Dr Lucia Gannon
Murphy, a man in his 50s, hesitated at the door of the consulting room. “I wanted to ask you, doctor, would there be any chance that you would take on my mother? Her doctor has retired and I really would like her to attend this practice.” Mr Murphy was not the first person to request that I take on the care of a relative in recent months. I was well aware of his mother’s situation and while she had my sympathy, in the interest of professionalism, safe practise and self-preservation, the answer had to be “no”. ‘I’m sorry,” I said, “we have no spare capacity right now. I can put her on a list and contact her if we manage to get another doctor. That’s the best I can offer for now.”
Mr Murphy, a rural-dweller all his life, did not need to be told that communities such as his are being eviscerated by Government policies and that the demise of the rural GP is just part of this process.
His mother was a patient in a practice close to me where the GP had recently retired. The list had been advertised for over three years with no applicants. A solution was found whereby a city practice, 40 minutes from the village, agreed to register these patients and provide them with a GP for four sessions a week, in exchange for a rural practice allowance. It is understandable that these patients wish to move to a neighbouring practice with a choice of three doctors, a nurse and a secretary. But providing these services costs and, as currently, there can only be one rural practice allowance per rural area, there would be no extra resources provided to another rural practice to take them on. Hence, the solution to support a city practice and reduce the service commitment.
In order to come to terms with this development and realising that living and working in rural Ireland for over 30 years could result in biases, I applied one of Edward De Bono’s thinking tools to the situation. The one I chose is called ‘Other People’s Views’. This involves assessing a situation from the point of view of all the stakeholders.
Actually getting into their shoes and trying to understand their reasoning.
The stakeholders in this scenario include the patients, the doctors who decided not to apply for the post, the doctors who agreed to take on the list, the HSE/DoH, the neighbouring doctors and our negotiating bodies, the IMO and NAGP.
1. The patients at least have a doctor, but it is a much-reduced service. They no longer have a doctor living or present in the area, outside of the four sessions provided. They must travel a considerable distance to see a doctor at any other time. They will probably never have a local doctor, nurse or secretary again. They are unlikely to be able to get a doctor in the case of an emergency and are a long way from a hospital.
2. Some recent graduates did consider the possibility of taking on this list but changed their minds when they calculated the cost of premises, equipment, staff, medical insurance and Caredoc fees. Even with a rural practice allowance, it did not make any financial sense. They went on to find work in urban areas.
3. The doctors who agreed to take over the list have additional patients and increased workload. As compensation, they get a rural practice allowance and all the benefits this accrues. They are providing a service that no-one else can provide, offering a helping hand to a community that would otherwise have no doctor, in an arrangement that makes perfect business sense for them.
4. For the HSE/DoH, this solution is the best possible outcome in the circumstances. The post is no longer vacant. Patients have access to a doctor at all times. The responsibility for care rests with the new GP.
5. As a neighbouring GP, this development is the worst possible outcome. I see the helping hand as a greedy paw. It creates inequality of care between neighbours and friends. It puts pressure on surrounding practices to take these patients on with no additional resources. As a rural-dweller and experienced rural GP, I consider this level of care unsafe, uncaring, and unresponsive to patients’ needs. I also consider it ineffective, as it will almost certainly result in increased out-of-hours consultations and emergency department admissions. To me, it demonstrates poor judgment and leadership by both GPs and the HSE and should not be facilitated or tolerated.
6. Finally, if GPs on the ground consider this level of care adequate and collaborate with the HSE to dumb-down rural practice, what hope have our negotiating bodies of attracting resources to re-feed this starving specialty?
I am taking up a lot of your time, doctor,” the young woman said, as she positioned herself on the edge of the chair, already fully dressed in coat, scarf, boots and cap, following her physical examination. I looked up from the computer, where I was typing a referral letter. “Just a few more minutes,” I said. “I’ll finish this and you can be off.”
When she first came in she had sat in that same way, on the edge of the chair, as if to convey that she didn’t want to take up too much of my time and in an apologetic tone, informed me that she had two problems that she would like help with, if that was okay.
The most pressing one was recurrent abdominal pain that had resulted in a recent visit to an emergency department. The second was a recurrent headache that she thought might be migraine. I reassured her that these were legitimate reasons to come to see me and that I would address both today. I suggested she give me her coat, scarf and cap so that I could hang them up and she could sit back in the chair, relax a little before we began. She did as I suggested and the consultation proceeded smoothly with a focused history and examination followed by a negotiated management plan for both problems.
It was at this point that she voiced her concern about the amount of time she was consuming, causing me to disengage from my typing and become aware of my external circumstances. I looked at the clock and saw that she had been in for almost 25 minutes. I could have sworn it was five. But, for once, this didn’t matter. This was the morning of Storm Emma and ‘Mary’ was the last of only four people who had attended me that morning. A further 12 had been afraid to brave the elements and were present only as red cancellations on the computer screen. All four who had attended had received more than 20 minutes each and like this consultation, every minute had been focused and necessary.
Freed from the usual time constraints, I had the opportunity to fully engage with each patient, deal with their agendas as well as a few of my own, conduct necessary examinations and decide management plans in an unhurried but effective manner. I had worked hard, but did not feel drained or overwhelmed and did not have a mountain of paperwork to attend to before my afternoon surgery, as is usually the case. It was a good feeling. I realised that what I had been experiencing throughout the morning was a state that psychologists call ‘flow’: A state where body, mind or both are fully engaged in an activity to accomplish something worthwhile. A state more associated with artists and creative work than run-of-the-mill workers like myself. A state that not only makes work seem effortless, but has proven beneficial effects on wellbeing.
According to psychologist Mihaly Csikszentmihalyi (pronounced Cheeks-Sent-Me-High), there is no reason why any activity cannot induce this state of flow, provided the conditions are right. These conditions include: Clear goals, no interruptions, being able to complete the task, immediate feedback, a sense of control, and absence of intrusive worries about everyday events. These conditions lead to an altered sense of time when minutes can seem like hours or hours like minutes and the experience is one of a deep sense of enjoyment. It is a state not often experienced in general practice with over-booked surgeries, constant interruptions and often, an inability to complete one task before having to consider the next one.
“You picked the right day to come in,” I said. “I wish it was like this all the time. I hate when I have to rush people or when I keep people waiting.” The woman raised her eyebrows and gave me a look of surprise.
“Well, the worst day ever it was here, wasn’t a patch on the NHS,” she said. “There, I don’t think I ever even took off my coat. I could wait up to three weeks for a GP appointment, go in, start to say something and find I was back out in the waiting room before I had finished my sentence. I saw a different doctor every time and to be honest the place was so busy that they barely looked at you. I gave up going in the end as I found it such an unpleasant and pointless experience. I hope it never gets that bad here,” she added, as she made her way to the door. “I hope not, either,” I replied, feeling a little selfish that I was grateful for the storm and the enjoyable morning’s work, but also wondering how long it would be until we are just as good as the NHS.
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