General Practice is Messy

I’ve just read a great post by Dr Marlene Pearce about the art of uncertainty in general practice.

As I found myself nodding in agreement to Dr Marlene’s wise and well-written sentiments, I was reminded of a conversation I had last year…

“I’m really surprised you settled for being a GP.  You used to be such an over-achiever!  Why didn’t you choose something that’s intellectually challenging?”

I hadn’t seen my old uni friend since Med School and after the first five minutes of listening to him boast about his prestige and income, I was reminded of why I hadn’t made the effort to stay in touch.  By the time he finally got around to asking what I was doing, I was seeking means of conversational escape.

I smiled sweetly and replied, “I did. Some enjoying fiddling around with bonsai, while doctors like me find challenge and reward in being swamp gardeners,” before politely excusing myself.

I was introduced to the concept of swamp gardening by GP, researcher and medical educator extraordinaire, Dr Louise Stone, during an address she gave at the 2011 GPET Convention, and I have to admit I’m quite taken with the metaphor.

It relates to the messiness of general practice: the reality that we spend much of our time dealing with undefined and sometimes undefinable illness.  In medical school we were taught to approach a presenting complaint in a stepwise fashion:  history, physical examination, investigations, diagnosis and then finally management.  In primary care, it isn’t always so clear cut.

Donald Schön, in his book ‘Educating the Reflective Practitioner’, wrote: “In the varied topography of professional practice, there is a high, hard ground overlooking a swamp. On the high ground, manageable problems lend themselves to solution through the application of research-based theory and technique.  In the swampy lowland, messy, confusing problems defy technical solution.”

The most horticulturally challenging swamp species are conditions without nice, neat diagnostic labels.  It is hard to wage war on a nameless, faceless enemy.  If they are tough for us, they are enormously more difficult for the patients they affect.   Many have been on the diagnostic treadmill for years.  Poked, prodded and imaged over and over by various GPs; bounced from specialist to specialist. They’re told everything they don’t have.  Some latch onto the labels they accumulate along the way, grateful for any name to explain their suffering.  I recall a patient for whom a somatoform disorder diagnosis brought immense comfort.  “It’s a real disease,” she’d tell her friends. “It means my body’s more sensitive than other people’s.”

Others find such diagnoses insulting, shameful and upsetting, desperate for a more “socially acceptable” explanation.  One such patient told me that the day she was diagnosed with breast cancer was the happiest day of her life.  “At least now people will believe I’m sick,” she said.  As Dr Stone said in her address, “There will never be a Fun Run raising awareness for medically unexplained symptoms.”

No one would deny that swamp gardening can be frustrating and draining.  However, if you are searching for meaningful, important and interesting work, you’ll find it in the swamp.

It is challenging to sail the diagnostic sea without sinking under the weight of over-investigation or being capsized by a missed serious condition.  It takes intellect and bravery to negotiate the treatment maze without a map. And there’s immense reward and satisfaction to be gained by wading through the swamp with your patients, weeding and planting.  Efforts which, if you’re lucky, will occasionally bear fruit.

Even if I had spent time explaining it, I suspect my old uni friend would not have understood the fundamentals of swamp gardening.  My cryptic answer made an impression though.  I heard that he’d commented that “Genevieve‘s gone all flower-power closet hippy.  Must come from living near Byron Bay.  Shame, that.  She used to be kinda normal.”

Adapted from my piece, “Swamp Gardening” first published  RACGP’s Good Practice magazine, Jan/Feb 2013  – “Portraits of General Practice” Column

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