DOCTORS ON THE FRONT LINE:The traditional rural GP once had the role of social worker, psychologist and benefactor as well as doctor, and their varied responsibilities inspired a series of novels by Patrick Taylor. Here, Taylor tells MICHAEL KELLYwhat inspired his stories, and five rural GPs talk about how their role has changed
THERE'S AN INTERESTING conflict going on in the mind of the main character in Patrick Taylor's novel An Irish Country Doctor. The book is set in Northern Ireland in the 1960s, where Barry Laverty, a strait-laced young doctor fresh out of medical school, is torn between general practice and a speciality. To help make up his mind, he becomes an assistant to the gruff Dr Fingal Flahertie O'Reilly in the tiny fictional village of Ballybucklebo.
Over the next 300 pages, the idealistic Laverty falls in love with rural life, a rural lass and general practice and learns things from the world-weary but kind-hearted O’Reilly that can’t be learned at medical school.
It's cliched at times – like a cross between Scrubsand James Herriot – but it's tremendously good fun and a veritable homage to country doctors and the rural way of life.
The first question that Taylor invariably gets asked in interviews is whether Barry Laverty is in fact an autobiographical character.
“Most of my friends think that the book is a conversation between an old Taylor and a young Taylor,” he says. “There’s certainly a lot of me in the book, but not in the purely autobiographical sense. The characters are the product of a very warped imagination and an amalgam of lots of different people and experiences from my life.”
Born in Bangor, Co Down, in 1941, he graduated from Queen’s University in Belfast in 1964 and after a year as an intern, studied anatomy while working weekends in rural practices (it is from this period that most of the characters in the book were gleaned, he says). Unlike Laverty, however, Taylor decided general practice wasn’t for him, and trained instead in obstetrics and gynaecology before emigrating to Canada in 1970 just as the Troubles were accelerating.
“It was partly to do with the Troubles, but mainly I left because of the hierarchical structure of the health system here. A young fellow like me couldn’t get a job until someone retired, which meant I would have had to wait an awfully long time to get a senior position. I’d had the opportunity to do a locum in Canada and I had the contacts. I never regretted it.”
He trained with IVF pioneer Patrick Steptoe and spent three decades in Canada researching in the area of human infertility. Though now retired, he remains in awe of the progress that was made in fertility treatment since those early days. “We confidently said at scientific meetings back then that we would never get the success rate of treatment over 10 per cent. It’s 50 or 60 per cent now.”
Taylor received three lifetime achievement awards for his work. His prolific research output morphed into a fiction-writing career as he moved towards retirement.
“I’ve always found writing cathartic. Medical research and fiction writing are based on the same premise – asking the question, what if?”
The characters of O'Reilly and Laverty first appeared in a monthly humour column he wrote for a Canadian medical journal, later published in book form as The Apprenticeship of Dr Laverty. A canny US agent changed the title to An Irish Country Doctorbefore US publication in 2007, and it was an instant New York Times bestseller. Two sequels ( An Irish Country Villageand An Irish Country Christmas) followed and Taylor is currently working on the fourth instalment, An Irish Country Girl.
“It’s not set in Ballybucklebo and there are no doctors in it, so I suspect that it will get me in all sorts of trouble.”
It’s easy to see why the books appeal to a US readership. Even minor characters are drawn with great fondness and an unerring eye for detail – the hard-working, kindly housekeeper (surely a role for Brenda Fricker if we ever see a film version); Laverty’s love interest; the town drunk; and O’Reilly’s dog Arthur Guinness, who has a rather worrying penchant for beer.
The two GPs are also lovingly portrayed. O'Reilly is far more than a doctor – he is the village's saviour, social worker, psychologist, benefactor and Jim'll Fix Itall rolled in to one. Are rural doctors are still so deeply enmeshed in the fabric of their communities?
“No, I doubt it very much. In order to be involved the way O’Reilly was, you have to have stature and respect and without that slight hierarchical thing, it’s impossible. We have moved to an egalitarian society now where doctors are seen as purveyors of a commodity.”
His work on the Irish Countryseries has been punctuated by more serious fare based around the North's sectarian conflict (a short story collection called Only Wounded: Ulster Stories, and two novels). Even in An Irish Country Doctor, which Taylor himself calls "a silly wee book", the beginnings of the Troubles are bubbling in the background. The evil villain of the piece is the Grand Master of the local Orange Order.
“I couldn’t resist. Listen, it’s very hard to write about Ulster, if you grew up there, without some of the sectarian issues coming through.”
Taylor has recently returned to live in Ireland and in search of rural idyll he found Cootehall, Co Roscommon. “At the moment I look at it through rose-tinted glasses. It’s just so nice to be back. I grew up on water and I pined for it when I lived on the Canadian prairie, so one of the prerequisites was that it would be beside water. Cootehall is no different to the places I grew up in as a boy. Everyone knows everyone else and the main pastime is going to funerals.”
So the love affair with rural living continues. As Dr Laverty remarks on a visit to Belfast: “Dirty old harridan of a city, and one that I don’t miss one bit. There’s a lot to be said for Ballybucklebo.”
DR JERRY COWLEY
MULRANNY, CO MAYO
PERCEPTIONS ABOUT the life of a rural doctor usually go something like this: they don’t make as much money as their urban colleagues; they are on call 24/7 and have no private lives; many or all of them will burn out before they reach retirement.
“Those myths are still out there, no doubt about it,” says Mayo GP, chairman of the Rural Doctors’ Group and former Independent TD, Dr Jerry Cowley.
“I think doctors want a home life now and they don’t want to be working 24 hours a day, seven days a week anymore. “Half of qualifying doctors are women and they just won’t put up with not having a life outside work. And in most cases, neither will the men. Things have changed.”
Some rural practices, however, remain relatively immune from the changes which are occurring elsewhere – almost as if they are suspended in time.
In Mulranny, Co Mayo, for example, Dr Cowley still operates surgery from his home and still does so alone. There is an out-of-hours service in the area, but there are still times when he has to get up in the middle of the night in his dressing gown to attend to a patient.
“If you have a medical emergency you have an obligation to deal with it. I think most people appreciate that doctors deserve a private life too, but the doctor is still the first port of call in every rural storm. I used to work 365 days a year without a break and I was on call 24 hours a day. With co-ops, things have improved considerably, but not every area has them.”
DR KEVIN QUINN,
ÁRAINN MHÓR, CO DONEGAL
ON ÁRAINN MHÓR, three miles offshore from Co Donegal, where Dr Kevin Quinn’s practice is pretty much as rural as it gets.
“I have a registrar here at the moment and she can’t believe the knowledge that I have about patients,” he says. “There is a sort of unspoken communal knowledge here that is very bizarre. That said, you have to remain slightly removed from it as a professional. I don’t believe that going totally native helps anyone.”
Born in England to Irish parents, Quinn came to the island 25 years ago with a plan to stay for a year or two – he never left.
“I had always wanted to be a career GP but I never really envisaged the rural life. I always sort of assumed I would end up working as part of a team of doctors. I wonder sometimes, will I stay here forever? Is there another career in me?”
The people of Árainn Mhór, he says, didn’t really care that he was so young when he arrived first.
“At the time they were just delighted to get a full-time doctor. People on islands and in rural communities in general are very unsure about services staying in place so they were all the time looking for reassurance that I wasn’t going to up and leave. They would say things like ‘You like it here, don’t you doctor?’ ”
He recalls Christmas Days where he has had a number of children with “bike injuries” to deal with before he can tuck into his dinner, though he admits the out-of-hours service has improved things immeasurably. “You don’t feel that you are on call all the time anymore. I would say the number of calls I get at night has fallen by 75 per cent.”
Though he loves island life, he’s adamant that running such a remote practice is not as idyllic as it sounds. “The physical barrier does create a sense of isolation. I remember thinking in my 30s that if I was going to stay in practice here I needed to do something else too and I decided to get into teaching and training. One day a week I go back to the mainland for that. You definitely need a sense of purpose and a certain amount of mental strength because of the isolation.”
DR FERGUS GLYNN
COROFIN, CO CLARE
In Corofin, Co Clare, Dr Fergus Glynn bucks the trend of young ambitious doctors avoiding rural practice. His first day at the office in 2006 must have been made more difficult by the fact that he was taking over a practice which had been run by four generations of the McNamara family. The last Dr McNamara had seven children, but none of them went into medicine. Enter Dr Glynn – tough gig.
Though he grew up in Co Meath, his grandmother was a local, which eased his way to being accepted somewhat. “I was sort of local by extension,” he says. “So there was no great resentment when I came in here. The fact that I have a relationship with the community plays a huge role in helping me to form relationships with my patients and that’s what being a GP is all about.
“There is a huge amount going on in the background of a person’s life that feeds into diagnosis. A rural GP is in a position to see these things.”
He studied at UCD and initially planned to specialise in paediatrics, but while working in Scotland he became aware of an impending vacancy in Corofin. “I had always been massively into the outdoors and I felt that I wanted a broader canvas than paediatrics provided. There is always a tension there, I think, between general practice and speciality. As a GP you are not the guy who knows everything about something. You know a lot about everything.”
GPs are now providing services equivalent to those of a small hospital, according to Glynn. “There is this notion that GPs are failed specialists, but I think that is less and less relevant now and that general practice attracts the best and the brightest. GPs in general have more management of chronic disease to deal with and rural GPs know the implications of referral to hospital so they tend to take on an awful lot more. That is what keeps me excited about coming to work – how much you take on in terms of knowledge is largely up to the individual.”
Unusually for a doctor his age, house calls are still a huge part of his practice. “I think if you work in a rural practice, you expect them. I have a large number of housebound patients and it’s not as if there are places for them to go. It makes the day longer, but it’s a side of the work that I find really interesting. Being at their house gives you a clearer picture of the patient. It’s not an efficient use of time, but then efficiencies are something we always struggle with in rural practice.”
So what about the other myth about rural practice – that a rural doctor will never earn as much as their urban colleagues? “I think that’s probably true, but to be honest I am not motivated by money. I’m young and enthusiastic and that’s what gets me up in the morning. The days are long, that’s the reality. It’s difficult to ward off burnout and the days can be never-ending. But it’s enormously rewarding. My grandmother died about two years ago at the age of 99 – she was an amazing person and part of my motivation for coming here was that I wanted to look after people like her. People who had that link to the past, to the land, to our culture. These fascinating, wonderfully warm and welcoming people – I think the last of them are around here now.”
DR RICHARD SHANAHAN & DR EAMONN SHANAHAN
FARRANFORE, CO KERRY
DR RICHARD SHANAHAN tells a great yarn about a patient knocking on his door in Farranfore, Co Kerry on Christmas Day many years ago. “I said I would call to you today, doctor,” said the patient, “because I know how busy you are on other days.”
Dr Shanahan has an array of anecdotes from a lifetime’s work as a GP (he retired in 2000), but the one about the yuletide caller best highlights the demands placed on the personal life of the country doctor. Richard Shanahan was part of an impressive unbroken line of ‘Dr Shanahans’ in Farranfore that spanned the generations. That legacy in itself acts as a commentary on the progression which has taken place in the personal and professional lives of rural doctors. He started work with his father (also a GP) back in 1952, a time when most doctors ran their surgeries from their homes. He recalls as a boy seeing patients practically accost his father looking for impromptu diagnoses outside Mass – so much for work-life balance.
His father died in 1954, leaving 26-year-old Richard in charge of the practice. He was the sole GP there for more than 30 years until his son Eamonn joined him in 1986. Over those years life expectancy in Ireland has increased dramatically, which means that latter-day rural GPs deal with increasingly ageing patients and an array of complex chronic illnesses.
In his heyday Richard Shanahan attended to 70 patients a day with an average consultation time of three to five minutes. His son would be lucky to get through half that number nowadays.
The surgery remained in their family home until about 10 years ago when father and son moved to a purpose-built facility (Farranfore Medical Centre), where there are now four doctors and a trainee. This reflects a broader trend of rural doctors coming together to practise – inevitably it means a better quality of life for the doctors, but it also means the classic model of the sole rural GP is a dying breed.
Richard Shanahan busies himself since retirement with music (he plays double bass), but says he misses life as a rural GP. “I never regretted a day that I spent in general practice. You are at the heart of families. I was out running errands recently and a young girl came up to me and said ‘Hi, I am a daughter of such-and-such,’ and afterwards I was thinking: I brought that girl into the world. You were nearly like one of the family.”
Most doctors, according to Eamonn Shanahan, experience that tussle between the attractions of general practice and a chance to shine in a speciality. “I deliberately kept my options open in med school,” says Shanahan, “but in fourth med, I spent some time in a purpose-built practice in Cork and was hugely impressed by how it was organised. That convinced me that practice was for me.”
Operating from Farranfore Medical Centre, as opposed to the family home, has the effect of ring-fencing his private life. “That situation my father had with people calling to the house rarely happens now. The 24/7 element to the job is gone. In one sense what has also gone is the very personal contract between the GP and patient. But the downside of that wonderful personal care that patients received was that the doctor was incredibly tied to practice.”
A sense of collegiality is vital to younger doctors, he says, and allows them to pool their knowledge. “I can go to my colleagues with questions and they can come to me. That’s so important because general practice is so broad and so complex now. Recruiting doctors is a constant challenge for rural practices and the more remote the practice the more difficult it is. If you are 60 miles from the nearest hospital, you are going to have to take on things which you might not if you were only five miles away. We would do a certain amount of minor surgery here, but our colleagues who are farther away from hospitals would do far more.”