My working day

I have delayed writing about my work because of concerns about confidentiality. This blog is accessible to anyone who finds it and the island population is so small that it would be easy for patients to identify themselves. I shall have to be circumspect in what I write and careful not to cause offence.

I knew when I accepted this post that it would be different previous work I have done. Working as a GP in the UK I used to see a huge variety of medical problems and move rapidly from one medical speciality to another as each new patient described their problems. Indeed I often dealt with several totally different problems during a consultation with a single patient. Up to a point it is no different here, when I am working in a general clinic the work is very similar to UK General Practice. It is what happens next that is different. Whereas in the UK there is always a specialist to refer to or take advice from on St Helena there are no specialists. There are three GPs Sarel, Wendy and myself, and a General Surgeon, Ramdas, to do everything.

We do have visiting specialists, there was an orthopaedic surgeon here for a couple of weeks in January but he won’t be back for a year or two. The ophthalmologist should be coming in August but we are awaiting confirmation and we are hoping to find a General Physician, if there are any left, to come for a couple of weeks before the end of the year. It is possible to contact various specialists by e-mail or phone for advice but that is time consuming and you still carry full responsibility for managing the patient. I find myself spending a lot of time on the internet in the evenings reading up about problems I am trying to manage. My two GP colleagues are helpful but unfortunately they do not always see eye to eye and I sometimes receive conflicting advice. Sarel is good on cardiology and obstetrics and Wendy is helpful on gynaecology but in other areas we have no shared expertise at a spcialist level.

I have been given Diabetes, Elderly Care and Psychiatry as my special interest areas and run dedicated clinics. Diabetes is a huge problem on the island with nearly 1 in 3 middle aged women having diabetes. Management in the past has often been haphazard mainly I think because some of the GPs who have worked here do not have the UK approach to Chronic Illness and do not always follow guidelines on best practice. They tend to respond to problems then do little to monitor a condition until the next problem arises. The result is that less than 25% of diabetics are well managed by UK standards and many patients have complications that might have been avoided with better pro-active care. I am attempting to reorganise the diabetic clinic, introduce some simple guidelines and even audit the outcome.
Psychiatric care is rather better organised, I have the support of a UK trained CPN and a monthly teleconference with a South African Professor of Psychiatry who has been to the island and understands the working conditions and constraints we have to adapt to. The GP type psychiatry is straightforward but I also have responsibility for the small psychiatric hospital and patients with learning difficulties as well as children with ADHD and adolescents. The latter group are a particular problem as there have been a series of teenage rapes by older men with family links.  I will also be taking on the child protection work when Wendy leaves.

The General Surgeon at present is Prof Ramdas Rai from India whose interest is endoscopy and GIT tract surgery. He is excellent in his specialist field but a little reluctant to move outside it. Also of course a surgeon requires an anaesthetist and that naturally is the role of the GP. Fortunately my past training in anaesthetics and a couple of sessions of updating my skills at Salisbury before I left has enabled me to take on this work reasonably comfortably. I do a day in theatre every third week and occasional additional emergency cases. I have given about 20 anaesthetics so far without major problems - touch wood!
Emergency orthopaedics is a major weak area. I have reduced and set a couple of minor fractures. Fortunately road traffice accidents are rare and violence uncommon but the lady with a fractured femur can only be managed conservatively until the next ship for Capetown which will be nearly 8 weeks after her fall. It was ironic that I was actually eating at her restaurant when she fell, the family knew me so I left my meal and was able to diagnose the fracture within minutes of her fall but she will wait 2 months for treatment.
We do have an X-ray machine and a nurse trained to take the pictures but must do our own interpretation. There is also an excellent ultrasound machine but again we have to do our own scans, I'm learning slowly.

The working day starts at 8:30 except on Thursday when we start at 8:00 with each of us taking it in turn to provide a presentation on a subject of recent interest. We have a half hour to discus any problems from the previous day and then go down to the wards to see our individual patients and catch up on paperwork and reports. I then do a morning clinic everyday except when I am anaesthetising.  Three days a week these are in the hospital but on Mondays and Thursdays in peripheral clinics. The Monday clinic is at Half Tree Hollow which is a rather dull dormitory community high on the hill above Jamestown it’s a busy clinic with 20 or so patients but usually fairly straightforward. On alternate Thursdays I attend the Levelwood and Sandy Bay clinics. These are rather ramshackle buildings high on the mountain and often in cloud but with stunning views on clear days. Despite being only a few miles from Jamestown there are patients who hardly ever go to the “town” they all speak the Queen’s English but some of them are barely intelligible. They are stubbornly independent and quite stoical. One lady had fallen and fractured her wrist but waited three days to see me in the clinic rather than come to the hospital. Monday afternoons I run clinic at the Community Care Complex which is a large modern building which provides residential and nursing home care for the elderly. Tuesday afternoons I assist the dentist with sedation for the large proportion of the population who seem to be needle phobic. Wednesday pm is my diabetes clinic, Thursday is catch up time and prison visits and Friday is my mental health clinic at the end of which I am more than ready for sundowners at Donny’s on the waterfront.

We are on-call one day in four but always have to be prepared to help out with an anaesthetic in an emergency especially for maternity cases. Out of hours is when life becomes interesting because whatever the problem you have to find a way of managing you cannot delegate to someone else. When a man died suddenly and unexpectedly I felt unable to provide a death certificate and suggested a post mortem, the next day I carried out my first post mortem. We have to recognise our limitations and acknowledge that some problems are beyond our resources. Last weekend a man was admitted with a leaking aortic aneurism, we did not attempt resuscitation but gave enough morphine to keep him comfortable and ensure that he died peacefully.

For non-emergency problems there is always the option of sending patients to the UK or Capetown for definitive care. This is a very expensive option from the managers point of view because not only must the island fund the cost of the treatment, in South Africa at least but also the cost of travel and accommodation while the patient is away.  Each Thursday morning we have a meeting to discuss priorities and decide which patients justify referral. Not an easy task, there are some guiding principles written down but it is never an straightforward decision.

The most frustrating aspect of work here is the attitude of many of the islanders particularly the older generation who are reluctant to take any responsibility for their health. One of the major reasons for the high prevalence of diabetes is the poor diet and lifestyle of the islanders. Obesity is far worse than in the UK and accepted as the norm. I’ve even had patients of ideal body weight concerned that they are too thin and cannot put on weight. That said I’ve some sympathy for their attitudes, fresh produce is expensive and not always available and the opportunities for exercise are limited if you cannot manage steep hills. Most roads and paths go either up or down there are very few opportunities for easy walking. The problem of attitude to health care remains and includes an assumption that it is the doctor’s duty to care for your health and that it is the Government’s duty to improve health care. They do not want to know anything about the details of their medical problems and often cannot provide a reasonable account of their symptoms or the history of their condition. A common comment about problems they have had before is that the doctor didn’t tell me anything, I’m suspect there is some truth in this but I’m sure that the real problem is that they didn’t ask or didn’t want to know especially when the message was unwelcome.

Minor niggles aside most of the patients are appreciative and supportive, I’m enjoying the challenge of my extended General Practice role and developing new skills though where I will use these skills next is another matter.