An Elective in Remote and Rural General Practice
My elective was on the isle of Islay in the
Southern Hebrides (off the west coast of Scotland for all of you
who have no idea where that is!). I spent 4 weeks in 3 practices
spread over the island. The population of the island is around
3700, and with 5 full-time equivalents, this works out as only 750
or so patients per GP.
This ratio, when compared to the 2-3000 or so
patients per GP on the mainland, allows for much more time to be
spent with patients, making it easier for me to remember the
individual patients. There was more time for home visits which
meant you could really get to know a patient, as well as get to
know their family and see the circumstances in which they were
living. It also meant that the patients remembered me, so within
days I was meeting people in the town who recognised me and wanted
to stop for a chat!
The reason general practice makes such a good
elective is that you really do not know what is going to come
through the door next. I was being asked to examine joints, look at
rashes, listen to chests, and come up with a differential diagnosis
and management plan for conditions I had not covered since the
first year. I could not have prepared much in advance for these
situations because there was no way of predicting what I was going
to see each day. This was brilliant revision for me, and also
confirmed the fact that the variety is what I love about general
practice. Since we were in a remote area with a small population,
there were no specialist phlebotomists or nurse practitioners, so
this also meant that I had a lot of hands on experience in the
basic clinical skills such as taking blood and giving injections,
exactly the kind of thing I am going to need to be able to do well
in my junior years.
Island medicine also had its own particular
challenges. The only hospital on the island is run by the GPs, and
staffed by nurses. The policy is generally, if one of your patients
is in hospital, then they are your responsibility. This enhanced
the elective, as it meant I had some experience of basic hospital
medicine as part of the training. The more serious and urgent cases
get the “ambulance” to the mainland, which in this case is a small,
but very well-equipped plane. In my 4 weeks I saw one patient off
on to the plane, which I have to admit was rather exciting.
The difficulty of getting patients to the
mainland meant that you had to think twice about referring to
secondary care, but equally you could not delay proceedings in a
potential emergency. Since it could take up to 5 hours to have a
patient transported to hospital by plane, you needed to think that
far ahead, and have a lower threshold for suspicion that things
could turn out nasty. However, referring a patient to hospital for
a routine investigation such as a mammogram could mean a 10 minute
appointment turning into an overnight stay in Glasgow, a very
expensive prospect for some patients. This was a tricky balancing
act, and it was fascinating watching the doctors who had worked on
the island for decades, and seeing how they each overcame this
potential problem.
The other reason for going on an elective of
course is to see another part of the world. Being in the Hebrides
meant that I did not actually leave the UK, but I was cut off from
the mainland for a month, adding to the sense of being “away”. It
made it easier for me, being in an English-speaking country, as I
could concentrate on the medicine without a language barrier, but I
managed to still see a beautiful part of the world I doubt I would
ever have been to otherwise. The scenery on the island is
spectacular, and the wildlife turned me into a bit of a
bird-spotter! Ornithology was never really my thing, but it’s hard
not to get sucked in when you have a golden eagle fly past your
bedroom window every morning. There are even dolphins and seals
visible from the window of one of the surgeries.
The islanders themselves were overwhelmingly
warm and welcoming, and I was fitted in to the strong sense of
community within days of arriving. I don’t mind admitting that when
the boat took me away again a month later, I stood on deck and
watched until the island had completely disappeared from view with
more than a little sadness. I will definitely be going back at the
earliest available opportunity.
So for all of those considering an elective in
general practice let me highly recommend it. Although I was pushed
within my clinical and academic abilities, I never felt
uncomfortably out of my depth. I never got bored of seeing
patients, in fact the best bit was seeing them again, a continuity
which is hard to achieve during medical school. If you do decide to
go for it, I would also recommend going somewhere remote where
doctors have to take on more varied tasks than they might otherwise
have to in a city-centre practice, as this will give you a broader
experience. And try to go somewhere with a low patient:doctor
ratio, as this gives you more time to spend with patients, and more
time for the doctors to teach you.