The breadth of general practice ‘stops with your imagination’
A doctor’s personal philosophy is one of the most important things to former GPRA President Dr Sama Balasubramanian.
According to Sama, a GP trainee should base their Extended Skills Training (EST)—and by extension, their future practice—around what aligns with them philosophically.
“You really can achieve good philosophical satisfaction by choosing an appropriate EST that speaks to you,” Sama says, “and your EST really gives you an opportunity to explore facets of medicine.”
“The breadth of general practice stops with your imagination.”
Choosing an EST is about putting yourself out there and taking a leap into the unknown, Sama says.
Sama notes that not all GP trainees are lucky enough to be able to pursue their first-choice EST.
“I hope that, in the future, we can work towards the ability for people to choose ESTs that they really want to do that help them grow as a GP and that speaks to them culturally and philosophically.”
“We need more lateral movement and transition in the training program to ensure people can achieve their extended skills dreams.”
However, Sama says that general practice offers a lot of flexibility for GPs to build on their clinical interests post-Fellowship.
Sexual health medicine
Sama’s area of biggest clinical interest is in sexual health, an area which he says is often the hidden agenda of a patient’s presentation to a GP.
“Sexual health is not just about correcting dysfunction, it is also about experiencing people’s attitudes, values and beliefs when it comes to sex, and what sex, gender, and sexual attraction means to them, and helping them build a complete picture and feel content within themselves and satisfied within themselves.”
Sama knows that sexual health can be a stigmatising topic, but it is important to address when treating a patient holistically.
A listening ear can be the greatest tool for a GP, Sama says.
“You look at the person and not the disease. You learn more about the person, and you learn that you need to understand communities, in order to provide healthcare that is suitable.”
“You glean a unique insight into the way in which society can subconsciously attach biases and stigma and shame to particular groups or individuals.”
Sexual health medicine isn’t about pointing to an answer in a textbook, Sama says.
“It is really thinking about what lens you come from when you talk to a patient.”
Sama’s advice for those considering a term in sexual health medicine is to think about what biases they have and to manage those biases appropriately.
“It doesn’t matter what your initial perspective or philosophy is, you have to be open, accepting and able to understand and learn from others that they can be different to how you are.”
“It was a very strange experience to start consulting in another language…because when your patients start looking like you and belong to similar cultural backgrounds as you…you almost feel you’re at home and you’re treating a family member.”
Refugee medicine
Sama completed his EST in refugee health, providing care to Sri Lankan Tamil refugees.
One of the most rewarding things about refugee medicine is being able to see the way in which small snippets of healthcare, particularly preventive and opportunistic care, can make a big difference to a community, Sama says.
Speaking the same first language as a refugee population goes a long way, Sama says, but if someone does not speak a second language, they should not be discouraged from considering an EST in refugee health.
“It was a very strange experience to start consulting in another language…because when your patients start looking like you and belong to similar cultural backgrounds as you…you almost feel you’re at home and you’re treating a family member.”
Sama says that providing healthcare to a refugee population quickly goes from treating a cough or a cold to learning a patient’s story.
“You learn about the history of torture, and trauma and abuse. You listen to the patient, you empathise with them.
You may be the first person that they reveal these things to, outside the vestiges of what they may feel is the government listening in.”
The key to managing the second-hand trauma is both appropriate professional supervision and self-care.
“Countertransference and transference is inevitable.”
“GPs can’t manage [a refugee’s] story in the same way that we can manage blood sugar or cholesterol levels. We must understand the way their story affects us, and then find the things we can do both positively and passively to deal with that.”
“You realise what your limits are as a practitioner in terms of what you are happy to hear and not to hear—we all have different limits.”
While refugee medicine has a lot of psychological care involved, there is also a large amount of clinical medicine involved—which would excite any clinician, Sama says.
“There are high rates of type two diabetes and its complications, previous histories of tropical and exotic diseases, high rates of cardiovascular morbidity—and you’re doing that complexity within the context of an emerging health understanding for that population.”
