Wednesday, 7 January 2015

GP Obstetrics in Shetland - a unique challenge

The view from Lerwick surgery!
I'm Dylan Murphy. I'm one of the few GPs still doing Obstetrics in the UK. This either means I'm mad or that remote and rural practice offers some challenges unavailable elsewhere. Hopefully it's the latter!

I came to Shetland 13 years ago and have been working as a GP here ever since. I'm also an Educational Supervisor. I wasn't drawn because of the obstetrics. I'm not a wannabe obstetrician. The practice I joined simply "did obstetrics." So I just got on with the job and found I actually liked it and was good at it. Since that time, things have changed both nationally and locally.

Nationally, practice is becoming ever more specialised, with hospital specialists performing ever more narrowly focused roles and GPs in most of the country overwhelmed with daytime work. Locally, similar trends have caused GPs to focus on their "day jobs" and leave other work behind them. Once upon a time, GPs in Lerwick did not just primary care work, but also the hospital medical ward, rehab ward, anaesthetics, A&E and forensic medicine. Now, only the forensic work and the obstetrics remains.

In hospital training, there are no longer O&G consultants - they specialise in either Gynaecology or Obstetric, and an island of 23,000 patients will never have enough work for a permanent consultant obstetric team.

So is GP obstetrics a dying art, or is there an opportunity here for tomorrow's remote GPs? I'd like to think it's the latter. Please allow me to tell you why.

Why GP Obstetrics?


Variety is one of the things that make General Practice such a rewarding speciality. It's why I chose to be a GP in the first place. It's one of the clich├ęs of General Practice that you look after people "from cradle to grave." A GP Obstetrician just takes it one step further and looks after the unborn too. And their mums of course. You also have the pleasure of looking after well people, while also judging risk, which in obstetrics, is a key skill.

How do you manage the workload on top of General Practice?


Protected time is the simple answer. When I first began GP Obstetrics, we covered the maternity unit while performing a full day's primary care. Cue cancelled surgeries, tired morning-afters and a service under threat. So, a solution was devised ( by me in fact!) in which the GP obstetrician of the week has no prebooked primary care appointments. This saved the service, and the sanity of the GP obstetricians. I still do all my admin - clinic letters, prescription requests, you know, all that annoying stuff. I also attend the practice meetings and so on. If it's been quiet on the maternity unit, I've even been known to volunteer to do some visits or emergency surgeries out of the goodness of my heart. If it's been busy, I am allowed to sleep it off.

Does it affect your training role?


A little, but not really. I am fortunate to have another ES at the Lerwick Health Centre, and he does the tutorials on the weeks when I am the obstetrician. We make sure I'm not covering obstetrics when he goes on leave. See - easy. Also, this gives the registrar a bit of variety, and helps the ESs benchmark and share ideas. It works well. Obviously, I'm at the practice quite a bit on my "obstetric week" and the registrar can get hold of me at any time, so it works nicely for all concerned.

Can the registrar do any Obstetrics?


Unsupervised - no, but there is an opportunity to accompany me at work. The amount of exposure to obstetrics depends very much on the registrar. If the registrar is interested or considering doing some GP obstetrics in the future, they can join me at the unit, but the core GP training comes first. Even if the registrar has no such thoughts, joining me for some antenatal clinics is useful to them, so that would always be part of the setup.

What does a typical working week look like?


I do a week on at a time. It starts at 5pm on a Friday. We have found this works well as a handover time, as if you need to catch the Friday ferry or the last flight to the Mainland, it's no bother.

Weekend


The weekend is purely on-call. Nothing routine at all.

Mornings


Mornings tend to have a few outpatients and time to discuss cases with the midwives. The appointments are at least 30 min long. The patients can only see me if the midwife needs an opinion. I've usually spoken with the midwife about each case beforehand. They tend to be about choices or decisions. We have a long list of risk assessment proformas which we have found to be useful over the years. We found that a lot of women were exercising their right to ignore the national guidelines on place of delivery and "insist" on delivering in Shetland. Typical examples would be women with high BMI, Group B strep carriage or a previous shoulder dystocia, etc. The proformas help us guide the decision making to ensure all relevant points are covered. Other cases would be women with medical conditions like hypertension in pregnancy. My involvement can avoid the woman making several trips to Aberdeen during the pregnancy.

Seeking advice


I liaise with Aberdeen colleagues fairly often. We have two consultants who are my designated contacts for Shetland patients, who will reply promptly either by telephone or e-mail. If I need emergency advice, there is always the on-call consultant or senior registrar.

Afternoons


The afternoons tend to be "down time" although I might have the occasional meeting. Generally, I can finish my admin (including catching up with Core GP work) and go home. But don't knock me for going home early. I do have to be on call overnight......

Out of hours


We all know obstetrics tends not to be nine-to-five, but most of the work is outpatient stuff. It's not unusual to be called for advice at some point through the evening, but I get a full night's sleep most nights.

Caesarean Sections


We do about 20-30 elective sections a year in Lerwick, for selected low-risk women. Of course, we have emergency sections too when required. I manage the complex labours with the midwife and decide when a section is required. They are performed by our consultant general surgeons, who have specific training to perform sections. I act as neonatologist then.

Did you say neonatologist?


Yes indeed. My job is usually to stand there and look calm and knowledgeable, but I am sometimes called into action on the resuscitaire. We also have an anaesthetist handy when things get tricky. Very occasionally, we will have a sick baby needing transfer, or just a fairly well 35 weeker who needs some monitoring prior to transfer to neonatology. The neonatal retrieval team come up to fetch the babies and always complement us on our management. Typically, we would need a neonatal transfer around 3 or 4 times a year.

How do you keep your skills up?


We only have 2-300 deliveries a year, so keeping skilled is important. Early on, I attended Aberdeen Maternity Hospital to upskill annually. More recently, however, although I have spent some time in Aberdeen, most of my learning is provided by NES who have two fantastic courses which are each delivered in Shetland every 2-3 years. One is on neonatal resuscitation and stabilisation. The other is on management of labour ward emergencies. Both are hugely beneficial. I attend them with my midwifery colleagues. Rural Shetland GPs sometimes attend too.

We also have learning sessions at the department to keep skills fresh in the meantime.

Teamwork


One of the best things about working as a GP obstetrician is the team approach we share with my midwifery colleagues. We have lots of opportunity to learn and discuss cases, and we get along really well. They serve as our community midwives and labour ward midwives. Coffee and biscuits are of course an essential part of the process. Never any shortage of biscuits and chocolates donated to the maternity unit!

Benefits for GP colleagues


Firstly, my colleagues find I am glad to be back in primary care on my primary care weeks. They also use me as a resource with my knowledge of obstetric medicine. Continuity for my patients is obviously somewhat affected, but I am still a GP more often than an obstetrician, so it isn't too much of an issue.

All in all


After a 168 hour on call period, it's nice to hand the phone over, have the weekend off and get back to primary care. After a busy week in primary care, it can be quite nice to face the slower pace of life in Obstetrics for a week. I find this variety stimulating.

GP training on the UK mainland simply doesn't prepare GPs for intrapartum obstetrics, but coming to Shetland gives a chance to get exposure to the field of GP obstetrics, and for those who find themselves interested, who knows, they could end up joining me, or at least pick up valuable skills in antenatal care and maternal medicine.

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