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Trusting doctors to do the right thing

The Rural, Island and Dispensing Doctors of Ireland Annual Conference, held in Clifden last month, was well reported in the medical press. The Saturday line-up of events included many topics of both clinical and political importance for rural doctors. Out-of-hours arrangements, the role of the coroner, an update on concussion, two political addresses and an update from both the IMO and NAGP on their efforts to keep rural practice on the political agenda were all featured.

For some, the conference ended on the Saturday evening; for others, the Sunday morning. A group of 25 die-hards, myself included, opted not to go home until Sunday evening and spent that beautiful autumn Sunday re-learning the basics of acute trauma management from the UCD Immediate Trauma Care team. Places on this course were limited to 25 and were booked up early on a first-come, first-served basis. What is it that makes GPs, who might only witness acute trauma a couple of times a year, or less, spend a full day updating and upskilling when they could be golfing in Ballyconneely, scaling the heights of the 12 Bens or enjoying a leisurely lunch in the historic and stress-free Renvyle House Hotel? There is no clause in the GP contract stating that a doctor must be proficient in acute trauma care. There is no special payment for doctors who acquire and maintain these skills. To the best of my knowledge, it is not a HIQA requirement. The motivation to sign up for such a course is intrinsic, fuelled by the desire to do the right thing, simply because it is the right thing to do. This type of motivation is often what first inspires people to choose medicine as a career. Sadly, it is also frequently cited as a reason doctors end their career prematurely, when they find that doing the right thing is no longer possible.

Some months ago, when facilitating a teaching session with GP registrars, I asked each participant to tell a story that demonstrated a character strength. This took a bit of persuading, but gradually the stories emerged. One young GP recounted how he was travelling home from work one evening when he came upon a multi-car accident. Despite his initial fear, lack of experience and self-doubt, he immediately set about seeing what he could do to help. By the time the ambulance arrived, he had helped make the scene as safe as possible, sorted out who needed urgent care, calmed the frightened and stabilised a cervical spine with the help of an uninjured passenger. As his colleagues pointed out the many strengths demonstrated by these actions — self-regulation to overcome his fear, generosity with his time, kindness, leadership and many more — his reply was: “I was only doing what anyone here would have done. I probably could have done it better.” Many GPs do not appreciate the immense difference they make to people’s lives in extreme circumstances such as these or the courage, bravery, generosity and compassion required to do this. Many healthcare policy-makers fail to understand this also or mistake it for weakness, thinking that because GPs chose to attend a traffic or sporting accident, they will also give vaccinations, monitor diabetes and provide pre-operative MRSA testing for free.

The scientific study of human motivation and personality explains how social and cultural factors can facilitate or undermine a person’s sense of volition and initiative. Conditions that support an individual’s psychological need for autonomy, competence and relatedness will lead to more intrinsically-motivated acts. This, in turn, leads to enhanced performance and an increased sense of wellbeing. Conditions that thwart any, or all, of these three psychological needs will have a detrimental impact on performance and wellbeing. Having the autonomy to decide what to do, feeling competent to meet each new challenge and believing that our actions enhance our connections with others will result in a high level of intrinsic motivation, a high level of performance and a sense of wellbeing that makes us more likely to perform similar acts in the future. Feeling compelled to do something that has very little personal value, that is either above or below our level of competency and that does not make us feel connected to others, will lead to poor performance and a decreasing sense of wellbeing that makes us less likely to continue to do such tasks in the future. 

Generally, doctors are prepared to go beyond the call of duty, demonstrating character strengths and intrinsic motivation that money cannot buy. To quote Walt Whitman, “character and personal force are the only investments that are worth anything”. If Irish communities, urban and rural, are to retain this personal force, there needs to be considerable investment in general practice and renewed trust in doctors to continue to do the right thing, simply because it is the right thing to do.

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