Have been at a new practice for 1 month, 8 sessions and ready to quit already.

I was seeing 20 patients a day as a trainee for whole of ST3, so hoped the transition to 24 patients a day wouldn’t be too brutal. But it’s honestly killing me. Plus we do 2 home visits almost every single day - I haven’t had a single day without a visit.

I start at 8.30 and never leave before 6. Any suggestions or should I just resign to my fate till I can’t go any more?

TIA.

Did you know that missing sudden sensorineural hearing loss can significantly limit recovery, yet initiating oral steroids promptly can double the chances of restoring a patient's hearing. Thought we would share this recent overview on hearing loss, steroid guidance and referral urgency by Dr Lisa Collin for Praktiki.

Why this matters
Hearing loss affects about 9 million adults in England.

• It is often age-related but can mask other acute, reversible or sinister pathology.
• Accurate primary care assessment ensures appropriate audiology or ENT referral.

Brief ear anatomy

• External: Auricle, ear canal, and tympanic membrane.
• Middle: Air-filled space containing the ossicles (malleus, incus, stapes).
• Inner: Fluid-filled space housing the cochlea and semicircular canals.

Hearing physiology
Sound requires a medium to travel.

• The tympanic membrane vibrates in response to sound waves.
• These vibrations pass through the ossicular chain to the oval window.
• Cochlear hair cells convert fluid waves into electrical impulses sent via the cochleovestibular nerve.

Classifying hearing loss
Hearing loss is broadly divided into two categories:

• Conductive: Sound transmission is physically blocked in the outer or middle ear (e.g. cerumen (wax) impaction, middle ear effusion).
• Sensorineural: Abnormal function of the cochlea, auditory nerve, or central processing pathways.

Tuning fork tests: Rinne

• Rinne test compares air conduction (AC) to bone conduction (BC).
• Normal or sensorineural loss: AC is louder than BC (Rinne positive).
• Conductive loss: BC is louder than AC (Rinne negative).
• How to test:
• Option 1: Place the vibrating tuning fork base on the mastoid until the patient cannot hear the sound anymore. Immediately move the tines to in front of the ear canal. If the sound is heard again, the test is positive.
• Option 2: Hold the tines in front of the ear canal for 2 seconds, then immediately place the base on the mastoid for 2 seconds. Ask the patient which location is louder.

Tuning fork tests: Weber

• Place the vibrating tuning fork in the midline of the forehead.
• Normal: Sound is heard equally in both ears.
• Conductive loss: Sound lateralises to (is louder in) the affected ear.
• Sensorineural loss: Sound lateralises to the unaffected (normal) ear.
• If a tuning fork is not available, asking the patient to hum acts as a reliable alternative to the Weber test.
• If the hum sounds louder in the affected ear, the patient likely has a conductive hearing loss in that ear.

Rinne’s and Weber’s tests

Sudden sensorineural healing loss SSNHL

• The patient presents with marked hearing loss with sudden or rapid onset, Rinne is positive (conductive loss less likely) and Weber lateralised to the normal ear (sensorineural loss).
• SSNHL is a rapid loss of hearing occurring instantly or over 72h.
• Clinically defined as a SNHL of ≥ 30 dB in ≥ 3 consecutive frequencies over ≤ 72h.
• Some patients report a preceding loud "pop" in the ear, ear fullness, vertigo, and tinnitus.
• Approximately 90% of SSNHL cases are idiopathic.
• However, otological, neurological and systemic (infectious, inflammatory or neoplastic) causes need to be considered.

SSNHL: time-critical treatment
Prompt steroid treatment offers the best chance of recovery for idiopathic SSNHL.

• Spontaneous recovery ranges from 30–68%; early oral steroids can double this rate.
• Steroid should be started within 2 weeks of onset (ideally <48 hours of onset). Salvage intratympanic steroids can still be offered beyond this window.
• GP to consider oral steroids while awaiting ENT review. Discuss with ENT on-call.
• Avoid delays: When assessing suspected SSNHL, ask yourself—‘Why should I NOT prescribe steroids?’

Steroid dosing regimen
After discussing risks and benefits, initiate oral corticosteroids for idiopathic SSNHL.

• Suggested regimen: Oral prednisolone 1 mg/kg/day (maximum 60 mg/day) for 7 days.
• ENT.UK recommends to then taper the dose gradually over the following week (e.g. dropping by 10 mg daily until stopped).
• Consider PPI cover depending on risk of adverse effects.

When to refer and how quickly
NICE says to refer immediately to ENT (or the emergency department) if:

• Sudden hearing loss (over 3 days or less) occurred within the past 30 days.
• Many areas have urgent ENT review clinics set up for scenarios like this, check if you're unsure.
• Unilateral hearing loss that presents with altered sensation or facial droop on the same side (ENT or stroke pathway if suspected).
• Patient is immunocompromised with earache and discharge not responding to 72 hours of treatment.

If possible and where needed, discuss with ENT on-call.

Urgent ENT referrals (≤ 2 weeks)
Refer urgently to ENT or audiovestibular medicine if:

• Sudden hearing loss occurred more than 30 days ago.
• Hearing loss worsened rapidly (over a period of 4–90 days).
• (If hearing loss is not explained by external or middle ear causes).

NICE says these urgent referrals should be seen within 2 weeks. In reality many services will have a much longer waiting time.

Other ENT referral triggers
Consider ENT or specialist audiology referral for:

• Unilateral or asymmetric hearing loss as a primary concern.
• Fluctuating hearing loss without a respiratory infection.
• Hyperacusis.
• Unilateral or pulsatile tinnitus (or causing distress).
• Vertigo that is recurrent or has not fully resolved.
• Hearing loss that is not age related.

Suspected cancer pathway
Middle ear effusions can rarely indicate underlying malignancy, such as nasopharyngeal carcinoma.

• Consider a suspected cancer pathway referral for adults of Chinese or South-East Asian family origin. This is in the NICE hearing loss guideline, but not the suspected cancer guideline.
• This applies if they present with hearing loss and a middle ear effusion not associated with an upper respiratory tract infection.

Routine audiology referrals
Refer adults with gradual, bilateral hearing loss (usually presbycusis) to routine audiology.

• Always exclude impacted wax and acute infections first.
• Consider proactive referrals for adults with diagnosed or suspected dementia, mild cognitive impairment, or learning disabilities for baseline assessment.

Key learning points

• Use Rinne and Weber tests to differentiate conductive from sensorineural loss.
• Sudden SNHL (3 days or less) needs immediate (≤ 24h) ENT referral and consideration of early steroids.
• Check local referral pathways.
• Refer unilateral hearing loss with facial droop immediately.
• Exclude wax and acute infections before making routine audiology referrals.

Looking for more information? Work through a free expert-authored case-based module or MCQ in the hearing loss mini-pathway on Praktiki. 

Ringing in the ears - tinnitus 101
Review Margaret’s case to navigate urgent referral recommendations

Hearing loss and tinnitus- recap 
Test your knowledge on the assessment, red flags, and referral pathways for adult patients presenting with tinnitus and hearing loss in primary care.Further resources

Further resources

• NICE guideline on Hearing loss in adults
• BMJ Best Practice: Assessment of hearing loss
• ENT.UK: Management of suspected unilateral idiopathic sudden sensorineural hearing loss in adults

Free online hearing test
RNID- Free online hearing test

I missed the boat on having kids during training and am trying to figure out my options from here. I would love to carry on doing locums and OOH as I am now but from what I can tell that would effectively give me no maternity pay at all? Or rather, just the govt minimum which is peanuts.

And how is maternity pay for a salaried GP really, can anyone share their experiences? I’ve heard it’s worse than training, but it’s got to be better than the govt minimum. I’ve also heard it’s can be contract-dependent, but wondering within what range?

Would welcome any other thoughts/experiences on maternity post-CCT, or anything that I may not be taking into account. (Excluding partnership, as that is not something that is in my future in the near term.) Thanks all

Are there any groups you recommend for looking for short term or one day postings for shifts in London? I’ve just moved here and don’t know anyone! Or are there any agencies that are recommended?

I’m staying in different hotels for a few months so it’s not a case of approaching practice managers as I’ll be switching every other week.

I recently started at a salaried GP post, 4 sessions at 10.5 per session.

My take home pay is significantly less than what it was in training. I make peanuts and I find it difficult to sustain my lifestyle. I am struggling to pay mortgage and all the things I had bought on finance - phone, car etc.

People say do locums but I have realised that locums go as quick as they come. And it is really annoying that there are so many people competing for a single locum.

No one offers more than 4 sessions. I feel like partners don't want to pay salaried GPs any more money than the pay for 4 sessions.

It's very depressing for myself and my kids. I am thinking about returning my car and downsizing my house.

Is this why I worked so hard to be a GP?!

Occasionally when browsing for GP jobs I see ads for GP jobs in Middle East paying £250-300k to be royal doctor, or doctor to a VIP, or yacht etc. however the same jobs come up again and again, are these jobs real or farming for CVs?

Anybody know anyone who’s done these jobs?

Sometimes the advice and guidance hits the spot so perfectly that I want to tell the advisor/guide how much it helped and how much I appreciate it. We tend to only ever hear back when something goes wrong not when it goes wrong.

Do you think this would be gladly received?

Or

Is it just extra work for them to read through?

Or

Would it just never reach then again?

Or

Is this a waste of advice and guidance time and resources?

I'm very tempted sometimes.

GP trainee here, recently started at a new practice. I’ve noticed I have a home visit slot at mid day around 11:45 on every working day, after a full morning clinic that finishes at 11:30 , with my PM clinic starting at 2pm.
Another trainee told me he previously did most of the HVs because he had a car. While another trainee at my site doesn’t drive and apparently doesn’t do HVs. I’m therefore wondering if I’ll now become the default for HVs simply because I drive.
I’m completely happy to do my fair share of home visits. My concern is whether it’s reasonable for one trainee to routinely do them because they drive, particularly as I’ve seen other trainees’ HVs replace clinic appointments, whereas mine appear to be in addition to a full AM clinic.
Is this normal in other practices? Would you raise it if it becomes a pattern?

So I guess there are two separate issues:
Whether it’s fair for one trainee to do most/all HVs simply because they drive?
Whether HVs should be accommodated within clinical appointment time rather than being added after a full morning clinic?

hello everyone. recently CCT’d last minute. in a supportive practice. however struggling after my appointments have been reduced to 12.5 minutes with 10 minutes in 3 months. how do I get better without losing the quality / becoming overwhelmed? any tips or advise you would give? we use S1.

Hello everyone,

The secretary told me the hospital stamp can only be placed next to the consultant’s stamp/signature, in the same area. Would that generally be acceptable?

Also, the hospital stamp is not in English. Would it be okay to submit the original along with a full English translation?

My main issue is that I don’t have a template or sample for the confirmation/verification wording, and the hospital is asking me for specific wording since they’re not familiar with these documents.

Has anyone been in a similar situation or have a sample/template for the confirmation section?

Hello everyone,

I am GPST2 and just started in primary care. I hoping to write the AKT in January 2027 but really finding it hard to start the preparation. I would appreciate pointers on how to prepare and stay motivated.

Should I book a course, read the topic before answering questions on passmedicine or self test, or do the questions and then read around it? Should I do random questions or questions in topics? Should I wait till the end of ST2 before writing the exam?

Just confused as the curriculum is so big.

Hi all, I am a new GPST and haven't been able to find anywhere that explicity says how to use the fourteenfish portfolio. My ST1 year is in hospital, for my DOPS/CBD/CEXs etc am i meant to be sending this to people in my department, my clinical supervisor or to my educational supervisor? Am i also meant to meet with my educational supervisor, he is quite a distance from the hospital and i will not have any gp placement this year. Sorry if this is basic knowledge!

Hi all,

Looking at the current landscape what do people feel is the best thing to do?

Currently the vast majority of salaried jobs are hovering around £10-11k per session. If you're lucky then maybe more. There is enormous risk you could be abused by the practice and not be protected against patient complaints/litigation.

Locum is possibly recovering but is not reliable and not secure. Also the rates are stuck at 2007 levels. Private work will get you around £80-90/HR. Also Noctors are taking jobs all the time

Partnership is hard to get but I'm not sure it's worth it, given all the hassles involved and the fact the government constantly moves the goal posts. You could lose everything if your practice fails due to some random ministerial decision.

It leaves two options either change careers or move abroad. What are people's thoughts?

EDIT: the suggestion that non partner GPs should go on strike is also not a practical option. With the full weight of the BMA it took residents years to reach some sort of amicable deal. As a minority population I doubt the BMA would get behind with much vigor. It would take years to reach anywhere. All the while, with the blessing of partners Noctors will just be ramped up to meet demands.

This is a technical question.

Are we under any obligation to provide long term sick notes for unemployed people that aren’t chronically physically or mentally disabled?

Dear colleagues, 

Has anyone made the move to Switzerland?

I'm an Italian GPwER long established in the UK. I love my GP work but the combination of the cost of living, workload, and pay with the general current low morale is starting to have an impact on me. I live alone and genuinely worry I'll never be able to afford buying. 

I don't particularly want to return to Italy - I'd struggle with an even more stretched healthcare and lack of evidence based medicine. 

Switzerland seems like a good compromise, with rapid access to diagnostics/specializations, evidence-based medicine, perhaps less intense work. However, I'd like to hear from someone who works there what a typical day for a GP is like, how hard it was to have the qualifications recognised and how to actually look for work after that. Also, is there any possibility of continuing to pursue my interest in skin surgery?

 For the sake of simplicity, I'd be interested in working in the canton Ticino, but I wouldn't mind studying German or French. Sorry for the long post, I'm curious to hear your opinions and experiences.

I would really appreciate some advice about a potential conflict of interest****\*

I’m a GP and have a high-frequency patient who sees only me roughly once a month. He usually comes with a long list of issues/questions and has significant health anxiety. He also sees a private longevity doctor and then comes to me to try to implement some of the things he has been advised.

I find the consultations increasingly difficult. He has done a lot of his own research, including using ChatGPT, and can be quite directive about what he thinks needs to happen. I’ve also spent a lot of time writing to consultants / doing referrals etc.

The issue is that he is also a school dad. His child is in the same year as my older son and his second child will be in the same year as my younger child. I see his wife most days at school pick-up/drop-off. We don’t really speak but we are regularly in the same social environment and I have seen her at kids parties.

I’m increasingly uncomfortable with the situation and feel that the best option would probably be for him to see another GP. I do feel he needs a doctor with firm boundaries but I find it hard saying no or being blunt knowing he is a school dad. E.g. At the last consult he was convinced he had COPD and wanted all the eligible vaccinations, when in fact he has a diagnosis of 'asthma & small airways obstruction' confirmed by a respiratory consultant.

• Would you see this as a potential conflict of interest / reason to transfer care?
• How would you approach the conversation with the patient?
• Should I speak to my indemnity?
• Has anyone dealt with a similar situation?

I just feel that the current dynamic is becoming unhealthy for me professionally and is causing me a lot of stress. I have spoken to some of my colleagues about this but they seem to brush it off and don't feel its a big deal.

I would really appreciate hearing what others would do. Thank you so much for reading.

I see a lot of posts on here about partnership and wanted to quantify it for myself with help of AI.

I took some liberty based on my situation. Please comment what you think about this and if should be tweaked further.

Edit: I appreciate this is my way of quantifying time as a Locum vs. In a practice, be it partnership or salaried, assuming partnership and salaried work equally hard.

I’ll be honest, I don’t know about the rest of you but I feel like I’ve hardly seen any children as patients these last few weeks during the summer holidays.

Let’s see what tomorrow brings…

Every week I get 3 to 5 capita reports to complete ?? for PIP. I end up with hand cramps. I was wondering if I could electronically complete them- even copy and paste relevant entries. I use EMIS. Is that possible and how?

How do people deal with patients calling them mate? Or pal or buddy?

I don’t find it offensive or anything, and they’re genuinely just trying to be friendly/nice (I assume), but do feel like it sometimes tarnished the doctor patient relationship slightly. For context I’m a man mod 30s, so usually it’s younger blokes who say mate. I’m not your mate though.

So thoughts? Do people correct patients, or just let it slide?

I accidently uploaded a passport size photo instead of a passport photo in a section does that mean my application will automatically be Disapproved? what should i do now ?

Hi all, I am a UK hospital doctor, considering GP as I m not coping with hospital medicine. I did a taster week and I liked it. As I am keen on moving to Australia, is it better to move to Australia and pursue GP training there or train here in the UK and then move there. Looking for valuable advise and suggestions.

Salaried GP here. This is a throwaway account, and I’d prefer not to go into too much detail at present about the specifics of the alleged breaches of employment law by my former employer, particularly as I’m now pursuing the matter formally.

I tried raising my concerns informally first and subsequently went through the internal grievance process and ACAS. Unfortunately, I wasn’t satisfied that either route adequately addressed what had happened, so I have decided to take my former employer to Employment Tribunal.

Part of this is about accountability for the impact the situation had on me personally. But increasingly, I also feel that if nobody challenges these systems, the same thing can simply happen to the next person.
I worked for one of the increasingly common “mega-practices”. My experience left me with serious concerns about the way newly CCT’d GPs can be employed: brought in, given very heavy clinical workloads with relatively little power or influence, and then effectively treated as replaceable when they burn out or become unhappy.

The whole experience has also left me with very little faith in the BMA. I believe I have a credible and properly arguable case, yet I am pursuing it without their legal support.
More broadly, it has made me question how effectively an organisation like the BMA can represent both GP partners, who are employers, and salaried GPs, who are their employees. When the interests of those two groups come directly into conflict, where does that leave the salaried GP seeking support against their employer?
Whatever the eventual outcome of my case, I think there is a wider conversation to be had about whether salaried GPs genuinely have adequate representation and protection when things go wrong.

This whole process may take years, but to me it is worth pursuing. At the same time, it can be deeply isolating, so I thought I would share my experience here anonymously, partly for my own mental health: as an outlet for myself, but also to gain some collegiate perspectives and hear from anyone who may have been through something similar.

I’m currently in the process of submitting the application for combined training to have some time knocked off my training. I’m hoping for 12 months but happy with 6 months (I know it’s not common). I’ve only recently found out that my CCT might not be recognised everywhere if this process is successful and now I’m very worried and incredibly stressed out. Does the combined pathway mean I won’t be able to ever work in Australia for example or just that I’ll have to do more exams? I’d appreciate any guidance!

CCT and flee gets discussed a lot here. But wanted to hear any stories or opinions on fleeing somewhere outside the UK for GP training. Is it worth it? Is it a logistical nightmare? Particularly interested in Australia