DR SAMARA AFZAL is a GP at the Limes Medical Centre in Stourbridge and the Urgent Care Centre at Russell’s Hall Hospital.
She works in an inner-city surgery with a lot of deprived patients, many among them are south Asians. She became a GP three years ago after training in various hospital departments.
Dr Afzal has been recording a typical week as a family doctor.
What does your week look like?
On Sunday, I do an eight-hour shift at the local hospital’s urgent treatment centre, seeing walk-in patients who may have chest infections, sore throats, insect bites, trauma, or getting calls that go through to 111. Monday and Tuesday, I’m at my own surgery. Wednesday is admin day, and Thursday and Friday, I’m on emergency call outs. At my GP surgery, I see a lot of (south Asian) women, who come with non-specific symptoms, such as feeling tired, with aches and pains. I then dig deep into their social background. They would have had a traumatic past, some are survivors of sexual abuse, others have lost a child. When you put it all together, you diagnose anxiety and depression. However, a lot of south Asians don’t accept this. They say, ‘we’re not crazy, there’s nothing wrong with us’. They can get argumentative, particularly the men. They should just get on with it and deal with their emotions. We know men are at higher risk of suicide, particularly young men, because many won’t seek help. They wouldn’t have gone to the GP to say, ‘I’m feeling suicidal’. We should target such people. When they come in with non-specific symptoms, I ask them about their situation. Some are worried because they’re new to the UK, they’ve just become unemployed, have big families to feed; you discuss those issues. I listen to their physical symptoms, order investigations or check their blood tests. I’ll bring it all together and say, ‘look, your blood tests are fine. This doesn’t add up to this, but with what you’ve been through, I think it’s anxiety and depression, and you need treatment.’ Usually, by that time, we’ve built a relationship and they are open to treatment. Very rarely now do I get women or men who refuse treatment for depression.
What challenges do you face?
We’re have only 10 minutes per consult. That is quite hard, especially if you’ve got a patient with mental health problems; you don’t want to rush, or with patients having complex social problems, particularly the elderly. We get calls to say that someone’s parent is alone and struggling to cope, could we arrange an urgent social care placement for them? You can’t do that in just 10 minutes, particularly now, with all the medical legal stuff. We have to document everything we say. It is many pages long, but if it wasn’t for all that, you’d fit in more patients. Sometimes if they’re really complex, we can ask them for a double appointment. There’s a lot of paperwork in terms of meeting criteria, you get paid for hitting certain targets. Some of it is linked to certain funding. So, for example, smoking cessation and services have taken a hit. No one’s there to provide that anymore, but I thought it was a crucial service, because long term, if someone stops smoking, you prevent them getting heart disease or cancer and the NHS will save money.
What happens on an ‘admin day’?
It’s not all paperwork. I look at blood results, prescription requests, clinical letters from hospital consultants for my patients, and action them. If I go into work on Thursday, and I’ve still got all this admin in the back of my head, and on top of that, I’ve got emergencies to deal with, you cannot deal with them both safely. I put in additional hours just to be organised.
So, this idea that the public has of the family doctor doing nothing except seeing patients is wrong?
Yes, absolutely. We do three-hour clinics in the morning and the afternoon. In between, we deal with emergencies, or see patients who can’t come to us. We visit them at home, or at nursing homes, and sort out emergency paperwork. Also, blood results, any urgent lab result or if anybody needs to be admitted to hospital, we’ll arrange that. There’s no time for lunch. I have coffee, or a couple of pieces of fruit until I finish for the day.
What about being on emergency call, what is that like?
I cover any emergency between 8.30am and 6.30pm. On Thursday afternoons, I’m the only GP for more than 7,000 patients. I may need to call emergency social services or paramedics. Every alternate Friday, I’m on call as well.
What changes have you seen over the past weeks with the pandemic?
We now phone patients first. Where patients couldn’t get an appointment for three to four weeks, now everybody’s getting appointments within two days, because they get a phone consultation. If I feel they need to be physically seen, then I’ll get them to come in and examine them. Also, elderly people don’t want doctors doing home visits as they fear doctors could be carrying the virus. Such patients are happy for you to deal with their problems on the phone. In some ways, Covid will change GP practices for the better, because we found these are more effective ways to work.
But there is a negative side to it because people are not going to the doctors, because they are afraid of the coronavirus pandemic and therefore putting themselves at greater risk. Are you finding that to be true?
Definitely. I’ve seen two patients, and from their symptoms, I’ve told them chances are they have cancer. They just will not go into hospital for the second part of their investigation because they say they’d rather carry on with the cancer than have Covid-19. It’s very upsetting; I’ve tried to explain that the cancer, if it progresses, there may be a point where they can’t be treated anymore. But they are adamant; they’re not going into hospital to have any tests until the pandemic is over. One patient had three cancers. She’s got through two of them, now she’s got a third one. She’s had surgery, she was having chemotherapy and sadly, she’s been told by the hospital that she isn’t being scheduled for anymore chemotherapy simply because of the pandemic and that she’s at high risk for Covid-19. Recently, I saw a couple of patients who needed urgent care in a hospital. Both had cancer, both were in their 50s. The cancer has spread. Both were told that their chemotherapy or radiotherapy had been delayed due to Covid-19. People are definitely presenting later with symptoms of cancer.
How do you cope with seeing and giving bad news day after day? It’s really hard; when we’re in hospital as a doctor there, sometimes you don’t see patients for that long, so when we have had to give bad news, it’s not as difficult. But, as a GP, where you’ve known not only to the patient, but their whole family, and when you have to give bad news, it’s quite traumatic. I really struggle with the younger patients.
I had a patient; she was in her thirties with breast cancer, which had advanced. She was a single mum, with a young daughter. I’ve got a daughter, myself; every time I saw her, I just could not help it, my eyes would tear up. It came to the point where I thought, should I hand over her care to one of the other GPs because I was struggling to see her. When she died, I was in tears that day; I came home, cried to my mum, and she said it was because I had a bond with these patients and mum said, ‘it could be your daughter losing her mum’. Another time, an elderly gentleman used to come and chat to me because he had no children nearby to talk to; I was almost like his counsellor. He had multiple problems. I would see him walking in the high street, going to the mosque despite his ailments. We got him through kidney failure, and then he succumbed to Covid-19. His daughter told me he died in hospital without anyone being there for him. I had seen him 18 hours earlier; that broke my heart, it made me quite tearful that he was on his own. Some people say we don’t have emotions, or we blank out the personal aspect of it, but because I’m so involved with them, you get attached to them.
Covid has shown us the contribution of south Asian doctors to the NHS. Have you been struck by how many BAME doctors have died on the frontline? How much does that worry you?
It does worry me, especially 80 or 90 per cent of those who died are from BAME communities; they’ve been GPs or hospital consultants. That is upsetting, and you think there is something more than just social inequality that is contributing to the greater number of deaths in our community. At the beginning of the pandemic, I changed some hospital shifts from face-to-face to phone triage because I’ve got an asthmatic daughter. Now I’m a little bit more relaxed because of the peak going down. But, some weeks ago, I was petrified. I’d come into contact with a patient suffering from a chest infection; she was in a nursing home. I’d seen her about two or three times and she then went into hospital. We found out she’s had Covid-19. Those seven or eight days I was scared thinking, I’ve was in close contact and must have contracted it. Luckily, I didn’t get it. But I was petrified. For at least a couple of weeks we didn’t have PPE (personal protective equipment). We had some surgical masks, but they were out of date. We were shocked, and thought, do we use them? When we started talking to colleagues, apparently it had happened to everybody. (The authorities) said the dates were changed, but that they were okay to be used. But the gloves, aprons, surgical masks are not what you would use in intensive care. I think BAME medics should have a step up when it comes to PPE. It’s the first time since I left a hospital job that I bought my own pair of scrubs off the internet, just because I didn’t like the idea of going into work unprotected.
What changes would you like to see implemented as a family doctor post–Covid?
In terms of the BAME community, I would say better access, and more culturally compatible services. For example, a lot of Asian women ask me for my personal number just because they can’t get through to the surgery or they can’t speak English. Or whoever is at home doesn’t or can’t be bothered to make the phone call for them or they’ve gone to work. They cannot make a simple appointment. I tend to book them a follow up when they come to see me, so they don’t struggle to get hold of someone or communicate. We also need health awareness programmes, and these should be more culturally orientated. With diabetics, for example, clinics led by a doctor and a nurse who can speak Hindi, Urdu or another Asian language as well as English. Prevention is better than cure, and it will save money for the NHS in the long run. We need more funding, but I don’t know where that would come from.
(Dr Samara Afzal was speaking to Barnie Choudhury).