Approaches to reflection on your topic area

You may want to write about:

- What you learnt

- Your thoughts on generalism

- Reflections on these themes through what you have witnessed on wards and in clinics

- Your experience of collaborating, preparing your presentation, presenting, dialogue afterwards

- Reflection on any creative enquiry text you produced or co-produced

What you learnt

Holistic care

Through the process of this presentation, I learned an immense amount on the nature of primary care itself, beyond generalism and uncertainty. Oftentimes medicine is more than just treating diseases.

Dealing with uncertainty

Researching and truly reflecting on generalism while preparing my presentation, I realised that the nature of medicine as I had always thought of was quite inaccurate. As medical students, our education has been centred around securing a diagnosis then forming a management plan. Therefore, I thought of uncertainty as an anomaly - a rare occurrence to be taken as a sign of something gone wrong, and as something to be fixed. However, I realised that from its very nature, undifferentiated presentations and the associated uncertainty are staples in general practice. Patients presenting to primary care physicians are often at the very beginning of the disease process, and thus by definition present with a degree of uncertainty. I realised that since it is such a fundamental aspect of primary practice especially, it would be important to simply accept uncertainty as an eventuality, and become familiarised with it and find ways of managing it, while being aware that sometimes, there will simply not be a straightforward answer.

To summarise, this project was useful to us and our learning. It made us think about the difficulties in primary care, and compare these to our the experience we were making currently in hospital placements. Uncertainty can cause stress for doctors, but also the patients and there are many tools that can be used to manage this stress and patient expectations. It once again, highlighted the importance of treating the patient and not just the disease. Especially in uncertainty, listening to the patients concerns and making sure these are looked after can be meaningful.

A third challenge is the notion of handling uncertainty – given the number of patients that GPs see, and the time pressure they face, GPs must make rapid decisions about referral and treatment of patients. For me, inherent in this is the fear that among many correct decisions, some incorrect decisions may be made. I feel this is a source of discomfort that will take me some time to get used to. Practicing advising patients under the supervision of a GP partner has been an extremely helpful exercise; seeing patients one-to-one while having the opportunity to discuss my own impressions and ideas around diagnosis and management with an experienced clinician has been an ideal way to learn and begin to tolerate some of the weight of responsibility that comes with guiding decisions about the health of others.

Undifferentiated symptoms

these scenarios were very effective at showing us how patients may present to the GP early on in the disease progress with very vague symptoms. For example, the symptom of fatigue can be caused by a vast range of underlying conditions, but at the time of presentation it may be the only symptom of disease.

A second challenge is the breadth of medicine that concerns can span. Concerns often cover not only the full breadth of physical health, but also other domains that affect health such as mental health and social determinants. Much of my pre-clinical teaching taught pathology in terms of siloed systems, rather than the cross-system multimorbidity many patients experience as a daily reality. Consequently, having the opportunity to see patients with a broad range of (often intersecting) concerns spanning multiple systems has provided me with a good introduction to the skill of being able to rapidly switch between pathologies affecting different bodily systems. My placement has helped me begin to mentally integrate different systems and the pathologies that can affect them.

Multiple concerns

One of the challenges that arose within nearly all of the appointments that I took part in is that patients frequently present with multiple concerns within a single appointment. Managing this within the limits of a 10 minute consultation can be difficult. In the past, I have particularly struggled with consultations in which patients discuss multiple concerns in quick succession, moving back-and-forth between different concerns. I am now feeling increasingly confident in being more assertive in structuring and refocussing conversations when necessary, so that I can investigate each problem methodically, helping patients get the most out of consultations. Three approaches that I have learned to navigate this difficulty are: rapidly establishing patients’ expectations from the consultation, subsequently using this to establish an agenda, and recognising when it is helpful to schedule follow-up appointments.

Your thoughts on generalism

Advocating for patients

As future doctors, I think we have a responsibility to change the current narrative surrounding obesity – which demonises and stigmatises individuals. I think it’s important that we advocate for government strategy to address health inequalities and improve access to weight management programmes for people with varying resources.

Decidedly, we have to challenge our own understanding of the complexities that contribute to obesity in the UK and until we address our own unconscious biases, we risk doing our patients a disservice.

Holistic care

It once again, highlighted the importance of treating the patient and not just the disease

Dealing with uncertainty

And what of the patient? I had briefly seen a patient in the surgery - a young woman with *** and ***, who had presented in distress. Speaking to her, I understood the nature of uncertainty as experienced by the patient, and had the realisation that I had neglected the patient experience as I was so focused on what I should do with uncertainty. Patients come to doctors expecting to find out what is wrong, and what to do about it. But sometimes we cannot give them that, and this must be incredibly frustrating. I remember this patient was extremely distressed by her pain and symptoms, and frustrated that it seemed as if nothing could be done about it. We couldn’t even give her the certainty of it being terminal or untreatable. The sheer uncertainty of the situation was incredible, and I knew it was taking its toll on the patient as she kept asking to be ‘fixed’, and asking for answers

For example, the symptom of fatigue can be caused by a vast range of underlying conditions, but at the time of presentation it may be the only symptom of disease. Examination findings may not reveal much else and other investigations are limited in primary care. I find this sort of uncertainty can be very stressful, to both, the patient and the doctor. So therefore I found it quite interesting and useful to learn in more detail, how you can cope with uncertainty in primary care, how you can reassure the patient in these situations and how you can provide patient safety in uncertainty.

Your experience of collaborating, preparing your presentation, presenting, dialogue afterwards

Our work focussed on the themes of multimorbidity and polypharmacy, in the context of obesity and diabetes. Reflecting on the complexity of the above topics, I felt intimidated at the beginning of the process. It was daunting thinking about how we would collaborate creatively whilst working remotely. We communicated via WhatsApp and shared our work back and forth via email. Despite the challenge of not being able to develop our ideas in person, we produced a meaningful and thought-provoking presentation.

After the presentation we discussed with the GP the concept of polypharmacy and how this can affect compliance of the patient. We also discussed ways to try to improve compliance when a patient has many medications. I felt that this discussion was really important because as a doctor I will be looking after patients who have multimorbidity, and thinking about how this affects the quality of their life is very important.

The presentation went well as we had prepared well and our content was thorough. It was great to discuss our topics with the rest of the group and listen to their experiences and thoughts on issues like uncertainty and what they had learned from their respective patient encounters

I enjoyed working as part of a team, we discussed the different topics together and decided what topics are best to choose. We also discussed our patient encounters and experiences regarding the various topics. I felt that it is was very educational learning together and listening about our experiences and reflections of those experiences. Learning how to work as a team is really important skill for a doctor, so I was happy I got to further improve and practice this skill with my colleagues.

On a personal note, putting forward ideas and contributing to this drawing, I realised how art and creativity is an excellent outlet for being able to express aspects of medicine that cannot be expressed using words. I am not a very artistic person and I rarely draw or paint; however, completing this project has inspired me to perhaps put more effort into creative enquiry in the future as I feel it has enriched my thinking and I feel less bound by the restrictions of reflection using only words. Reflection is an integral part of medical school and will continue to be going forward in my career, and I find it very exhausting to sit and find words to be able to reflect on every situation. Through poetry, art and other creative mediums, there is a chance the process of reflection will become less tedious and more enjoyable subsequently encouraging me to do more of it.

I was apprehensive at first to include a drawing as part of the creative work. I was envisioning something along the lines of a photograph or a video roleplay, which I thought would be a little easier and more fun. Plus, I was well aware that my drawing abilities were non-existent, and I expected to find this work frustrating or even embarrassing. However, I took the initiative to venture outside of my comfort zone and accept the challenge.....I first began by opening a discussion on the medium by which to express the piece. Pen and paper, surrounding objects, powerpoint (e.g. making a collage of different graphics) - multiple ideas were thrown around. In the end we decided to use an iPad and Apple Pen to draw on the app Notability. Next, we looked at the subtopics of generalism and delegated them within our team. I looked specifically at the shared decision making aspect.....

My biggest takeaway was how we organised ourselves and worked together to make a thoughtful drawing. I recently finished reading the biography of Pixar Animation Studios, Creativity, Inc. I was particularly fascinated by the founders’ ingenuity in combining artistic style and story with a technological medium. But, perhaps more crucially, how they organised and managed the team in order to facilitate optimum creativity. Returning to the issue at hand, I approached this creative assignment as an exercise in how to generate a creative piece as a team - as if we were creating our own Pixar image.