Rural practice. The challenges and rewards of living and working in the same community

Keywords: confidentiality, general practice, privacy, professional boundaries, professional ethics, professional identity, reflective practice, rural practice, self-awareness, self-care, self-disclosure.

GP in small town

I have saved lives but mostly I just watch lives, unfolding, as they do.

I mainly give out tissues and condoms and tend the wounded.

I am driven by curiosity: things are seldom what they seem.

I have heard the bodies of those who cannot speak and heard the judgments of those who can.

I thought I would change medicine, but it changed me, for better and for worse.

I am the keeper of the town’s secrets and the town’s criers.

And I put Band-Aids on.

For two decades I lived in a small rural town, where I also worked as a GP. It was an incredible experience, and a complex one. As a doctor in a town of 6000 people, your patients also teach your kids, fix your car, do your accounts, live next door, play with your children and go to the same clubs, parties and community events. Patients even clean your house, build your house and fix your blocked toilet. One night I had 12 friends for dinner, ten I had consulted as a patient.

In a small town this seems normal, but it’s hard to explain that to colleagues from the city who believe any self-disclosure as avoidable and unprofessional. It is definitely tricky territory, and it has to be thought through.

The reality is you cannot be ‘unknown’ in a rural town; patients have probably walked past my home and seen my underwear on my clothesline. My patients have seen my toddlers have tantrums, they have seen me dance in the pub, they have seen my teenager vomit at the after party, they have seen me get changed at the pool, they have seen me fall over, get mad and cry. We are doctors but in a small town we are human.

To avoid this problem, the only option for rural GPs is to work an 80-h week and literally hide the rest of the time, with your partner doing all the out in the community family stuff. But that was not appealing to me, and I didn’t have a wife. I needed to find a way to be both doctor and person in the same community. That meant moulding different types of boundaries.

I did decline to put my home on a house-tour fundraiser for the toy library. The interior of my home needed to remain my personal, private space. Of course, patients who were friends, cleaners, builders and plumbers could come, but not random patients who just wanted a look.

Early on our practice decided that privacy was paramount. We would not initiate a conversation outside of work with a patient about their health or even reveal that someone was a patient. We would not tell someone else, we had run into so and so today, if we had seen them at work. Patients learned, if we didn’t talk about medical things outside the medical centre, they didn’t.

Patients are alert to privacy breaches and from that assess the safety of their information. In a small town it is hard to find a place where you can share your secrets safely, but for the medical centre to be that safe container, all the staff had to adhere to very high levels of confidentiality. I think this boundary was critical.

It also meant that the staff could have a life outside, relatively free of our medical role. It meant I could be out at a social event standing with a small group, knowing the person next to me had an unwanted pregnancy. No one would even know they were my patient.

One of negative sides of not talking to patients outside, was in situations where something significant had happened in their life but you had not yet seen the patient, eg maybe they had had a still birth in the city and you bump into them at the petrol station or the supermarket. You desperately want to say something, but I don’t think it is for us to initiate that conversation in a public place. Best to smile, touch their arm, say ‘We’ve been thinking of you, I’ll give you a call’. If they start to weep and need to be held in front of the frozen peas, so be it.

This boundary also created some interesting effects. I ceased to gossip. I couldn’t say anything about anyone (even if they weren’t patients) because no one would know where I got the information. I did a lot of listening to other people’s conversations, often about a patient I knew. I saw how quickly we judge without much information and without the curiosity to wonder what might lie beneath. Someone might call a patient I knew a ‘snobby bitch’, but I knew she was overwhelmed with postnatal depression. Of course, I could say nothing.

In social conversations about other people, I quietly listened and sometimes asked questions, gathering information about local people and families. I would sometimes hear things about a patient’s life that the patient didn’t even know, eg their 12 year old was having sex, or their wife had just had an affair, or they were considered a bad employee who might lose their job.

On the other hand, in the consulting room I learnt from patients who was good to work for, which committees (and rural communities have a lot of them) were dysfunctional and which were great. I had massive database of information that I couldn’t share but could use in my consultations.

When you don’t live and work in the same community you can assume the ‘patients you see’ are the ones with the issues, and the ‘people you know’ are normal people. I can assure you they are one and the same. I was frequently aware of how the private self, revealed in the consulting room was obscured behind the public self, presented to the world outside.

I also learnt about how stories change when they have been through multiple mouths. I could hear a story in the community, about a situation I had been involved in as a doctor, say an emergency but the story I was told bore no relationship to the facts. I couldn’t say anything. I got very good at nodding and wondering about the nature of truth. Sometimes I was told things in the community that made me wonder about the truth of things I had been told by a patient. Truth is a fluid thing and maybe we are all putting out stories in a way that makes us look good.

Sometimes as the doctor you are the subject of negative talk, because you did something that annoyed someone, or got something wrong and you would have to listen to altered versions of these events circulating back to you. Or someone might leave your practice without explanation, as they are entitled to, but then you would run into them everywhere and you are back to smiling and nodding and holding yourself in some sense of integrity.

The other problem living and working in the same place is that everyone looks familiar, but you can’t quite recall where you met them. It was a nightmare being introduced to someone socially. I might be thinking, I know that face, have I just done her smear, or did I see her at school pickup? You can’t say, ‘Are you a patient?’ It looks really bad if you have forgotten the consultation because they remember it. I learnt best thing is to smile, say hi, be very warm and wait for them to reveal where we had met.

How do you handle consulting with people you know, your neighbour, your lawyers receptionist, the school principal or someone you saw at a BBQ last night? I would say the closer the acquaintance and the more complicated the problem, the trickier it gets, so it requires an alertness to your own process. Always get people to make an appointment, sit in waiting room, pay and do the normal patient-doctor ritual. The hazard it that you can overdo it or underdo it. Overdo means you get worried about getting something wrong and over investigate or over treat. Under-do means you bring some casualness into the room; you don’t think it through and then you are at risk of missing something. You have to make yourself attend really carefully to your cognitive, diagnostic processes.

There is the potential for social isolation. Younger doctors starting out in rural practice have asked, ‘How do you make friends?’ It feels pretty safe to meet people in a group, by joining a club or playing sport. People who belong to a church seem to have instant community. The people who are your patients may ignore you and choose to step back or accept your presence.

Friends or workmates will invite you to social events where you will meet people, including those you have consulted as patients. Occasionally a patient might ask you over for a coffee. As a general rule an invitation initiated in the consulting room feels all wrong, although I did once go to a garden club on invite from an older female patient. I took a friend, and it was a semi-public group space, so it felt OK but I wouldn’t have gone to her house for a cup of tea. On the other hand, if my child was friends with a patient’s child, that is a connection made outside the consultation room and so being in and out of each other’s houses seems normal. But not talking about their medical problems.

However, for me there was a problem with finding really good friends. I only need one or two people who I can really share myself with and be myself. But I need them. One challenge is that the people who you might be good friends with, tend to choose you as a GP. And fair enough, I like to choose a GP that I have an affinity with.

And if they only come once a year for something minor that is OK. But if you have supported them through huge life events or mental health issues, then it doesn’t feel OK to have a friendship where they are supporting you in your own vulnerabilities. Maybe it could be done but it felt like if I had shared myself, it was harder to hold the ‘doctor’ space for them. Sometimes when people you have seen as patients, start to become really good friends, through connections outside, then the best thing is to stop seeing them as a doctor at all. Although even that rule is problematic because I have certainly been to after-hours emergencies where it was safer to treat a person close to me, than to take time finding another doctor.

Maybe an antidote to isolation is closer relationships with colleagues, keeping up contact with friends out of town and a good solid long-term relationship (being single as a GP in a small can be really hard). I also used professional supervision so I had some place to share myself. Having your own GP is great, but in rural areas your own GP may also be your colleague or social acquaintance, even if you go to another town to see them.

Living and working in the same small community is a great learning about life. In many ways I think ‘being known’ made me a better doctor, less separate and distant. I learnt how to keep secrets. I learnt that knowing another person is always provisional, we can make up a story about someone else but never assume our story is true. It probably won’t be.

Not applicable.

The author declares no conflicts of interest.

This research did not receive any specific funding.