In September 1996, James McCormick, a GP and emeritus professor in the department of community health at Trinity College Dublin, had an article published in the Lancet, which offered an arresting view of the role of the family doctor.
“In the past 30 years the doctor as a father figure has become unfashionable and derided and is even seen as unethical. Yet the doctor as plumber denies some of the fundamental needs of those who are, or believe themselves to be, sick.”
For decades in Ireland, the family doctor was an archetype: the reassuring, overcoated figure arriving at all hours in stricken homes with his – and it usually was a he – solicitous air and a heavy, formidable black bag that seemingly contained all the tinctures and instruments known to medicine. Every family in Ireland had “their” doctor and they stuck with them as rigidly as they did their political beliefs or local pub.
“I had the privilege and honour of seeing out a woman who was a couple of months shy of her hundredth birthday that he had seen into the world,” says Dr Eamonn Shanahan, speaking about his grandfather, who started a family tradition in Farranfore, Co Kerry, in 1921. Shanahan succeeded his father as the local GP; his daughter Bríd is the fourth generation of family GPs and works in Summerhill in Dublin.
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In his paper, McCormick, lauded as a challenging and original thinker, argued that the crucial connection between doctor and patient was fast being eroded by “the growth of group practices, duty rotas and mobility within society”.
It’s an observation that seems more pertinent than ever. Among the general practitioners to whom McCormick served as mentor is Dr Rita Doyle, who is preparing for retirement after 40 years of private practice in Bray, Co Wicklow. The landscape for general practice across Ireland, urban and rural, has changed radically over her career. An acute shortage in GPs across the country is a well-documented concern. Small towns and villages are losing local doctors to retirement. Replacing them is proving impossible. Group practices, in custom-built surgeries, have all but erased the 20th-century model, where doctors worked in surgeries adjacent to their private homes. Burnout and a relentless patient register, irrespective of season, is a common theme at conferences and anecdotally. Patients complain that they can no longer get to see “their” doctor any more: that they have to make do with an appointment with whichever doctor is free
“There is legitimacy in that,” says Doyle of that common gripe.
“The first thing to say is that the patient population is more demanding now. And we have a lot of vulnerable people in our communities. But I would be absolutely passionate about keeping the role of the personal doctor because I think that is the model of perfection. You see Dr X; you get on with them and each consultation is a continuum of the previous. You don’t have to start again. We know from all studies that patients get better outcomes and doctors better satisfaction. And there are ways to encourage this. I preach it where I go. And I will be shot for saying this, but I have a real issue with corporate general practice. I do not see it as an answer to any model that we have. It is just not. Because their motivation is profit. Of course, you have to make a living, but it is not the raison d’être for becoming a doctor. Personal doctoring is time efficient and cost effective and has better outcomes.”
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Doyle set up her own practice after the senior partner in the practice where she worked died at a tragically young age. She and her husband bought a house in Bray and turned the basement into a makeshift surgery. Eight years passed before they could afford to convert it into a proper functioning surgery. She graduated into a patriarchal system: there were just 20 women in her class out of 130 students. One time, when she sought cover to have a baby delivered – one of her own – an acquaintance told her, sorry, he would be golfing that day. Now, 46 per cent of doctors in Ireland are female, with the figure rising to 52 per cent of doctors in the 20--35-year-old age group. Doyle believes that while the ideal of personal doctoring is possible to maintain within a group practice, the rise of what she calls “corporate practice” has alarmed her and she is “absolutely terrified” at the thought of it becoming the future in Ireland. Doyle is a pioneer: in 2018, she became the first full-time GP and the first woman to be elected president of the Medical Council. She also served as president of the Irish College of General Practitioners (ICGP). But for many years, she was pushing the bike uphill.
“I would not like the women of today to do what I had to do,” she says.
She was a doctor during decades when Ireland became busier and more populous and when medicine became more complex. For years she was on rota with other GPs in the locality to work one night on call per week and one weekend every so often, which was always a blur of phone calls, middle-of-the-night car journeys and absolute exhaustion. The local doctors sharing the on-call system realised that something had to give after one of their number had 73 contacts – patient visits – over a single weekend. That system was becoming unworkable.
There are about 3,600 GPs in Ireland, with 700 of those scheduled to retire over the next five years
But for decades, the national arrangements with doctors were curiously intimate. Either the patient came to their home, or they came to the patients. Eamonn Shanahan was born two years after his grandfather died but learned about what his grandfather’s work entailed through his own father.
“My understanding is that his life as a country GP was not dissimilar to what we do now, as it’s the same sicknesses and illnesses. Of course, antibiotics were not available in the way they are now, and the work involved home deliveries.”
His grandfather worked during a period when tuberculosis was a prevailing health concern and when, prior to Noël Browne’s Mother and Child Scheme, figures for maternal and perinatal mortality were “horrendous”. Gastric problems were common, often the result of appalling dental hygiene. “Damp houses were another factor,” he says. Both his father and grandfather had surgeries in their homes. “It was just the norm,” he says of growing up in that environment.
“I think the biggest impact was on my mother. She was the secretary and receptionist and everything else. And a lot of older patients speak highly of her. There was a GPs’ wives association at one stage. They weren’t employees of the practice; they were just doing what they needed to in order to support their husbands.”
Shanahan’s father and the local vet were among the first professionals around to acquire a radio telephone. The calls would come through to the house phone, and his mother would relay the message to him when he was doing his rounds. Recent years have seen a sharp decline in the number of GPs in Shanahan’s vicinity. Cahirsiveen once had five doctors: it now has one full-time GP. Rathmore has none. Ballyduff filled a vacancy after a long wait. Waterville and Sneem filled posts with doctors from EU and non-EU applicants. There used to be enormous competition for these posts. The same story is applicable in every county in the State. There are about 3,600 GPs in Ireland, with 700 of those scheduled to retire over the next five years. The ICGP is working with the HSE to raise the number of annual graduates to 350 by 2026. But training takes four years and not all graduates will remain in the country or the profession.
“It’s the old cliche: the problems are multifactorial,” says Shanahan of the general disappearance of the lone rural GP.
“A big part is work-life balance. My father worked 12-hour days, five and six days a week for most of his life. People aren’t prepared to be available like that any more.”
For a lot of younger GPs, it is not negotiable any more: they are going to be home when their children are going to bed
He points out the basic costs for many emerging GPs who might be considering setting up in private practice for themselves.
“To start, they might have €100,000-€150,000 of loans for college fees. If they move, they will have to build or buy a house, and that’s another arm and leg and 35-year mortgage. Then you will probably need to buy a premises for your surgery. Irish GPs are contractors to the HSE. They are not employees. So you are looking somewhere north of three-quarters of a million to get started. It all adds up. If the doctor has a partner, then their work and career is another consideration. Then the work. A ‘session’ used to be four hours. That doesn’t happen. I work 12-hour days three days per week, and then shorter days on Thursday and Friday. But for a lot of younger GPs, it is not negotiable any more: they are going to be home when their children are going to bed – something I would have missed even myself when my kids were growing up. So, there is a drift to urban areas and to group practices for cross-cover.”
In Churchtown, Dublin, Dr Knut Moe is usually in his surgery at 8.30am after dropping his children to school. He runs his practice with his wife, Hana Maka, also a doctor. A three-hour session of seeing patients usually runs over by at least half an hour. “If you have a mental health presentation, then you give that patient the time they need. And then you see the faces staring at you in the waiting room. People have busy days. Waiting is not ideal for them.”
Referrals follow the patient consultations. Lunch is usually at the desk, and the afternoon session is 2.30pm-5pm. Administration keeps him in the office until 7pm, occasionally later. He now works three days in the office and one from home. The practice has been operating at capacity for several years, and the couple are unable to take new patients. It is, says Moe, “hell for leather” busy. But he hopes the general concern about burnout and GP shortages does not obscure the fact that it is a deeply rewarding career and life. Moe was set for a career in investment banking but realised, at 24, that while the lifestyle seemed fabulous, the actual work left him cold. He too comes from a family of physicians. His grandfather, Egil Moe, was from Trondheim in Norway, and served as a lieutenant colonel in the Norwegian army and was head of their mobile army surgical hospitals (MASH) or medical corps. He served in Korea and was awarded a Legion of Merit by US president Dwight D Eisenhower.
His father, Knut Harald Moe, came to Dublin to live in Ireland via the Royal College of Surgeons. His mother, Helen, was a physiotherapist in Limerick and also came from a medical family. The couple returned to rural Norway for a while, during the oil crisis, Knut Harald was one of the very few in the area with a key to the local petrol station so he could fuel up to cover his rounds, which spanned hundreds of miles of snowy countryside. They returned to Dublin to set up a practice in south Dublin, where Knut Harald established himself as a treasured GP and still works, aged 78. Egil worked in Trondheim until the age of 89. Knut grew up in the stereotypical Irish doctor’s house, where whoever answered the phone was the de facto secretary.
“Yeah, my mother would have answered the phone, and the appointments were written on the scribble box in The Irish Times next to the crossword. The first time Dad got a secretary was when he became his own secretary with the advent of the phone. And a lot of patients had his number – and that was not abused in any shape or form. It is rare enough now. But the great thing is that I still get to hear a lot of stories about how marvellous a GP he was and is.”
His father has a prodigious memory and can re-create a vivid network of families and parts of Dublin through patients he tended for decades. But Knut Moe acknowledges that the way medicine was practised in his father’s generation has all but vanished.
“Those days were not ideal. You were a bit of a lone ranger, and I am not sure anyone wants to go back to that day. Medicine has become so complex that, because we are the last of the generalists, where everyone needs to know a lot more about everything, we need to protect our longevity.”
But he is convinced that the qualities championed by his father and grandfather’s generation – the sense of vocation, the personal connection – can be carried through.
“The profession has changed,” he says. “But those changes were mostly needed as the demands of society changed. Irish general practice is still really high quality, adaptable and patient-centred. I think it is still really varied and interesting, and there is still a vocational element to it. There is still an opportunity to look after patients and families for their lifetime, even if the continuity of care looks a little different than it did when we were growing up.”
