Tariq Koor – 1353519

Self Reflective Piece

I found the first two days of my preceptorship to be very enlightening. I didn’t really know
what to expect during my time with Dr Rozelyn Rabie, a family physician as well as a
allergologist and immune specialist. The majority of the patients I saw in first two days were
chronic patients dealing and suffering with an array of immunological conditions, from
asthma and urticaria, to Chron’s and primary immunodeficiency. I was initially overwhelmed
by the complexity of some of these conditions and their management, as I was expecting
more common medical conditions. However, what I soon realized is that that the complexity
of the conditions isn’t an important factor in family medicine. These patients also had ideas
and concerns that stemmed beyond their main conditions which required a family physician
approach to manage. I will use some observations and a patient encounter to further
substantiate this.

One of the first things I noticed was how critical conversation is in the consultation process.
Each and every session with a patient begins with a five to ten minute conversation. These
conversations are centred around the patients’ lives, their hobbies, jobs, holidays and
families. Whilst this is easier to do with established patients, it is easily something that can
implemented with new patients. Not only does this process put many patients at ease
initially, the continued conversation throughout the consultation leaves almost every patient
with a sense of satisfaction and gratitude. I found myself being told by a number of patients
of how lucky I am to be doing my rotation with such a wonderful doctor, who takes the time
to listen to their complaints. What this highlighted for me is that despite the complex and
often debilitating conditions patients suffer from, the journey of their treatment and
management can be eased by something as simple as good rapport and a good bedside
manner. This is something mainly found in private practice and more significantly in family
medicine.

An interesting patient encounter I had was with a 34 year old male who had recently been
diagnosed with Coeliac disease and Chron’s disease (IBD). He presented for a follow up for
these two conditions, as well as established eczema and new onset acne. The array of
conditions the patient had was due to the complexity of autoimmune disease and the mixed
picture immunological conditions can often present as. Beside the interesting biomedical
aspects of this case what really struck me was the patients journey in his illness. I had the
opportunity to converse with him and he told me about the extensive lengths he went
through before he was able to find appropriate care. When symptoms of his IBD and Coeliac
disease were really impacting on his functioning as university staff member, he sought care.
His symptoms became unbearable and he found he had reached his limit of tolerance – a
reason for encounter related to a patients behavioural triggers (Sparks, n.d.). However, he
was bounced around from provider to provider and had inadequate testing done, which had
a psychological toll on the patient. What really shocked and upset me was learning of how
one physician attributed his symptoms to his psychological state – a huge ethical dilemma.
The patient so desperate to alleviate his suffering accepted the explanation and was put on
medication for depression and anxiety. This treatment, doomed to fail from the beginning,
created immense suffering for the patient both physically and psychologically. It was only a
few months down the line when turning to Dr Rabie for help did the patient find some relief.
He explained how the doctor took the time to really understand his condition, his history and
experience of his illness as well as previous experiences with doctors. He was reluctant for
further testing, which was understandable, but the doctor was able to counsel and reassure
him. After appropriate testing, including genetic testing, was completed the correct
diagnoses were then made and appropriate care implemented.

What I took away from the situation was the extensive harm health care professionals who
are careless in their methods can create. Not only did they fail to alleviate his suffering by
failing to diagnose and even misdiagnosing him, but they also negatively impacted on his
psyche and hurt his confidence. I understood the importance of adopting a holistic approach
and taking the time to really understand what the patient is experiencing and saying to you
is critical in finding clues and factors that will allow you to provide the best holistic care. The
principles of patient centredness was evident in this case when exploring the ideas of the
patients illness experience as well as the patient’s agenda (Cooke, n.d.)

During further observations, other principles of family medicine that I have covered over the
last two years became apparent. I value moments where theoretical knowledge that I have
read and learnt about becomes integrated in practice. Furthermore, it instils a belief that
seemingly arbitrary topics are in fact not arbitrary and will eventually fall into place in the
journey of becoming a holistic physician. There were a few principles that stuck with me.
Firstly, I became aware of the value of continuity of care in practice. Continuity of care is
“the process by which the patient and his/her physician-led care team are cooperatively
involved in ongoing health care management toward the shared goal of high-quality, cost-
effective medical care” (AAFP, 2015). In order to achieve this it is important for patients as
well as members of the health care team responsible to communicate and provide feedback
to each other, as this often provides crucial information that is often overlooked but may be
crucial in the management of the disease. This is known as informational continuity where
“Information is the common thread linking care from one provider to another and from one
healthcare event to another” and where “knowledge about the patient's preferences,
values, and context is equally important for bridging separate care events and ensuring that
services are responsive to needs” (Haggerty et al, 2003). It allows for a complete and up to
date picture of the patient’s condition to be known which is critical in providing the best and
most informed care. This is especially important when caring for patients with chronic
immunological and autoimmune conditions, as laboratories, pathologists and specialists such
as rheumatologists and dermatologists all have valuable information to contribute to the GP
and vice versa in the management process. I witnessed how this lack of communication by
health care professionals leads to a delay and mismanagement of patients.

Furthermore, I learnt that signs and symptoms of autoimmune conditions are often seen
years before the full blown conditions manifest. Hence, it is critical to regularly follow up
with patients and to take note of these signs & symptoms as early as possible in order to
formulate a management plan that will prevent complications. In addition, by recognizing
diseases in their early states it allows the physician to practice preventative medicine and
hence decrease the burden of disease. Preventative medicine entails an ideology which is
focused on the protection, promotion, and maintenance of health and well-being (SGU,
2018). Hence, it is important to note how subtle yet critical observations can be used to
enhance a patients care as well as in practicing preventative medicine . I really found the
value in this, after seeing the devasting effects these diseases can have, if allowed to
manifest.

In conclusion, although I have only spent two days in family medicine practice, many
principles and concepts have already been highlighted to me. Admittedly, prior to these two
days, the usefulness of these principles have been understated and undervalued by myself
and I suspect many other GEMP 3 students feel the same way. I am grateful to be gaining
this opportunity to see these principles in practice and to change my mindset regarding
family medicine, both on a personal and professional level. I intend to continue observing
their critical function in the coming days of consultation and hope I will eventually adopt and
integrate them into my own interactions with patients.

References:
1. Sparks, B not dated, Reason for Encounter, lecture notes, Department of Family
Medicine, University of the Witwatersrand, delivered 2018.

2. Cooke, R 2017, Patient Centredness, lecture notes, Department of Family Medicine,

University of the Witwatersrand, delivered 2018.

3. American Academy of Family Physicians 2015, Continuity of care, definition of

Leawood (KS): American Academy of Family Physicians, [cited January 16 2020].
Available from: http://www.aafp.org/about/policies/all/definition-care.html.

4. Haggerty JL, Reid RJ, Freeman GK, Starfield BH, Adair CE, McKendry R. 2003,
Continuity of care: a multidisciplinary review. BMJ. 2003;327:1219–1221.

5. St George’s University 2018, What Is Preventive Medicine? A Look at What These

Proactive Providers Do, SGU, [cited January 16 2020].
Available from: https://www.sgu.edu/blog/medical/what-is-preventive-medicine/