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How my



toughened me

up for practice

Dr Rob Wheatley feels the lessons he learned as a GP registrar during his tour of duty in Iraq will stand him in good stead throughout his career

Late last year I left Tidworth army base in Wiltshire as part of the UK medical group destined for Iraq. My thoughts lingered with my wife and two-and-a-half-month-old son, but although looking forward to my return six months later I was determined to make the most of the training opportunities that would present themselves.

It could be argued that in the current climate of general practice the generalist is increasingly being replaced by the specialist. But in Iraq the diverse nature of the work undertaken by soldiers and certain civilians necessitated a truly generalist approach by the medical team.

The British Army is part of Multinational Division South East. At the northern edge of this, close to the Iranian border, is the remote town of Al-Amarah. Together with a trained GP, I was posted there on the first part of my tour to ensure the continuity of care of casualties whose only route of evacuation was by air.

The primary care workload was to be typical of the rest of the tour, ranging from the treatment of simple minor injuries to dealing with outbreaks of diarrhoea and vomiting.

In contrast to my training to date, there was more emphasis on the pre-hospital care of traumatic injuries and the wider provision of medical services, such as disease outbreak management.

One of the most useful lessons I learned during this period was how to build a primary care team consisting of people who had little experience of general practice. It was vital to utilise effectively the skills of individual members of the team ­ for example the qualified A&E nurse.

But equally it was important to ensure that these skills were seen as part of the larger capability of the practice and not simply role defining.

For GPs as independent contractors, and therefore employers, the training of practice staff is of great importance. I was tasked with creating a training programme to teach battlefield first-aid to the Iraqi Police Tactical Support Unit. Again I feel the skills I learned here will be of lasting value.

Colleagues' family loss

In considering the first-aid training to be offered, a major concern was the potential cultural impact of the material . From an initial show of hands it was clear that the police recruits not only had personal experience of major trauma but that many had suffered family loss as a result. The situation in the UK would be completely different.

Language was a further barrier, compounded by the need to translate medical terminology. Through prior discussion with the interpreter, mis-communication was reduced and the material reviewed to avoid causing any offence.

By the end of December I had moved to Basra, to the old Shatt-al-Arab Hotel. This was under the direct supervision of a GP trainer and I remained here over the Iraqi election period. The medical facility was well-established, with a proactive clinical governance (CG) framework in place.

Even on operational tours, the army strives to provide a service as close to the standards of the NHS as possible. CG therefore played a very active role during the whole of my tour. My views and attitude to the CG process evolved during my time in Iraq. During my hospital training I had tended to fit the question around answer. This now changed.

Clinical governance has now become a vital component part of my 'practice toolkit', enabling the service offered to be responsive and flexible.

At the Shatt-al-Arab hotel we worked with regular audit, case analysis, significant event analysis and a formalised practice professional development plan. There were clear benefits both in individual patient care and continuing quality improvement.

Moving CG to the forefront of our day-to-day medical practice was a difficult transition for a primary care health team with largely secondary care experience.

In an environment remote to both the UK and to other medical facilities, it falls very much to the individual practitioner to maintain his or her professional integrity and development.

As a GP registrar, this included weekly tutorials, caseload logs, CG activity, and monthly overviews of educational activity undertaken.

Staying in touch with home

I also managed to maintain my links with my GP vocational training scheme back in the UK. The weekly timetabled subject matter was sent to me in Iraq. This was then discussed and reviewed with my group leader by e-mail.

My formal appraisal took place while in Basra and my personal development plan was a useful foundation for continuing education. Throughout the tour there was good access to the internet, journals and medical textbooks. It was possible, therefore, to actively reflect upon the clinical workload and to make sure the best and most current practice was followed.

For the last two months of the tour I was employed in a medical management capacity. The tiers of medical management in the NHS impact on GPs daily whether through seeking funding from the PCT, guidance from NICE or involvement with LMCs.

It is such an integral part now of being a GP that to be involved in the process was probably the most valuable aspect of my tour.

My remit included contribution to the CG activity within three medical centres and input into the redesign of the Al-Amarah medical centre in terms of its layout, buildings and functional capacity.

In particular, the design of a medical facility to meet a changing requirement could be very useful in an NHS GP partnership considering expansion of its surgery or commissioning of new services.

I returned to the UK, looking forward to my post-tour leave and recouping some of the time lost to my family.

My time as a GP registrar will always be divided around this six-month period and it will take time to fully reflect on my experience. I can only foresee its value to my future practice continuing to rise.

Rob Wheatley is a captain in the British Army and is currently in his army GP registrar post

Pointers for future

Lessons learned that will be of value in my career as a GP

· Reinforced my skills as a generalist

· Taught me how to build an effective primary care team

· Taught me how to harness the medical skills of a team

· Honed my ability to train practice staff

· Taught me how to deal with people who have suffered severe trauma and loss

· Made me more responsive and flexible in provision of care

· Boosted confidence in my ability to deal with the managerial side of NHS

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