waiting room while inviting the next person in. Only one chronic depression and a new generalised anxiety disorder in amongst several diabetic reviews, smears, childhood ORL problems, two postreview joint replacement reviews and a couple of smoking, sitting time bombs for coronary artery disease and I’m finished just one hour late. Now for that coffee. Two hours later, the inbox is not so scary, but not empty. The task list of referrals is only 20 items long– I can live with that until tomorrow. I steel myself to call the Oranga Tamariki family to

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explain what will happen next; I have to do it now because it’s quite conceivable they'll be in bed really soon. Not a five-minute phone call. Once I can't think swiftly anymore and I'm having to read things twice, I know I have to leave. The two ACC reports and insurance reports will just have to wait until tomorrow or the next day. And I'm thinking it’s lucky World Family Doctor Day falls on a Wednesday and not a Monday because I could have been really busy. North Island GP

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A

t clinic from 8.30am to 6.00pm. Saw 11 patients in the morning from 9.00am to 12.30pm, then 10 from

2.00–5.30pm, running about half an hour late for both sessions. Today was a fairly even mix of simple to complex consults, with up to four problems presented per 15-minute appointment slot. One minor emergency, dealt with in clinic. No acute referrals to hospital. We had a staff meeting while eating lunch 1.00–2.00pm. Probably spent about two hours during the day dealing with phone calls, emails, faxes, as well as making a start on lab results, various reports from hospital clinics, private specialists and imaging. Currently up to a week behind with reading and processing of lab reports, emails, reports and referral letters to do. Tomorrow I will be spending most of the day doing ‘paperwork’ – catching up! So, a fairly typical day in general practice. Waikato/Bay of Plenty GP

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J

ust a selection of my day: vasectomy for a 32-year-old man with six kids; hardworking wonderful person –

funded by local contract for long-term contraception. Fifty-nine-year-old patient with head injury with ongoing ST memory issues plus depression. Spoke to her husband last week who’s struggling to cope as her behaviour can also be erratic, but she's not aware… Elderly man with Hx of occupational asbestos exposure with progressive shortness of breath. Elderly gentleman for driver licence medical exam who has refused to take antihypertensives for years, but managed to bring him round today. Middle-aged woman with rash on abdo, actually bites ?cause – phew that was easy! Middle-aged man with recent significant shoulder injuries able to return to work but ruminating on his extent of his depression and will things ever get better – but how much is actually the way he chooses to live his life. Young girl with growing pains

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– phew that was easy! Another elderly driver licence, not known to me – opportunity to also briefly review meds – should he be on something more than aspirin for his AF, also has CHF – I think so – task to self to do his CHADS-vasc etc. and get back to him for further discussion. Elderly man with 2x prev stroke and aphasia and now dementia with unintentional wt loss and now cough – going fishing for possible malignancy? Youth who has lost a dad one year ago then watched mum die four months ago, struggling with grief. Five-year-old post-op genital surgery – quick wound check – phew that was easy! Nineteen-year-old considering whether or not to go through MRI hip requiring contrast for ongoing pain ?labral tear – she's claustrophobic with Hx anxiety and hates needles – weighing up pros and cons... Middle aged man who simply eats too much insisting that it’s impossible to lose weight and ‘nothing works’, wanting duromine. In between: more

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depression, quick viral gastro, lady needing smear and by the way my periods are bad, quick viral URTI, cellulitis, asthma review... plus inbox, MMH patient portal emails, regular emails, signing off trainee intern report and audit, phone call to physician re patient with bizarre resp symptoms not obviously related to his CHF, AF, previous AVR Managed 20-minute lunch today and even quick 10-minute morning tea – bonus. And tomorrow we do it all again‌ North Island GP

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S

cooting up to the Koru Lounge, I thought I may be able to present my silver card from Virgin Australia to gain

entrance. Virgin Australia had assured me that I would be able to have two passes to the Lounge after my demotion from gold… The receptionist at the Koru club appeared to be in her late 20s. There was some problem with my card. Another Koru club worker phoned Australia to see if I was eligible to enter. Meanwhile the young woman asked me where I was going and for what purpose. I am going to a police training in forensics. She seemed interested – “ Do you work for the police?” “No,” I replied and told her that I was a doctor who did some forensic work. “Ooh,” she said, “like CSI? I laughed. “Well similar, but I don’t shake my hair around in the crime scene.” I explained that I did mainly sexual assault work and that involved going to court as well. She smiled. “So – how long have you

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been a doctor?” “Well, I have been a GP since 1994. “Oh,” she said. “So you are just a GP?” I stopped. I nearly lied… I thought desperately what I could say that might change the ‘just a GP’…then I felt confused. I thought about my day. I had seen a young woman with a baby with extensive chicken pox who was supposed to be flying internationally on our own airline. She had needed a certificate for the baby to say that she was no longer infectious. A 50-year-old man presented with a threeweek history of pain behind his knee but was now short of breath with some pleuritic chest pain. I arranged an ambulance for transfer to hospital and it turned out he did have a pulmonary embolus. A young woman had mastalgia and thought she might be pregnant (and did not want to be). Another woman had presented with digestive problems and cried her entire way through the consult. I removed a suspicious looking mole on the

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back of an older man. I discussed cholesterol levels with another who had a poor family history of sudden death. I chatted to another woman who had seen her cranial osteopath and was told that she had ‘water on the brain’ and who had asked how I was now going to investigate this. I had inserted an IUCD into a Vietnamese woman who did not want more children. I saw a woman who was suicidal and who had just been told by her psychologist that she could not see her the following day because she was “in crisis”. Then I thought about my qualifications – BHB, MBChB, Dip Obst, Dip Clinical Nutrition, FRNZCGP, and a Diploma in Forensic Medicine from Monash University in Melbourne. I had spent part of my day peer reviewing another doctor’s formal written statement that she had written for court following an examination of a 14-yearold girl after alleged rape. I thought about

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my MEDSAC accreditation, and what I had needed to know and experience for that. “Yes,” I answered, “I am a GP.” The other Koru club worker had returned by then, advising me that my silver card only qualified me to go to Australian domestic lounges. I left and duly got my tandoori chicken roll and glass of Pinot Gris in the main airport terminal. While there, I noticed that my boarding pass was absent. I hurried back to the Koru Lounge reception to be greeted by the young one. She was very pleased to see me and whispered in my ear: “Go in, but don’t tell my colleague.” I smiled and wished her well. North Island GP

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A DAY IN THE LIFE OF A KIWI GP

I

am assuming you want to know what I did after I walked the dog, did the grocery shopping, saw to the pile of

laundry, talked to the grandkids in the UK (as an older GP I now work part-time). My seven- to eight-hour GP day started at 1.00pm, so‌ I checked results that had come in overnight, phoned a couple of patients about them and left messages for my nurse to action others. I wrote up three or four prescriptions for people who did not need to be seen this time for their regular medications. I saw a 64-year-old professional to monitor and treat her hypertension and we talked about the pitfalls of using regular night sedation. Next was an older, getting more frail, gent who was struggling to maintain his independence. I treated his chronic heart failure. A young mother came in who was battling with emotions since her second child was born three months ago. We talked about

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strategies to cope, and I referred her to an outside agency for support. I also checked her fractious two-year-old for ear infection. Next I met a young woman who had sustained a serious injury while working in the UK for two years. She was not able to get ACC support so needed WINZ forms completed and an orthopaedic specialist referral. I discussed with a middle-aged woman about options for her heavy menstrual bleeding. I examined her, took swabs and a smear and made arrangements to insert MirenaÂŽ at another date. A young woman for review of her asthma control and repeat of her medication. Another middle-aged man came for repeat of his blood pressure medication, and I challenged him about dietary changes for his obesity. About time to grab a quick cup of tea, congratulate the practice manager on becoming a grandmother and phone the PHO about CME events. Then I had six consecutive

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slots for young children to be seen – two with nasty colds, one for management of eczema, one with an ear infection, a baby who had been referred by Plunket for a hip check and who needed a scan, and the last little one was well but had a few spots on her trunk (unknown cause). All these slots are also a chance to connect briefly with the caregivers and get a sense of how they are coping. After the kids I saw an 82-year-old man for driver licence assessment – thankfully he passed. That was followed by a young woman who wanted a sexual health check. In my final hour and a half of the day, I referred a man with osteoarthritis of his hip to the hospital to consider hip replacement; I examined a 10-year-old with abdominal pain and arranged for review in a further 24 hours; I saw a middle-aged widow to repeat her antidepressant medication and we talked at some length about alternative ways to

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cope and how to very gradually wean her medication down; I examined an older lady who had a likely skin cancer near her eye so I took a photo and referred her to the public plastic surgery service. Finally, I rechecked results, wrote a couple of specialist referral letters and discussed practice management issues with a senior colleague. Home for a very late dinner, catch-up with my husband, a spot of TV and then to bed to fall asleep with my book on my chest! I do enjoy my days, which are never the same twice. Canterbury GP

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G

oodness. Random day and details changed to protect confidentiality. Write notes on patient who died

after long illness; home visit to see them and provide death certificates/check on family night before. Early patient (walkin emergency start of clinic); acute severe pain, also complex medical but might be straightforward and could be really complicated/dangerous. Already running late by ‘official’ patient number 1. Skin complaint. Nice and easy? (Multiple social stressors and ‘life sucks’, so long consult discussing lifestyle and screening for suicidality/risk etc). Depressed ?suicidal teen #1. Long consult, safety checks/plans/supports; well supported so not too stressful. A string of coughs, colds, some potentially very unwell. Complex gynaecological issues needing investigation/ follow-up and referral; also complex social issues. Screen for domestic abuse/safety.

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Running even later now. Child behavioural issues/ADHD/meds/sleep review. Check how parents coping. Luckily happy to rebook for themselves as they need some TLC. Need to apply for special authority numbers; computer (their end) not working – need to try again end of day (wasted 10 minutes). Complex older medical. Strokes, heart issues, joint/orthopaedic issues. Med/safety review. A bit low in mood due to medical issues, depression screen/safety. Chat re supports, referral. Concerns re newborn growth. Full exam/screen for multiple issues. New mum – not confident – screen for PND; keep an eye on. Another infant+mum – breastfeeding issues. Bit of BF observation and coaching – did really well. Mum feeling confident – follow-up next week . Lunch: worked through lunch as usual discussed with our fabulous nurses and dietitian. Various tricky cases, also forms/

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paperwork. One of our nurses spent four hours trying to get additional help/finances for a patient this week; very frustrating. Lab tests/referrals to catch up on. Tasks via our ManageMyHealth system (direct emails from patients). Reply to patient queries. Grab four-minute bite to eat. Loo. Seventeen prescriptions to do! Manage a few – rest will have to wait until after my day ends – several ‘needed today’ mmm… pm: Anxiety. Plus complex rheumatological complaints – on immune suppression. Meds/monitoring/labs. Another baby – breastfeeding issues/growth concerns. New mum. Lots of reassurance. Breastfeeding coaching again. (Love this – always rewarding). Orthopaedic complaint – ongoing – not responding as expected; referral to specialist – luckily have insurance (yay). Teen – very severe anxiety/mental health issues; isolated, relatively unsupported; tricky. Risk assessments. Jumping through

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hoops to get support. Frequent visits and telephone consults as they can't afford to see me as often as I feel safe with (will worry about this one). “List” skin/bp/pain/cough/others; luckily nothing worrying. Contraception choices (easy). Neurological disorder – long-term monitoring. Checking coping/supports. Liaising with secondary care – more referrals. Smears – several with gynae period problems; all need follow-up. Severely depressed male. Chronic pain syndromes, complex psychosocial issues. Regular risk assessments. Moderate risk of suicide but not enough to qualify for secondary supports – another worry. Doesn't like my treatments but doesn't want counselling either – tricky. Chest pain – acute. ?heart attack/other. Manage in rooms with ECG/urgent labs. Keep patient here awaiting labs. Patient grumpy at me for this. All tests OK but will need to follow up next

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week and refer to cardiology outpatients. This takes 45 minutes plus chasing lab tests. Am forgiven by patient. 3x over-85-yearold patients in a row. (This is always tricky and always blows out my ‘time budget’); all complex – Alzheimer’s and depressed – with stressed (angry) carers. I cannot get any secondary care help; I'm told to ‘refer them to Alzheimer’s support’. Not bad enough to qualify for rest home. Carers also physically unwell (cancer+heart issues) – very fragile situation. Patient refuses home help/MOW etc. Frustrating. One recently widowed and grieving hard – as well as renal/heart and resp failure. Acute HF – another 30 minutes. Quick skin check – cancer – booked in with me for full excision in the next week. Love doing minor surgery. Patient worried re cost. End of day six million warfarins (approximately) to sort. Feels like it. Sorting out ‘GP monitoring’ of a patient discharged

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from specialist with a medication I have never heard of. Needs weekly reviews, but the patient can't afford that. Write to hospital team for a letter, info, advice and protocol (none came with the patient); no idea what I'm going to do about charging – I've already done almost two hours of unpaid work on this in one week. “Forms to fill in” patient sent by hospital, “your GP can do that for you”; specific forms – no forms here – takes 30 minutes just to find the form online. (I am grumpy now). One-and-a-half hours’ lab tests results/communicating with patients – even via TXT/ManageMyHealth, this takes time+++. Further hour and a half of referrals/ insurance forms/disability forms/ACC forms. Spend one whole hour researching notes of newish patient with extremely complex needs and trying to update records to a logical/ workable fashion. Check work emails. Give up on work emails. Think about my overdue

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audit and CME – too hard basket; think about this tomorrow. Go home. Haven't seen child number 3 for 48 hours. Hugs and kisses. Cook late dinner. Grumble about the mess. Do tax return. Give up approximately 1.00am. Wake hubby. Grumbles about the noise I make. Blessed sleep. Dog wakes me 1.30am to chase imaginary hedgehogs in the garden. I think she just missed me. Did I eat a healthy diet? Sort of – healthy snacks, anyway. Did I exercise? About 5,000 steps at work. Did I rest? Watched some TV with kids. Older kids showed me rude GIFs and cat videos. Giggles. All in all a good day. Canterbury GP

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T

oday I flew to a small island off the coast of the beautiful Bay of Plenty for our monthly satellite clinic. Not

a typical day, but one of the highlights of my month. We delivered flu vaccinations and routine health care to the resident population and ensured that, despite their isolation, the residents continue to receive high quality and timely health care.

Waikato/Bay of Plenty GP

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I

am currently volunteering at a small remote hospital in Vanuatu which hasn’t had a permanent doctor for four years.

It’s a bit challenging to be here, as it’s all basic clinical skills and no fancy tests, X-rays or specialists to call on easily. So this morning I arrived for a ward round. Currently we have nine inpatients. There was a man who had been assaulted by his wife with a machete just arrived in the little acute room. So I was cleaning him up and examining his injuries, which included a large laceration on his scalp that went behind his right ear but fortunately didn’t take it off! He also had a large laceration on his lower leg. So once assessed and organised, I left him with a senior nurse who sutured him up. Took two hours! I did the ward round with another nurse, reviewing a child who had been admitted with a LRTI, a man recovering from a stroke, a lady with a nasty leg abscess and so on. I also arranged

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transfer to Vila of an elderly man with multiple issues, including a pleural effusion that needed draining. It’s challenging and refreshing to be using basic clinical skills again and looking after really sick people. It’s almost easier than dealing with the worried well and First World lifestyle problems that I mostly see in New Zealand. Overseas hospital doctor/GP

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T

oday was a lovely autumn day in Nelson. I worked from 7.45am to 6.15pm, but I did get out my mountain

bike for 50 minutes round the local MTB track, which is only five minutes’ ride from my surgery. I did one vasectomy, one BCC excision, removed a JadelleŽ and reinserted new rods, liaised with the local CAT team to see a suicidal 20-year-old male who was fitted in (after making sure he didn't take his craft knife with him), juggled the medication of the hypertensive diabetic whose renal function dropped a little to an eGFR of 20, visited an 80-year-old at home following calls from her daughter in Christchurch that things weren't good, arranged more home help for her and phoned the daughter at the end of the day, referred the dyslexic lad for audiometric processing assessment (whatever that may be), went through some cases with the registrar and looked at some skin things with her, discussed the risks and

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surveillance programme with a guy who has Lynch syndrome, did a couple of ACC reports and filed about one hundred lab results and letters. There were some other patients and I had a morning coffee with the staff and other docs in our noisy staff room. Fairly typical day but leavened by the chance to get a ride at lunchtime. Nelson/Marlborough GP

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H

ere is why I love my job. Today was such a mixed bag of young, old, sick, well and unexpecteds. My first

patient of the day was for a repeat script, but not only that. He had new bowel symptoms following what he thought was just from food poisoning three months ago. He was an older gentleman and had some red flags. A simple routine consult became something much more. We talked about still samples, did a rectal exam and referred him for a colonoscopy. I had a two-year-old well check; always good to brighten the mood to have fun with a kid and mum for 15 minutes! I had another middleaged man come in with an Aspen® neck brace.

But, he just wanted repeat meds – phew! I had an ACC renewal for concussion. I then had the opportunity to talk to the same lady about medication overuse headaches. What a great opportunity for patient education. I had a young female with a sore throat – viral URTI but exposure to strep throat. On exam,

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just a virus. My most complex patient of the morning was a late-60s female who hadn’t seen a doctor in a long time. Worsening SOB, new chest discomfort, left arm pain on occasions. On exam a new irregular pulse, raging murmur, crackles on the lung. She had a whole host of other problems to deal with on her list including low mood, a spot on her nose amongst others. She had also recently had a fall and thought her pain was from this. She was terrified. The nurse did an ECG and bloods and I carefully treaded through her anxiety to inform her she needed to go to hospital for a likely PE. Later, my diagnosis was confirmed. I ate a brief lunch, chatted with the nurses in the tea room and walked briskly (for my sanity) to do some rest home visits. I was on late finish this evening so had a whole host of other interesting consults. Now, I am relaxing with a work-out at the gym, writing my novel on the spin bike. I can’t wait to enjoy dinner later with my husband. I love my job! Canterbury GP

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T

oday as usual was very varied. I assessed and transferred a man with abdominal pain who had a subacute bowel

obstruction. I arranged for another man to be acutely assessed for his nonspecific hepatitis by specialists in Christchurch. I took an X-ray of a man with a nail through his hand from a nail gun and then successfully removed it. I attended an elderly gent who was ? a CVA but turned out to be having a hypoglycaemic event. I discussed the likelihood that this person’s fatigue was related to post-earthquake fatigue. I informed patients on the pros and cons of joint steroid injections and performed one for a carpal tunnel and another for OA knee. I prescribed and reviewed a number of patients for their chronic conditions. I had a multidisciplinary meeting with the local physio, the serious head injury team’s physio and psychologist, ACC case manager, the client and his wife. I supported many staff members who are struggling with the workload and went home exhausted! Canterbury Rural GP

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V

ery busy day. Started at 8.30am. First consultation was a 70-yearold complex multiple problem

patient. Made plans to get things done. Then a lady with a very sensitive issue, and also her daughter with fever (PUO) just brought in without an appointment. Then a few easy patients with skin infections and mouth ulcers. Last patient before lunch was a home visit – 10-minute drive one way. My lunch break was only 10 minutes, as I had to sort out a mental health patient whom I referred yesterday urgently for a mental health assessment. After a quick snack lunch, I saw a lady with R-sided chest pain who is planning to fly to Samoa this Friday. Organised some urgent bloods. One patient DNA, so I got some time, then I saw a few common GP problem patients. Suddenly my last urgent slot got filled with a walk-in patient – 10-yearold boy brought in by parents. He was coming downhill on the bike, then front wheel gave

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away and fell off. Presented with multiple injuries. Managed the patient with the help of another colleague and send to ED by ambulance (around 5.30pm). After writing this I have to log in to Medtech to finish my paperwork – may need two hours. Wellington GP

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I

had the privilege of having a trainee intern (due to start work as a doctor in a few months) accompany me for

the day’s consultations. Fresh eyes change my perspective, and what has become commonplace for me is remarkable for her. I try to inject fun into practice, whilst retaining the sense of importance of the work we do to help our patients. The Fish Philosophy, of “have fun, be present, make their day, and choose your attitude” is hopefully embedded in my work. We unmasked a diagnosis of severe COPD using spirometry on a man who had a chesty cough that didn’t come right with antibiotics. We used a hand-me-down slit-lamp to find a corneal abrasion and rule out serious damage in a woman who had something flick in her eye when she mowed the lawns. We had a young man whom I had previously visited in the Police cells. It has taken a couple of

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years for specialist psychologist assessments to confirm long-term problems from foetal alcohol syndrome. He attended with his father who is able to support him, and he’s keeping out of trouble and feels understood. North Island GP

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A DAY IN THE LIFE OF A KIWI GP

M

orning walk followed by a day at work. Twenty patients covering eight specialties. Three gyn

patients. Five children including follow-up for a family of five with giardia contracted in Chile. Three older patients with heart failure and hypertension. Finished paperwork and telephone consults. Home to make late afternoon tea for an elderly neighbour. Cooked dinner. Getting stuff ready to go away at the weekend to Samoa. This is a pilgrimage to Robert Louis Stevenson. Finished reading his essays whilst living in Samoa. Ready to put my feet up, but telephone kept ringing. Friend has had a stroke. Another friend’s daughter found dead in the USA. Quite a day.

Canterbury GP

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A DAY IN THE LIFE OF A KIWI GP

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I

arrive at work at 7.30am, unlock the door, turn on the lights, make a coffee and start tackling my task box in peace and

quiet. Colleagues arrive, exchange greetings as they sit down to do the same. 8.30am and our ‘urgent’ patient slots turn blank, the triage page fills up and we start calling patients. 8.45am team huddle, plan for the day so we know what roles everyone is playing. We have a happy workplace. First few patients are relatively straightforward, then a new patient with depression and substance abuse issues, an elderly woman with a severe headache who I speak to the neurology registrar about before referring to the hospital. I'm now running 30 minutes late and thanking all my patients for their patience. I skip my designated paperwork time, instead using my lunch break to catch up on it. The afternoon I see a mother worried about her baby’s development, a

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patient wanting to reduce medications, a patient with symptoms wanting more medications, family members concerned about their mother developing dementia, a growth on a woman’s cervix, a classic case of vertigo from BPPV, 92-year-old with multiple comorbidities that I had to tell he wasn’t safe to drive anymore, a few children with respiratory illnesses double booked by the nurse, and before I know it, it’s 5.00pm and I'm quickly writing a few referrals and nothing urgent has come in to my inbox before I leave. My mother has already fed and bathed my young girls. I get to read a few stories then sing them off to sleep. After eating dinner, I spend a few hours looking up things that confused me during the day and keeping up to date with the latest medical articles. Waikato/Bay of Plenty GP

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T

oday I saw some of the former refugees that arrived in New Zealand in the preceding week. My job as the

GP is to see the people with ongoing health issues, while other clinicians at the centre do the more in-depth health screening. So today I saw a mother and her infant born with a congenital problem that affected the infant’s development. This was significant and needed to be prioritised. I saw some off-shore vaccination records for children and scanned them into the PMS after getting the interpreter to translate the vaccine information into English. Our team will use that information when deciding what catch-up vaccinations are needed. I saw a middle-aged man with diabetes and hypertension, examined him and organised baseline bloods and urine tests so next week I have prescribed medications for him. I saw an adolescent who has allergic rhinitis and needed relief of his symptoms.

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I saw a woman with epilepsy and organised a trough drug level to help me decide on the dose of her anti-epileptic medication and educated her about the driving rules in New Zealand with regard to seizures. I agreed to two standing orders administered by our nurses – one for paracetamol for a child with a fever and the other for laxatives for a young woman with constipation. I reviewed bloods for 25 patients that had a battery of blood tests done two days previously. I saw some other acute cases – a man with neck pain and headaches and a child who had crushed his finger in a door and I needed to release the blood from under the nail to give him some relief from the pain. Finally, I saw an adolescent with poor sleep and nightmares for some months who is struggling to cope with her day-to-day life and referred her to see a psychologist to learn ways to deal with her past traumatic experiences.

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All the people I saw today come from a variety of cultural backgrounds and I used interpreters speaking their languages. These people have come to New Zealand as a final resettlement option because they have no possibility of returning to their own countries. Our team has the pleasure of welcoming these former refugees to New Zealand and work hard to diagnose and improve their health issues, and pass on an electronic health record to their new primary care services as they settle around the country. Auckland GP

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I

am a GP on contract in a low decile practice. I was on a 10.00am to 6.30pm day. I am struggling to keep up with

my paperwork, so went in a couple of hours early to work my way through referrals for people who either couldn’t be contacted by the hospital for their appointment or missed it (we try to contact them and see if they are willing to go to their appointment and re-refer them). I did a variety of reports and worked at nutting out some management plans for some of my trickier patients now that their results are back. I had booked appointments. I was averaging 20 minutes per patient rather than 15, as we are behind with some of our screening as a practice so are working hard on the opportunistic stuff, plus a number of patients just had more issues than is possible in 15 minutes. I find that some are not always able to get back for another appointment that easily. Also their health agenda may

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be different to mine, as they often don’t have the big picture with things like illness prevention, eg blood pressure and diabetes management vs the boils on their legs – so lots of explanation and education required. I admitted one child to hospital. Big ups to Middlemore registrars and consultants who really get the population of people we work with and are generous with advice and ease of allowing admissions. Rarely do I have to put up a fight to get someone seen acutely. Several times my patients had WINZ forms, which is normally a half-hour appointment as they usually come with a list over and above their form. Working on the issues that prevent people working takes time and asking the right questions. Four of those booked for WINZ were only booked for 15 minutes. So I got quite behind. However, one young woman is making some amazing progress rehabilitating from drug and alcohol use. So good to hear the most recent narrative of her journey.

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At 4.00pm I was scheduled to go on the walk-in queue. The line built up quickly and I realised that I was the only doctor left – normally we have one finishing at 4.30pm and another finishing at 5.30pm. I managed to whip through a few, but then had a complex situation that took 25 minutes to sort, so had a few unhappy patients after that! Did some good education over the day. I figure that the more people understand about their health, the less ‘ambulance at the bottom of the cliff’ we are. Also met some lovely people – our patients are what makes the work so rewarding. Also rewarding to be able to create a safe space for people to face their health challenges and learn and grow. Auckland GP

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A

part from falling out of bed, a coffee, breakfast on the run, and putting my pumps and lipstick on so that the

rest of the world can feel I ‘have it together’ (even I’m a little more convinced when I see the reflection in the mirror!), I consulted with several young women in various stages of emotional and or social development – about work or chronic health problems, or weight problems, or medicals needed for army training (and then discussed why they refuse spacers with their inhalers). A simple gynae problem (our second consult) turned into the fact that my young patient’s still birth occurring eight months ago had not been further discussed with her, no postmortem results forwarded to her (where are all those follow-up notes on this tragedy? None at all in her inbox or files). A flick to the nurse for Depo-Provera® and a call back to me, “Did I know she had seriously considered

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suicide last week?” I’m seeing her again tomorrow for a 30-minute consult. She’ll keep herself safe until then (whew). A woman who hit her head four weeks ago when the dogs tripped her on the beach – highly functioning, running her business, huge amounts of energy – struck down with intractable and terrible headaches, nausea, sleeplessness, tearfulness. The urgent CT scan was normal… and I’m relieved… but it’s no comfort to her at all! A wade through the referral pathways for concussion post-head injury and our 15 minutes is well and truly gone… we agreed she’ll see me again soon for further discussion. Then there’s the gent who’s alert and lively and just coming for a licence renewal at 75 years (a comprehensive medical – akin to an insurance medical check – in 15 minutes?!). Physically he checks out pristine, but there’s

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something odd – evasive almost – about his conversation approaches. So I dig a little further... 0/3 road signs recognised but elaborate descriptions of what they remind him of (nothing to do with driving!) and I suspect undiagnosed frontal lobe dementia – back to the RN for a moca which is 13/30! The staff and family up in arms because I have said “no further driving for now”, and then begins the damage control with upset family and staff who are certain this must be an error. Less than a quarter of my consulting day above (I forgot the youngish gent with CAP, just starting to decompensate, that I admitted to our adjacent community hospital – that was a 15-minute apt too). My paid locum work time finished 90 minutes ago… I’ve been doing ‘patient-related paperwork’... (and I can hear my colleague chatting to the cleaner next door)... why the hell am I even bothering to write this? But I love my work. It’s an

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incredible privilege. And I guess I would just like to let you know that. I’m still wearing my super comfy pumps… more lipstick on now and I’m about to rush to the local community music committee meeting. Text hubby on the way that I won’t be home for dinner after all. Good night. Waikato/Bay of Plenty GP

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Thank you to all the GPs who have shared a typical working day with us, ahead of World Family Doctor Day.


The Royal New Zealand College of General Practitioners Level 4, 50 Customhouse Quay, Wellington PO Box 10440, Wellington, 6143 Telephone: +64 4 496 5999 Facsimile: +64 4 496 5997 rnzcgp@rnzcgp.org.nz www.rnzcgp.org.nz

A day in the life of a Kiwi GP  
A day in the life of a Kiwi GP