Introduction by Croakey: As a GP in a rural town “you become a beacon for rough seas” especially during a pandemic, writes Dr Amy Coopes in this profound and reflective article below.
Coopes, a junior medical officer and Croakey editor, spent five months of her internship in general practice and saw how primary care is doing so much of the heavy lifting during COVID-19 outbreaks and lockdowns and educating patients about vaccinations “conversation by painstaking conversation”.
‘Crossing Black Dog Creek’ was first published in Medical Republic and is republished here with permission.
Amy Coopes writes:
For weeks and months through the long, lean stretch of winter I travelled the highway across Black Dog Creek.
Leaving the hospital for two terms of general practice had been a lucrative carrot through the slog of ward and ED-based work in a health service stretched to the seams by population growth, years of underfunding, and an influx of delayed presentations and postponed care due to the pandemic.
Compared to hospital work, previous interns had said, general practice was a welcome change of pace.
It was slow going at first as I found my feet, and I relished the opportunity to really sit with a patient and nut out a diagnostic or management dilemma. All those abstractions of medical school were suddenly there, in the flesh. Autoimmune diseases, cancers, obscure presentations that – beyond a final-year OSCE – I had assumed I’d never be the first to see, much less diagnose, in a patient.
In terms of flexing the grey matter, there was little comparison with life as a hospital intern, where you were integral in many pragmatic ways but rarely the fulcrum upon which someone’s fate could turn.
I had a collective of incredibly knowledgeable, experienced and canny supervisors who took the time to teach and to mentor me in the art and practice of rural primary care. These were doctors who never saw an intractable problem, only solutions. They managed complex patients and presentations with compassionate acumen and a holistic paradigm that met the community where they were, at all walks and stages of life.
I know much is said about general practice and GPs being your “specialist in life”, but five months as a junior doctor in primary care has given me a newfound respect and appreciation for the extraordinary breadth and agility of my generalist colleagues, who are undercompensated and too often underappreciated for what they do.
They cut out cancers and birth babies, provide a safe haven for the homeless and hopeless, for victims of family violence and those living with mental ill health; they look after your elderly, sick parents in residential aged care, run peripheral rural hospitals with a fraction of the resources but bucketloads of experience and acumen, managing heart attacks and traffic accidents with the calm ingenuity of someone who has never thought twice about running towards a scene.
They palliate the dying with dignity and compassion in their homes, immersed in love and comfort; these are patients they have known for years, decades even, a lifetime of the body’s peaks and troughs smoothed by the tenderness of their hand.
Heavy lifting
Much of the media reporting and public conversation around COVID has focused on our tertiary centres and the acute coalface of the pandemic itself: our emergency departments, ICUs, respiratory wards and all the tireless, selfless people who continue to front up to them, day after day.
But primary care is out there doing so much of the heavy lifting. In its own way, general practice is the pandemic’s frontlines. Conversation by painstaking conversation we have helped people come around to vaccination.
We have inoculated millions and millions of Australians against SARS-CoV-2, and countless millions more against the much larger epidemic of misinformation and fear.
We have kept people well between specialist appointments that are increasingly delayed or diverted to telehealth.
And general practice is managing a huge hidden pandemic of mental distress downstream of years in lockdown, isolation and destitution. Successive inquiries at state and federal level detailed a mental health system in crisis well before COVID-19 paralysed our communities, and this has been laid bare – in confronting detail for those of us walking alongside the worst-affected – as the pandemic has dragged well into its second year. Psychologists are closing their books, public services are stretched to the point that they can only respond to crises. When people hit rock bottom, it is left to the GP to pick up the pieces and patch together some kind of a solution.
After months and years, the moral injury takes its toll. I watched a number of colleagues, burnt out by the mounting challenges of 2021, walk away from the job for a breather. Some may never return.
One veteran clinician told me she had never worked as hard in several decades of general practice as she had this year. For juniors, she said, it was an order of magnitude more challenging; while established GPs largely manage their regulars and mostly have their books closed it is the training doctors who end up with the walk-ins, those who have soldiered on until they reach breaking point. The wayward, the lost-to-followup, people who have fallen through every crevice imaginable and are desperate to come up for air. As a GP in a rural town, you become a beacon for rough seas.
I crossed Black Dog Creek for months before the shadow of its namesake began nipping at my heels; the culmination of countless vicarious blows, the slow erosion of faith as genuine agnosticism about vaccination gave way to hostility, too many nights spent lying awake nursing anxieties about patients on the edge in a system stretched thin by design.
Perhaps naively, I had believed burnout was not something that could happen to me. Primary care is so often depicted as a “lifestyle” profession, and it had been sold to me as the obvious choice for an intern year that offered breadth and clinical independence with the time and space to really enjoy it. It felt, instead, at times, like treading the rapids.
I learned just as much about our system, and about myself and my limitations, as I did about prescribing, pathology and patterns of disease. I was challenged in ways I could not have foreseen.
Empathy and compassion are attributes that make an exceptional GP; they can also double back to become a great weight when the heft of pain, multiplied, is upon you, and you have little more than yourself to give. Yet give you do. Because, against impossible odds, every day in general practice you make a difference. You heal through listening, in partnership; by showing your patients the best version of themselves and who they might long to be. You share the burden. And some days, you save a life.
Dr Amy Coopes is a junior medical officer in Victoria and an editor for Croakey
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