Adapting to community medicine

My first job as an FY2 has been in community geriatrics, at a small hospital in a rural area of Cornwall. It is a GP led ward which accepts all kinds of eldercare admissions, from acutely unwell patients, to end of life care, to the medically stable requiring ongoing physiotherapy. Having come from the acute trust, I spent my first couple of weeks feeling a little bit like I had been sent back in time, and adjusting to the slightly rustic practices took some getting used to. However, the lack of resources or immediacy of results has culminated in the exponential development of my clinical reasoning, examination skills, and ability to ask the questions ‘do they really need this?’ and ‘How will it alter management?’.

With no onsite lab, blood bikes come twice a day to collect samples. There is no gas machine, but there is a point of care machine, attached with a cost of £24 per sample. Specific blood tests have to be individually requested – there is no ‘general medical bundle’ like I became used to at the DGH. This has required me to engage my brain and step away from the formulaic ways, considering which specific blood tests, if any, are necessary. Furthermore, are they so urgent that an additional blood bike must be called to make the 45-minute trip to the lab? I have learnt a lot from the GPs working here about weighing up these decisions, as well as the importance of treating the patient and not solely the numbers. This has become particularly apparent with oral vs intravenous antibiotics. With no ultrasound on the ward, another piece of equipment I had become quite used to having around, and having no med reg or anaesthetist to call, being unable to cannulate is a more common occurrence. The necessity of the IV route is therefore brought into question. For many antibiotics, the oral bioavailability is very similar to that of IV. Lots of the patients on the ward do not wish to be re-admitted to ED, and so it is often in their best interests to oral switch. I still find these decisions challenging and sometimes uncomfortable. However, the GPs’ approach to patient centred care and best interests vs treating a number is something I commend and is incredibly important in this cohort of elderly patients.

Requesting imaging involves booking ambulance transportation, as the patients must be driven across the car park (!!) to the get to the X-rays and CT scanner; this often cannot be done that same day. This has prompted me to home in on my examination skills; the question of fluid overload vs infection cannot be immediately answered by a CXR. The GP will instead ask me ‘what exactly did you hear on chest auscultation, what exactly did the crackles sound like?’, causing me to more often than not return to the patient for another listen. The art of the examination is something I feel had been somewhat lost on me during FY1, with the availability and immediacy of scans and investigations making it seem somewhat redundant a lot of the time. Not only have my examination skills improved, but I have also rediscovered some of my love of just how cool medicine can be, and how much we can learn, discover and diagnose by spending a bit more time listening to and examining the patient.

Overall, I have had a very positive experience in the community hospital, and although I was hesitant at first, it has been the most enriching learning environment so far. Taking the time to question more of my decisions for investigations, and going back to the examination, is something I plan to take back to the acute trust for my next job. That being said, we are still trying to get phone lines installed in the Doctor’s office, so there are some things I won’t miss!

Dr Katie Briggs

F2, Peninsula Foundation School

All previous HOFP articles can be found on our HOFP webpage