17 minute read
YOUR COUNTRY NEEDS YOU
from RCSI Alumni Magazine 2023
by RCSI
The lack of primary care physicians in rural populations worldwide is troubling, and those RCSI alumni who work in such locations all share a desire to serve the underserved
DR MICHAEL HARTY MEDICINE, Class of 1977 Retired GP, Kilmihil, Co Clare
Medicine, Class of 1977
"I was appointed to a single-doctor practice in Kilmihil in West Clare in 1984. At the time I hadn't decided whether it was for the long term, but my wife Gerry worked as my practice nurse, we built a house and the children went to school locally. I retired in February 2022 after 37 years, and there were no applicants for my job. The Health Service Executive (HSE) took over the practice for five months and then appointed a couple who are both GPs. They are doing very well.
The biggest challenge of rural practice is that you’re running a small to medium-sized business, which we were not educated to do. We were trained to be doctors, but not to be responsible for everything from the building to the computer system. When things go wrong, the buck stops with you. Quite often I was the last person to be paid.
The problem of professional isolation has eased over the years as the Irish College of General Practitioners (ICGP) has developed. They broke down a lot of barriers which existed previously among GPs, and increased our collegiality and support for one other.
It was always very difficult to get locum cover to get a break, and that became wearing, the fact that you were dependent upon the kindness of others to get a holiday. The advent of the co-op system was a huge leap forward, it meant I was no longer on a one-in-one or one-in-two rota. I was lucky to be on a one-in-five rota, and later a one-in-ten. Because you were a self-employed contractor rather than an employee, you were left out on a limb by the HSE who hadn't any great interest in supporting general practice.
The situation isn’t a whole lot better now. I campaigned on the ‘no doctor no village’ banner and was elected to the Dáil. The campaign was much wider than it sounds, it was about the maintenance and development of the services – garda stations, post offices, schools etc – that make up a rural community. They were and still are under threat. When I came to West Clare there were eleven full-time contract holders, and now there are five, and other people who have part-time contracts and work a couple of days a week, which is very important for their own work-life balance but means the pressure on the existing practices is intense.
I found the whole experience in the Dáil quite frustrating. As a GP, I was used to doing things and finding solutions, in the Dáil things work a little slower. I was part of the Sláintecare Committee, which sat for a year. It was a very positive, pro-active, cross-party committee, which devised a blueprint for health reform. One of the fundamental building blocks was the development of a strong, integrated primary care service, to include general practice but also public health nursing, community intervention teams and nursing homes, delivering services within the community as opposed to delivering them within the hospital structure. at hasn’t happened. It requires a doubling of GP numbers if we are to deliver true quality primary care services, and until that happens recruitment will be very difficult because the workload is too onerous.
The ICGP and the Irish Medical Organisation (IMO) are anxious that the independent contractor system continue, and I do believe it delivers quality service, but when it can’t continue in rural areas then the HSE has to consider employing salaried GPs or establishing incentives, such as the provision of premises and staff, so the GPs can concentrate on delivering medical services. Trying to convince the Government to introduce a policy which would sustain practice under pressure has not succeeded so far.
As a rural GP you may be 50 miles away from a secondary or tertiary hospital, so you take on more responsibility. There is a different quality to the practice, you are more independent but it is wearing. You take on a lot of palliative care, and chronic disease management, and you support people living in isolated areas, perhaps alone. You become involved in the local community and its organisations.
On a personal and family level, the level of social isolation is not as bad as it was, the world has become a little smaller. And professional isolation is decreasing, because we have a very good continuing medical education network which meets once a month. We’re not competing with each other any more, because there are more patients than anyone can deal with.
Rural practice is a very satisfying type of practice to become involved in. I wouldn’t like to put people off it in any way, but it does have its challenges.”
DR TAYLOR JESPERSEN MEDICINE Class of 2020 Family Doctor, Vernan, British Columbia, Canada
Medicine, Class of 2020
"I grew up in a small community in Canada and always envisaged coming back to a similar place to practise family medicine, so I sought a predominantly rural training programme. Every rural residency is different, but I spent my first year in an urban centre and tertiary hospital, where I saw acute medicine and participated in a wide variety of work with different specialists, and during my second year I spent four months each in the very rural communities of Revelstoke and Smithers in British Columbia (BC).
In these communities there were well-supported hospitals run almost entirely by family doctors. We did obstetrics, and there were doctors trained to do Caesarean sections, emergency surgeries, colonoscopies, anaesthesia and other specialised skills. I enjoyed the type of medicine that I could do in a more rural community in terms of the scope of my practice and the breadth of skill involved.
My rural residency coincided with getting married, buying a house, my husband getting his long-term career position and deciding to start a family, and the prospect of being in an isolated rural community with no family support to help us raise a child made us rethink. We decided that a smaller community which is not classified as rural but would allow me to have a greater scope of practice was a happy medium for us.
I now work in a full-scope, longitudinal family practice with a full spectrum of patients from babies to elderly patients. There’s a shortage of family doctors across the whole of Canada, in BC there are over one million people who don’t have a family doctor.
While rural medicine in Ireland is very different to rural medicine in Canada, recruitment difficulties and inequity of access is common to both. The extra layers that Canada has are the vastness of our geography and our indigenous people.
When I did an elective in Saskatoon I worked in the Cancer Agency with young males with testicular cancer. Many were from northern Saskatchewan, a 10-14-hour drive away, and were choosing to forgo treatment or surgery because they could not either financially or in terms of time afford to come to Saskatoon for treatment. It’s not that the service wasn’t there, it was that they couldn’t access it.
Canada is a vast beast. We have patients who are a 30-hour drive away, and no way of getting an aeroplane or helicopter to them. You can only access some communities in the dead of winter via ice roads, which melt in the summer and cut off access. The geography aspect is fascinating to me.”
DR LAURA CULLEN
MEDICINE Class of 2009
GP, Bantry, Co Cork, Ireland
Medicine, Class of 2009
After my intern year, I went straight onto the North Inner City GP Scheme started by Dr Austin O’Carroll. I knew I wanted to work in disadvantaged urban settings.
Then I met my now partner, and moved to West Cork in 2017. Because so many rural GPs are retiring, there were many opportunities for me. I settled on the practice I felt was culturally right.
Bantry has a large, remote rural hinterland. It’s a medium to larger practice, and we are growing rapidly. We haven’t closed our books yet, but other practices in the area have. It is difficult for more vulnerable patients who don’t have transport to get to the doctor, and although it’s not an efficient use of GP time for us to be on the road making house calls, I regularly visit elderly people 40 minutes’ drive away.
Because many GPs who are retiring are not being replaced, the workload is heavier for the rest of us in terms of call frequency. The out-of-hours service is under pressure. I usually work 12-16 hours per month on top of my day job, which isn’t too bad, but one third of my rota is due to retire within the next five years. In other towns, where there is already a greater shortage of GPs, the system is collapsing. We have to look to allied health professionals such as community paramedics and advanced nurse practitioners for the provision of out-of-hours and on-call services, and give them the training they need.
We have a community hospital but no access to paediatrics, surgery, oncology or obstetrics and gynaecology locally. Those services are mainly in Cork. While I understand we need centres of excellence, the consequence is that our patients are on the back foot when it comes to certain types of care. I’ve always had an interest in sexual health and gynaecology, and I have developed a role for myself as a primary care gynaecology and sexual health doctor. In rural areas, the lack of services for disadvantaged and marginalised communities is made worse by the fact that these people are less likely to be able to afford a car. Getting help for people in homelessness or those with addiction is much more difficult compared to urban environments, and my role as an advocate is made much harder by the fact that poverty is often hidden and shame around it is rife.
I have had multiple experiences of sitting with patients for hours on end waiting for ambulances to arrive. When the HSE shut down the emergency departments in the community hospitals, continued provision of care required many more ambulances. This didn’t happen. We are not going to attract new GPs if things stay the way they are.”
Dr Pat Naidoo
Medicine Class of 1976 Emergency Medicine Consultant, Townsville, Queensland, Australia Formerly: Retrieval Doctor, Aspen Medical, Western Australia
Medicine, Class of 1976
"I have worked mainly in Australia since graduating from RCSI in 1976. My retrieval positions have included working with the Australian Defence Force in East Timor and the Solomon Islands, supporting both the defence force and the civilian community, and within Australia. From 2011 to 2022, I worked with Aspen Medical retrieval service in the oil and gas sector in Western Australia.
Australia has a large land mass and low-density population. Rural and remote areas have limited or no access to specialised health services and retrievals from these areas involve distances ranging from several hundred to several thousand kilometres. My ‘fly in, fly out’ roster included three weeks of 24/7 care in the gas and oil field sectors with many retrievals, both onshore and offshore, taking six-eight hours.
The retrieval system provides patients with rapid access to the skills of a specialised doctor in emergency, anaesthetics or intensive care who facilitates transfer to better equipped urban hospitals. This is a process that provides specialised assessment and management prior to and during transfer of critically ill patients from areas where resources are inadequate to a destination of definitive care.
The Australian retrieval system uses centralised coordination centres and teams of nurses, doctors and paramedics with complementary skills and experience. Transport platforms use helicopters, fixed-wing aircraft, road transport and marine resources. The evacuation of a medical patient in a helicopter looks dramatic on television but we minimise the drama and complexity without sacrificing the quality of care.
Aeromedical settings provide a challenging clinical environment and retrieval staff must meet required professional standards in critical care, emergency or anaesthetics and must have specific training in the retrieval environment and critical care in transport settings.
The advantages are that the work is fast-paced and exciting, interesting and diverse. You have to know how to respond to many and varied situations.
The work is demanding and requires challenging interventions and the provision of 24/7 on-call care. It can be emotionally and mentally exhausting because you often see patients with severe and traumatic conditions. The role is pressurised because trauma-related cases require immediate decisionmaking and because you often work in isolation your skills must extend across all specialities.”
DR TERRY LYONS
MEDICINE Class of 1987
Family Doctor, Yarrahah, North Queensland, Australia
"My introduction to rural medicine was as a student on the rural rotation to Kilkenny which encouraged me to apply for the medical internship rotation there. Kilkenny provided excellent teaching, training and craic.
After intern year, I went to the Ibn Al-Bitar Hospital in Baghdad and then to the UK where I did accident and emergency, orthopaedics, paediatrics and anaesthetics.
I moved to Australia in 1990 and joined the College of GPs’ rural clinical training pilot project in Toowoomba, Queensland. I did some more anaesthetics, obstetrics and psychiatry, and then rural placements. Australia is an exciting place to work, particularly in the bush. Rural doctors have the opportunity to work in both primary and secondary care in remote settings.
After Toowoomba, I started working as a GP anaesthetist and obstetrician in remote areas, including the Torres Strait Islands, which have an indigenous population, and Catherine in the Northern Territory, where I worked in a hospital and did outreach clinics as a district medical officer.
My wife, Geraldine MacCarrick, is also a GP, and an academic and hospital administrator. We have worked in a lot of different states and did a few years in a rural practice in Ireland too. Now we are semi-retired and work as rural locums.
I’m no longer doing anaesthetics and obstetrics, but I do emergency medicine and general practice, and run small rural hospitals and outreach clinics. We’re just back from a trip to Western Australia (from our home in Huon Valley, Tasmania), and we’re heading up to Cairns, in the far north of Queensland; we’ll be there for four weeks.
There’s a shortage of doctors everywhere but early exposure to rural medicine is very important when it comes to recruitment. It certainly helped in terms of sparking my interest. In very remote areas where recruitment is difficult, the government employs senior medical officers on well-paid contracts with plenty of time off. When I work as a locum it’s often to cover their leave.
In Australia, the indigenous population has specific problems. The people are dispossessed, and they’ve got the problems of poverty, alcohol, and no work. In remote communities, diet is a problem because good food is expensive. So diabetes is a huge issue, as are all the alcohol-related and sexually-transmitted diseases, and childhood neglect. Life expectancy is 15-20 years less than for non-indigenous people. Part of the problem of recruitment is that some of these communities are not safe, they can be violent and they are not somewhere that as a doctor you can bring your family to live. Many doctors work on ‘fly in, fly out’ contracts.
Now we have the Australian College of Rural and Remote Medicine (ACRRM) which is the first rural college of medicine in the world. I’m one of the foundation fellows. There have been tremendous developments in rural medicine since its inception. The doctors are very well trained in general medicine and they choose a specialist skill as well. Because the sun shines so much here we all do a lot of skin cancer treatments. You’re always looking at what your community needs and where the deficiencies are.”
DR MARK WILLCOX
MEDICINE Class of 2009
GP, Scotland (recently moved to Australia)
Medicine, Class of 2009
For six years, I was a GP on the Isle of Barra, in the Outer Hebrides and then I moved to the mainland to the very northwest of Scotland, to a place called Tongue, which probably doesn’t even figure on any maps. Both places are quite remote, with very real and different challenges.
I was in the army and did a degree in marine biology before going to RCSI to do Graduate Entry Medicine. After my intern year in Ireland, I did some orthopaedics and gynaecology because I felt that for a rural GP those were important. I did my GP training in Liverpool.
I grew up on the Western coast of Scotland but I had no connection with Barra when the job came up. The retiring GP had been advertising for a couple of years – he probably wouldn’t have taken someone fresh from GP school if he’d had the choice. But he took me on and was a great mentor. We overlapped for four and a half years.
During the pandemic, he stayed in the surgery and I took care of the hospital and seeing anyone with respiratory symptoms and the COVID-19 patients. It was a rough 18 months. When he retired I carried on for 18 months, but it’s not a job you can do 24/7, 365 days a year. I have a family, and it wasn’t feasible. During the pandemic my family went to stay on the mainland and we were separated for five months. It was very difficult.
When I moved to the mainland I came to a practice that hadn’t had a GP for four or five years, and had lost its practice nurse and practice manager. I’ve been here since December 2022 assessing the situation for the Health Board but now I’ve decided to move to Australia.
The real difficulty in rural practices is with patients who become acutely unwell and how you get them to secondary care. In some ways it was easier on Barra, because even though it was much more isolated we had a community hospital where I could admit patients and stabilise them while I was waiting for the air ambulance. In bad weather, that air ambulance might not arrive for four days, but I could do the basics in a hospital. On the mainland, although we’re only two and a half hours away from a hospital, you could be snowed in for two or three days and the ambulances are under a great deal of pressure. Doing that pre-hospital medicine, you’re on your own, without nurses. The only support staff in the practice are two part-time receptionist/dispensers. It’s just not viable.
I love my job. It’s a huge honour and privilege to be a general practitioner, wherever you are. And the additional aspect of doing pre-hospital medicine, dealing with car crashes and emergencies is interesting medicine, if you can step aside from the immediate stress of the situation. So primary care has a real role. But in the UK we’re in a period of quite terrible cutbacks and change, and the situation is going to get a lot worse before it gets better.
I remember these issues being discussed when I was a child growing up on the west coast of Scotland and 40 years later it’s worse, not better. I don’t think this is peculiar to the UK or to Scotland – talking to friends in Canada and Ireland I hear the same stories.” ■
