Stephen A Margolis
The pre-vocational pathways to general practice are many and varied, yet all include a period in hospital-based practice. During this time, trainees rotate through a variety of distinct disciplines, which, broadly speaking, encompass the range of conditions they might encounter once ensconced in community-based primary healthcare. As these experiences are structured on the apprenticeship model, each participant can expect to interact with patients with sufficient familiarity to gain a clear and focused appreciation of the history, physical examination findings, investigation results and treatment paths. All of these build on medical school experience and form the foundations required for formal vocational training.
Yet within this experience, many pre-vocational trainees repeatedly express a desire to ‘feel’ more like a doctor. When asked to explain this notion, the common answer is ‘through the performance of procedural medicine’. Perhaps this is not surprising as the intellectual/decision-making process of contemporary junior medical staff is overshadowed by the rigorous application of close-range supervision by more senior clinicians, in part to ensure patient safety. This means few junior doctors are truly empowered in their decision-making processes, leaving the notion of physically ‘operating’ on the patient rather enticing.
Although general practice is not a predominantly procedure-based discipline, there are a range of office-based procedures that are intrinsically related. These constitute a distinct category of learning and assessment in both The Royal Australian College of General Practitioners and Australian College of Rural and Remote Medicine curricula, and sit well within community expectations of general practitioners. The list of important procedures varies across locations and time but an indicative list of 112 items defined though a Delphi process for contextually relevant list of core procedural skills was published in 2011.1 This list demonstrates a broad sweep across a range of seemingly distinct areas of medical practice.
To help celebrate this generalist spread of skills, this edition of Australian Family Physician (AFP) provides updates across a range of commonly practised office-based procedural skills. Fraenkel, Lee and Lee discuss a pragmatic approach to the removal of corneal foreign bodies, especially for those without access to a specialised slit lamp.2 Douglas and Wood, from the world-renowned Royal Perth Burns Unit, present the latest information on burn dressings.3 Pearson, Stewart and Bateson provide hands-on guidance on Implanon insertion and removal.4 We have also included a paper by Lim and Ho on the uncommonly practised procedure of office-based venesection,5 as both an update of changes in this area and to celebrate the breadth of experience across the Australian general practice community.
General practice procedural medicine is alive and well, remaining an intrinsic component of office-based primary healthcare. When procedural work is defined in the broadest sense, it remains reasonably common in contemporary Australian general practice. In 2015–16 there were 17.6 procedures per 100 encounters and 11.4 per 100 problems managed.6 Office-based GPs retain their strong commitment to procedural practice by focusing on those techniques that are safe, feasible and relevant to their patients and clinical environment. Perhaps the adage is true: ‘A clinician is complex. He is part craftsman, part practical scientist, and part historian’.7
Stephen A Margolis MBBS, MFM, MD, GEM, DRANZCOG, FRACGP, FACRRM, is the Senior Medical Editor of AFP; Professor, School of Medicine, Griffith University, Queensland; and Medical Officer with the Royal Flying Doctor Service.
- Sylvester S, Magin P, Sweeney K, Morgan S, Henderson K. Procedural skills in general practice vocational training: What should be taught? Aust Fam Physician 2011;40(1–2):50–54.
- Fraenkel A, Lee LR, Lee GA. Managing corneal foreign bodies in office-based general practice. Aust Fam Physician 2017;46(3):89–93.
- Douglas HE, Wood F. Burns dressings. Aust Fam Physician 2017;46(3):94–97.
- Pearson S, Stewart M, Bateson D. Implanon NXT: Expert tips for best-practice insertion and removal. Aust Fam Physician 2017;46(3):104–08.
- Lim HY, Ho WH. Performing therapeutic vensection in a doctor’s surgery. Aust Fam Physician 2017;46(3):98–102.
- Britt H, Miller GC, Henderson J, et al. General practice activity in Australia 2015–16. General practice series no. 40. Sydney: Sydney University Press, 2015.
- McDonald P. Oxford Dictionary of Medical Quotations. Oxford: OUP, 2004; p. 1.