Rural GPs - NUI Galway Study
Monday, 2 April 2001
General practitioners in rural Ireland express grave concerns about their lack of time off and complain that the large proportion of time committed to out-of-hours care greatly infringes on their social and family life.
A qualitative study on the experiences of rural general practitioners of the provision of out-of-hours care, conducted by the Departments of General Practice and Psychology at NUI, Galway, has just been published in the British Journal of General Practice, the world s premier academic general practice journal.
The study was carried out by Mrs. Nuala Cuddy (Health Psychologist, currently working as researcher in the Department of General Practice at NUI, Galway), under the supervision of Ms Anne Marie Keane (Lecturer at the Department of Psychology at NUI, Galway;) and Professor Andrew Murphy (Professor of General Practice at NUI, Galway). This is the first comprehensive research to qualitatively explore the attitudes of rural general practitioners to out-of-hours work. Although general practitioners expressed general satisfaction with their work, including the satisfaction they experienced from helping to make people better and providing comfort for the terminally ill in a small rural community, Nuala Cuddy reports that the demands of out-of-hours care is one of most stressful aspects of their job. "While they accept that it s part of the service they provide, the GPs believe there s far too much of it, and it places unreasonable restrictions on both themselves and their families", she said.
Closely linked with restrictions was the irritation general practitioners experienced by what some described as constant interruptions and unrealistic patients expectations of their doctor. "Patients calling to their door and sleep interruptions were viewed as particularly stressful", said Nuala Cuddy. "Older general practitioners found these especially trying." She went on to say that one general practitioner remarked, 'They know I m off, but people think I am just there at home and it s only me… they don t realise there are another thousand people who think it is only me'!The researchers point out that 'a persistent theme throughout the research was the negative impact out-of-hours care provision could have on family life. Many male participants, in particular, expressed concern for having to leave so many household and family responsibilities to their spouses. Nuala Cuddy noted that 'being on call not only restricted them in their own lives, but also greatly restricted their spouses as they could not pursue any social or occupational activity outside the home in the evenings. One spouse remarked, ''My husband couldn't mind the children if I wanted to go to a night class when he is on call… he couldn't even mind them while I go to Mass !
Most general practitioners had difficulty in getting locums. Nuala Cuddy notes that they felt that locums were not interested in coming to rural areas because of the isolation, the work intensity, the larger catchment areas and the smaller volume of private patients' fees compared to urban practices. According to one GP: "Locums just don t want to come to the rural areas; they want the soft pickings of the cities and the towns.'
Providing accommodation for locums in some rural areas also proved very difficult. Consequently, GPs and their families were obliged to leave their own homes in order to accommodate locums!. They strongly resented this and viewed it as an enormous infringement on their privacy and family life.In terms of coping with out-of-hours care provision and its consequences, all general practitioners felt that patient education was of paramount importance; however it is sometimes difficult to implement this in a small community. As one general practitioner said: It s so much hassle sometimes trying to educate people. It is often easier to say give me the form and I ll sign it"!
Professor Murphy and Ms Keane emphasise that 'the findings of this and other similar studies suggest the need for both individual orientated (e.g., patient education and stress management approaches) and organisational responses (e.g. central provision of regular locum coverage to rural practitioners).'
Fundamental organisational changes in the delivery of out-of-hours care, including general practice co-operatives, have recently occurred in the United Kingdom, Denmark and Finland. The first such co-operative was established in Ireland in 1999, with most health board areas now either implementing or organising them. This study describes very clearly why this is happening. It also emphasises why rural general practitioners, in particular, must be included in such initiatives.
Nuala Cuddy is available for interview on the findings of her research.