Practising as a GP in a rural area

Professor Rodger Charlton discusses the challenges faced by GPs practising in rural areas.

You have to make decisions, sometimes difficult ones, such as whether to call an air ambulance (SPL)

I started my GP training in a rural single-handed dispensing practice in Scotland. I then moved to a suburban multi-partner practice in the Midlands for seven years, including a sabbatical in New Zealand, before taking over a single-handed practice in a West Midlands village, where after five years, I became a partner.

Last year, I did a short locum in an isolated rural practice in Scotland with a small list size, which reminded me of the joys and challenges of being both rural and single-handed.

1. Staying anonymous

This is not possible. You cannot hide, you are on display, whether going into the village store, buying a ticket at the rail station, ordering a meal in a local restaurant, having a drink in the village pub or going into your GP practice.

Being the only doctor, you have daily contact with all of your practice staff and the ancillary staff, such as the district nurse.

Inevitably, all of your choices will be scrutinised by staff and patients, from clinical decisions down to the clothes you wear. This takes a bit of getting used to.

2. Your family

It is important for your family to have a normal life, even though as the doctor, you will be much talked about, not so much as a village celebrity, but as a necessity.

It is important to be a member of the community, to attend village meetings, pick up your children at the school gate, buy your Sunday newspaper from the village store and take your parcels to the local post office.

However, you must ensure the locals recognise that in the surgery, you are the doctor, but outside it, you are the same as them.

They will respect this. You and your family need this personal space.

3. Decision-making

Your practice may be a long way from the nearest hospital. In Scotland, it was 75 miles on poor roads. You have to make decisions, sometimes difficult ones, such as whether to call an air ambulance, and ones where you need to regularly review, for example, a child who is unwell, when ideally you would have asked the on call paediatrician for their assessment.

You will spend more time with your patients, as you have fewer to see, but because you are dealing with uncertainty and more difficult access to specialists, you will take even more detailed histories, conduct very thorough examinations, perform investigations where possible and ensure you are available for frequent patient reviews.

4. Dispensing

This can seem daunting if you have not done it before, but usually, there will be an experienced receptionist who is trained as a dispenser.

You do need to check every prescription carefully to ensure it is what it says it is, the amount, the instructions to the patient and the expiry date.

Similarly, you will develop a very limited formulary for immediate stock, although most medications can be requested and delivered within 24 hours and sometimes quicker.

It is vital to keep your emergency drugs, including those for injection, up to date.

5. Home visits

Home visits need to be carefully planned because you will be covering a wide practice area and travel time will be lengthy.

Someone at the practice needs to know where you are in case of an emergency, bearing in mind that you may have a poor phone signal (or no signal at all).

For some, this means going back to general practice before the advent of mobiles, with staff monitoring an emergency landline for the surgery.

6. Workload

Although you may not be seeing large numbers of patients, working on your own can lead to a feeling of professional isolation, as you have limited contact with colleagues. Rather than going to clinical meetings for CPD, you may keep up to date by teleconference or eModules.

Holidays can be difficult because you need to find reliable locums who understand how to operate your computer system and will be happy with the accommodation you provide. There is also the anxiety that you are still responsible if they become ill or unavailable.

Your team of staff will be small and you will often need to multitask.

This is rewarding work, however, as you are in the privileged position of finding out what happens to all of your patients and can provide real continuity of personal care, developing a service that meets the needs of your community.

  • Professor Charlton is a GP in Hampton-in-Arden and director of undergraduate primary care education, school of medicine, University of Nottingham

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