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At the heart of general practice since 1960

I set my heart on a career in cardiology

He may not have felt he was cut out to be a consultant cardiologist but that did not stop

Dr Mike Gumbley from pursuing the specialty as a GP ­ a clinical assistant post at his local hospital was just the break he needed

'Cardiology ­ a good, clean, neat discipline.' That is how my medical registrar sold the subject to me when I was an impressionable house officer in the mid-1980s. He is now a consultant cardiologist in a teaching hospital in the North-East. Me ­ I am a contented GP in the west country, where I have been for the past 15 years.

My imagination was sparked still further when, while an SHO, I attempted to grapple with an echocardiograph under the guidance of a gifted senior registrar. He is now a consultant cardiologist in Salisbury. Me.......!

Do I sound bitter? Not so. Such influences enabled me to broaden my horizons within general practice. I continue to love my job, not least because I am able to combine interests in many different aspects of medicine with the pursuit of one particular specialty.

Shortly after I started in practice the local district general hospital advertised for clinical assistants in cardiology. I applied and was successful.

These were exciting times ­ post-MI management was improving, thrombolysis was established, the role of statins was much clearer, heart failure treatment was moving beyond diuretics, cardiac rehabilitation was developing an evidence base, and diagnostic facilities were expanding. I remained enthusiastic, staying in the post for six years.

During this time it was useful to observe the 'good, clean, neat discipline' from within, but also to take it out to my workplace wherever possible. Those diagnostic facilities included ECG, 24-hour ECG, 24-hour event monitoring, exercise tolerance testing, trans-oesophageal echocardiography, MUGA scanning and angiography. I continue to perform 24-hour ECG event monitoring in the surgery, resulting in at least four of our patients getting pacemakers.

I also maintain a friendly professional envy of a neighbouring GP who has developed a highly innovative community echocardiograph service detecting and managing heart failure in our semi-rural locality.

Experience at the hospital was also valuable sitting on, and later chairing for two years, a primary/secondary care multidisciplinary implementation group promoting high standards in CHD. Working with dedicated, enthusiastic hospital clinicians, GPs, senior cardiac nurses, rehab nurses, paramedics, cardiac technicians, pharmacists, and, dare I say, managers, a 'care pathway' approach was adopted and achievements were considerable.

Primary prevention such as smoking cessation clinics and healthy eating information was widely implemented. Protocols for angina, secondary prevention, atrial fibrillation and heart failure were disseminated to primary care. Patient information documents on managing chest pain were sent to key local outlets. ECG telemetry from ambulance to district general hospital was set up, and paramedic thrombolysis is now locally established practice.

Rapid-access chest pain and post-MI clinics expanded, while community echocardiography services with associated heart failure nurses were created. The rehab service was dramatically expanded, developing phase 4, then phase 3 projects in peripheral community hospitals and leisure centres.

Indeed, I still take pleasure in talking to the phase 3 rehab patients about their medications on a regular basis ­ a group that started with just six patients, now expanded to at least 20 every eight weeks. In itself, this is a reflection of success of secondary prevention in recent years.

Working at the hospital facilitated a master's degree in prescribing sciences, researching factors affecting compliance with post-MI medication, alongside the department of clinical psychology. In the fullness of time, this was partly responsible for my further appointment on the GMC.

Funding issues have severely limited the hospital's ability to attract GP support. Finances increasingly limit the PCTs. The new contract and QOF have concentrated my focus on practice work, moving my direction away from CHD.

However, as an optimist, I remain confident about the future. The Department of Health has included guidelines for those keen on developing CHD for GPSIs. Practice-based commissioning may provide the ambitious cardiac-keen GPs with creative ways of plying their trade.

The new White Paper for Primary Care may also stimulate those with an interest to develop competitive local services to continue their interest and enhance local services.

That 'good, clean, neat discipline' will continue to stimulate me, at the same time not detracting from my enjoyment of my day job.

Mike Gumbley is a GP in Westbury, Wiltshire, and sits on GMC fitness to practise panels

Interest in Cardiology?

· Be enthusiastic about it ­ there is always work out there if you look

· Remuneration is negotiable according to PCT requirements

· The NSF for CHD has increased demand on cardiology services ­ creating a need for GPSIs

· Training is variable ­ no fixed requirements but some experience in cardiology would be needed to fulfil the requirements set out in the Department of Health guidelines for appointing CHD GPSIs in May 2002

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