Reflections of Australian general practitioners during the first year of the COVID-19 pandemic: a qualitative study

Keywords: COVID-19, fear, general practice, government-GP relationship, interviews, pandemic, patient-doctor relationship, primary health care, qualitative research, teamwork, thematic analysis, uncertainty.

General practitioners (GPs) have played a crucial role in Australia’s coronavirus disease 2019 (COVID-19) pandemic response (Desborough et al. 2020). GPs have assessed and managed cases, vaccinated millions of Australians and provided patients with trusted advice (Huston et al. 2020; Australian Government, Department of Health 2021a), all while continuing to provide primary health care.

There is a growing body of research on the impact of the COVID-19 pandemic on general practice. This research has predominantly focussed on pandemic-related changes to clinical practice (Khan et al. 2020; Kippen et al. 2020; Krist et al. 2020; Verhoeven et al. 2020) and quantifiable measures, such as changes to work hours and income (Kippen et al. 2020; Scott 2020; Homeniuk and Collins 2021). There has been little systematic enquiry into the experiences of GPs at the level of personal and professional identity. Only a small number of studies have explored the impact of the COVID-19 pandemic on GPs themselves (Amerio et al. 2020; Monterrosa-Castro et al. 2020; Scott 2020; Sotomayor-Castillo et al. 2021; Vilovic et al. 2021). The majority of these studies are cross- sectional surveys and are therefore restricted in their capacity to describe narratives, explore experiences and establish causality.

An improved understanding of the experiences of GPs working during the COVID-19 pandemic has the potential to identify changes needed to better support GPs. Therefore, the aim of this study was to describe and explore the experiences of GPs, both personally and professionally, during the first year of the COVID-19 pandemic.

To achieve this aim, this study conducted semi-structured interviews with 15 Australian GPs. Their experiences are described here in key themes and explored in relation to findings from existing research.

This was a qualitative study using semi-structured interviews and thematic analysis.

Australian GPs (excluding GPs in training) practicing during the COVID-19 pandemic were invited to participate via emails to the network of ACT- and NSW-based GPs affiliated with the Academic Unit of General Practice at The Australian National University (ANU; approximately 300 GPs) and via the Australia-wide GPs Down Under Facebook group (which has approximately 9700 GPs). Due to the nature of emails and Facebook posts in particular, it not possible to know how many people saw the invitation to participate. Overall, 49 people responded to the invitation. And 15 participants were selected utilising purposive sampling to ensure a diverse participant group in terms of age, gender, geographic location and practice ownership. A participant sample size of 15 was chosen to capture a range of views while still enabling in-depth interviewing.

Fifteen semi-structured interviews were conducted in June 2021 by the same interviewer (SO) over videoconferencing (n = 13) or telephone (n = 2). The average interview duration was 40 min (range 23–64 min). An interview guide with 10 open-ended questions was used (Appendix 1), asking participants to reflect on their experiences working from the start of the COVID-19 pandemic in March/April 2020 until the time of the interview (June 2021). Interviews were audio-recorded, professionally transcribed and de-identified. Participants provided written informed consent.

Data were managed using NVivo-12 software (QSR International). Thematic analysis, guided by the six-phase framework proposed by Braun and Clarke (2012), was conducted. Initial codes were developed independently by two researchers (SO and KA) from line-by-line inductive coding of six transcripts. Discussion confirmed inter-coder consistency and generated a final coding scheme. The remaining interviews were coded by SO. Findings were discussed iteratively among the research team to develop themes.

Reflexivity was ensured through intentional research team discussion and enhanced by the different experiences within the team. SO is an Royal Australian College of General Practitioners (RACGP) Academic Post registrar whose first year of GP training coincided with the start of the COVID-19 pandemic. KA is an experienced GP and academic with an interest in doctor’s well-being, the doctor–patient relationship and medical education. MC is a GP and academic with an interest in digital health and health policy. EH is a qualitative researcher with a background in nursing and interest in staff–family relationships.

The study received ethics approval from the ACT Health Human Research Ethics Committee (Reference 2021.LRE.00026).

The participant sample comprised 15 GPs, eight of whom were female and seven were male (Table 1). Participant ages ranged from 29 to 67 years, with an average age of 44.7 years. There were junior and experienced GPs, ranging from 3 to 41 years of experience working in general practice, with an average of 14 years of experience. Four participants were practice owners. Participants came from South-Eastern Australia; five from the Australian Capital Territory, five from Victoria, four from New South Wales and one from South Australia. And 12 participants worked in urban areas and three worked in rural areas.

Table 1.  Participant characteristics.

Five main themes were identified from the interviews (Table 2).

Table 2.  Overview of themes.

All participants described experiencing fear during the COVID-19 pandemic. Participants were fearful about becoming infected with COVID-19 and the implications of this.

I was anxious that any person coming through with your typical cold and flu symptoms … had COVID potentially, and COVID being an unknown, is this something that could kill me? Which I’ve never had to face before. (GP6)

Lack of personal protective equipment (PPE) worsened this fear.

I certainly remember a lot of alarm and depression that hasn’t gone away about of the lack of PPE. (GP8)

Participants were afraid that if they contracted COVID-19, they would transmit it to their friends, families and patients.

I still have a massive amount of anxiety about being the person that takes COVID to the nursing home … and I’m worried about my own family, because my husband’s immunocompromised and I didn’t want my kids to get sick.… Every time they did a contact tracing I thought, god, what if that was me? (GP11)

Practice owners had additional fears about their staff becoming infected at work.

I felt that if someone caught COVID and died I would be personally responsible for that … there was this term that I heard called industrial manslaughter, and that maybe I could be held liable for someone’s death in the workplace, and that was a big stress for me. (GP10)

Participants grappled with the conflict between their fear of infection and their desire to continue delivering patient care.

I’ve never experienced anything like a pandemic in my lifetime, so it was obviously very stressful trying to protect yourself. Like, I’m a mother, I’ve got two kids, my two parents, so you’re trying to protect your family whilst you’re caring for the community. (GP7)

And we wanted to serve the community, but we really felt like possibly we were sacrificing ourselves at that time. So that was a big decision. There were some tears shed. (GP10)

Telehealth was appreciated because it enabled participants to deliver care without risk of infection.

Telehealth helped. It helped me feel safe and it helped me feel that I was keeping my patient safe. (GP6)

Dealing with the uncertainty surrounding COVID-19 was a challenge for participants. Participants were uncertain about how to manage COVID-19, how to advise patients about COVID-19, and how to maintain safe practice during the COVID-19 pandemic.

The feeling of complete uncertainty is the only way to describe what it was really like … I know as a GP, you’ve got to be used to sitting with uncertainty, that’s kind of our thing, but … this was different. (GP11)

I didn’t know who to trust or what to do and what would be the safest thing to do. Was I overreacting? Was I not overreacting? It was an absolute minefield in terms of what we should do and how we should keep everyone safe and keep ourselves safe … Nobody knew what to do. (GP6)

Participants reported feeling particularly uncertain due to the lack of guidelines for general practice.

We didn’t really have any guidelines about how a GP clinic should run in a pandemic. You just sort of had to make it up. (GP15)

I think there was a lack of clarity in recommendations and there still is. … what is best practice for running your clinic, in terms of PPE, in terms of triaging and all that. (XXX)

When there were guidelines or information updates, they came from multiple sources and changed rapidly, creating information overload that further intensified uncertainty. To alleviate their uncertainty, participants spent significant time reading about the COVID-19 pandemic. They felt unable to ‘switch off’ (GP6) after work, leading to a negative impact on their work–life balance, with the COVID-19 pandemic displacing other life activities and contributing to feelings of burn-out.

It was hard to unwind when you got home because you were too busy reading guidelines, and what was happening around the world, and following the statistics and trends … I remember when my family was getting annoyed because I’m spending all my night just reading all these articles … I think juggling the balance between work and life was really hard because I found I became very consumed. (GP7)

All the changing and the weekly updates … I think that was one of the key challenges, now that I’m thinking about it, was keeping up to date, and not imploding and just going this is too hard, see you in a year. (GP9)

I think at this stage everyone’s pretty tired, like we’re all fairly over it, just the extra stress … and just the constant changing of everything. (GP15)

Another consequence of the uncertainty was tension between GP colleagues. In the milieu of information overload, different GPs developed different ideas and concerns about COVID-19, leading to conflict between GPs within practices and on social media.

Even within one clinic, we’re all in exactly the same boat and we couldn’t keep people happy. Some people felt things were too much, some people felt that things weren’t enough. How do you run that? (XXX)

The majority of participants expressed frustration with the relationship between the various levels of government and GPs. Participants were exasperated by government communication, considering it poorly timed and not specific to GPs.

I thought the communication from the public health unit was fairly terrible to be honest, we’d often find out from the 60 cars in the car park that were there waiting to be tested, that testing protocols have been changed overnight … but that was communicated to the public by social media, Facebook, whatever it might be but there was no heads up to us that it had been changed. (GP3)

Participants also felt the COVID-19 pandemic highlighted the governments lack of understanding of, and appreciation for, general practice. Participants referred to examples such as a lack of involvement of GPs in the COVID-19 pandemic response planning, inadequate provision of PPE to general practices, funding arrangements and vaccine priority groups.

I think it’s becoming increasingly obvious that we are a little invisible…knowing that we were not even included in the initial 1A vaccine roll out was just a slap in the face … And I think that’s again a lack of the government’s understanding of our actual role. (GP7)

I think we had a sobering appreciation of where governments and others see general practice fitting in or not fitting in to the system. [The pandemic] probably highlighted all the gaps and the overlaps and deficiencies in the system and in some respects a low regard … like what happened in the bushfire disasters, GPs were not only left out, but actually told to go away, which is just unbelievable. (GP8)

Tensions emerged within the patient–doctor relationship during the COVID-19 pandemic. Participants expressed frustration at patients’ inadequate appreciation of the seriousness of the COVID-19 pandemic and the need for general practices to initiate infection precautions.

Trying to explain to people they weren’t allowed to come in if they were sick. The public said, ‘We thought that’s why we went to doctors’ … A lot of that fell on the staff that would take the phone calls and deal with angry patients. (GP8)

There’s patients who are now becoming blasé about it, and when receptionists try to triage and ask if they have respiratory symptoms, they’re still going, ‘Oh, no it’s not COVID. I’ve got a cough but it’s not COVID’. And you check if they’ve had a test they’re like, ‘No, I haven’t had a test I just know it’s not’. (GP7)

Participants felt upset and angry when patients acted in ways that increased infection risk for themselves and their clinic.

No matter how many things we put in front of that patient to say ‘are you sick and unwell’, they will say ‘no’ until they’re coughing in that doctor’s consulting room. (GP10)

Participants also acknowledged that patients were often frustrated by having to get tested for COVID-19, the infection-control precautions and being offered telehealth appointments as an alternative to face-to-face consults.

They wanted to see us, they wanted to talk to us, and then when we couldn’t see them because we didn’t have masks or whatever, it created a lot of uncertainty, a lot of angst amongst patients and it was very palpable on our daily life. (GP7)

Despite these tensions, many participants felt their relationship with patients was strengthened. Participants described greater communication with patients and feeling more connected due to the shared COVID-19 pandemic experience.

I suppose it was an opportunity for the patients that you do see or talk to on the phone, to grow the relationship, just about how they were doing, how they were coping and they would ask the same thing of us often. (GP4)

In one sense it’s made [the relationship] better because we’re going through something unique together, even though we were experiencing different emotions and things, you know there are some things that we can all resonate with. (GP14)

Participants spoke with pride about making a deliberate effort to deliver patient care during the COVID-19 pandemic. In return for their effort, they felt trusted and valued by their patients.

The patients were looked after because we made sure they were. (XXX)

This year has reinforced that patient’s trust us and they’ll listen to us … Definitely my patients I’ve noticed trust me and want to hear my opinion on this stuff and when they have concerns from the news they’ve watched or something they’ve looked up they talk to me about it, and they know that I won’t judge them for listening to stupid things or over the top things because I just explain things to them the way I see it. (GP6)

For several participants, the COVOD-19 pandemic served as a reminder that caring for patients is their motivating force for working in general practice.

When I look at the big picture I feel sad, but then when I go to work, and I see the difference that I’m making in my patient’s lives, I’m like, ‘Oh, it’s fine, it’s worth it. We’re doing it for these guys, not for us’. (GP7)

With limited external support, participants turned to their practices and colleagues for support. Participants recognised the importance of teamwork within practices, because effective teamwork facilitated rapid adaptation and helped staff feel safe.

We learned that we can all really work as a team and that we were very agile and that our staff were able to change daily with new things. (GP15)

The clinic responded very rapidly so I felt quite safe in that they set up PPE appropriately, everyone was wearing scrubs and all this kind of thing... It mattered quite a bit, feeling protected by the clinic. (GP5)

Participants also recognised the importance of having strong leaderships within the practice teams.

One of the positives was that our practice manager took on this big leadership role and just said, right, this is what we’re going to do, and someone really needed to step up and do that. That really supported all the staff, doctors and receptionists. (GP14)

Participants expressed an increased appreciation for the staff within their practices who supported them.

I now have more respect for [the practice owner], the nursing staff and the front reception. It’s not just an easy-going practice that survives without coming under pressure, it actually survives with pressure as well, and the staff didn’t crumble. So I think [the pandemic] highlighted the quality of the staff across the board. (GP13)

Participants noticed there was an increase in communication and comraderie among GPs within their own practices, their local geographic region and across the wider Australian GP community.

My colleagues, we banded together and put the patients first and everybody did which was great. We helped each other through that very busy time. (XXX)

I set up, myself and a few other GPs outside my clinic, set up a monthly Zoom chat session, where we’ll just talk about all the issues we were experiencing, and it was good to get a different perspective from different clinics as well. (GP5)

Everyone was in it together and learning as we went along. That was the main support I suppose, that we’re all experiencing this and no one is an expert. (GP1)

Through in-depth interviews, 15 GPs from Victoria, ACT, NSW and South Australia provided valuable insights into their experiences working during the first year of the COVID-19 pandemic, including insights into sources of both stress and support.

It has been widely documented that GPs in Australia and internationally have experienced increased stress during the COVID-19 pandemic (Amerio et al. 2020; Monterrosa-Castro et al. 2020; Scott 2020; Sotomayor-Castillo et al. 2021; Vilovic et al. 2021). Consistent with our results, previous research has identified fear of infection (Kippen et al. 2020; Verhoeven et al. 2020; Copp et al. 2021; Sotomayor-Castillo et al. 2021), uncertainty and information overload (Desborough et al. 2021; Kurotschka et al. 2021; Sotomayor-Castillo et al. 2021), and frustration with government engagement with primary care to be major sources of stress for GPs (Copp et al. 2021; Desborough et al. 2021; Kurotschka et al. 2021). The semi-structured interviews in this study further explored these stressors, generating novel insights.

The ethical issue of risk to self versus duty of care has not yet been explored in the context of the COVID-19 pandemic. Previously, Qureshi et al. (2005) found that healthcare workers were less willing to respond to catastrophic disasters that posed risks to themselves, such as infectious pandemics or radiological events, and Ruderman et al. (2006) provided interesting reflections about ethical issues and duty of care during infectious disease outbreaks in the aftermath of severe acute respiratory syndrome (SARS). In this study, participants reflected on the struggle that arose between their desire to protect themselves and their family from infection, and their sense of duty to deliver care to patients. For many, this struggle went to the core of their identity and their commitment to the vocation of general practice. The need to be altruistic has long been part of the Hippocratic tradition; however, many participants, and probably many Australian GPs, have never previously encountered a situation where their work could lead to their death or disability. Despite the risks and their fears, all participants in this study made a deliberate choice to continue providing care for their patients.

Another novel contribution from this study were the insights into the consequences of uncertainty. Several studies have reported an increase in GPs work hours during the COVID-19 pandemic (Kippen et al. 2020; Sotomayor-Castillo et al. 2021). This study has further revealed that the impact of uncertainty on GPs extended to their home life. Participants spent significant time after work researching in an attempt to reduce their uncertainty. This displaced their time, attention and energy away from their personal lives.

Interestingly, although other studies have documented GPs’ frustrations with governments in the context of current and past pandemics (Kunin et al. 2013; Copp et al. 2021; Desborough et al. 2021; Kurotschka et al. 2021), participants in this study were particularly vocal and emotional about a perceived lack of respect from the Australian Government. Participants saw the COVID-19 pandemic as a magnifying glass that amplified current issues in the relationship between the government and general practice more broadly. This is an important finding that needs to be addressed for the long-term sustainability of general practice and the health system in Australia.

This study found that the COVID-19 pandemic influenced the relationship between participants and their colleagues in both positive and negative ways. Uncertainty and information overload led to tensions when GPs had different ideas and concerns about the COVID-19 pandemic; however, teamwork within practices and among GPs increased. Kippen et al. (2020) also found that Australian GPs turned to colleagues for information and sharing of resources (Kippen et al. 2020), and Kurotschka et al. (2021) found that professional collaboration provided both practical and emotional support for Italian GPs. Interestingly, although the mainstream Australian media has shone light on the pressures on GP receptionists during the COVID-19 pandemic (Ball et al. 2021), there has been little formal research documenting the importance and benefits of teamwork within general practices during the COVID pandemic.

The patient–doctor relationship was also a source of both stress and support. Participants were frustrated and perceived their empathy and tolerance had been undermined when patients acted in ways that put themselves and others at risk, such as not disclosing respiratory symptoms. This tension was described in the media (King 2020; Tsirtsakis 2021), but has not been formally described elsewhere. Conversely, many participants felt patient–doctor relationships were strengthened throughout the COVID-19 pandemic. Although other studies have found that GPs experienced an increase in patient gratitude during the COVID-19 pandemic (Kurotschka et al. 2021), this study identified additional positives, including increased communication and trust. In fact, the COVID-19 pandemic reminded many participants that caring for patients was their driving force for working in general practice. The impact of the COVID-19 pandemic on the patient–doctor relationship from the patient’s perspective would be an interesting question to explore in future research.

The number of participants was low; however, this was an explorative study and producing results that could be generalised to all Australian GPs was beyond the scope. Nonetheless, the richness of the data generated through interviews allowed us to generate a meaningful picture of the experiences of the study participants.

Further, the findings have to be interpreted within the context of the location of the participants and time the interviews were conducted, as the impact of COVID-19 has varied dramatically in different places and at different times during the COVID-19 pandemic. The participant sample only included GPs from Victoria, ACT, NSW and South Australia, and therefore no comments can be made about the experiences of GPs in other states and territories of Australia. The interviews were conducted in June 2021. At this time, there was a relatively low number of COVID-19 cases in Australia and the vaccine rollout had just commenced (Australian Government, Department of Health 2021b). Although participants were asked to reflect on their experiences over the first year of the COVID-19 pandemic, the COVID-19 situation at the time of the interviews would inevitably have coloured their reflections. Additionally, as the COVID-19 pandemic is constantly evolving, conducting the interviews at a different time would likely have raised different concerns.

Despite these limitations, it is hoped the results of this study can help guide research and translational work to support GPs in the ongoing and future pandemics. The following recommendations are proposed as key areas of work needed to reduce stress and bolster support for GPs:

1. Priority access to, and provision of, practical measures to reduce the risk of infection for GPs (e.g. provision of PPE, immunisation and facilitation of telehealth)

2. Development of a single source of up-to-date, evidence-based and concise information specifically for GPs providing key updates and best practice guidelines for general practice during a pandemic

3. Ongoing work to improve the relationship and communication between Government bodies and GPs

4. Development and support for strategies that improve teamwork within general practices and among GPs

GPs have played, and will continue to play, a critical role in Australia’s COVID-19 pandemic response. Ensuring that GPs are recognised, valued and supported in this role is essential for the wellbeing of GPs themselves and of Australian primary care as a whole.

The data that support this study will be shared upon reasonable request to the corresponding author.

The authors declare no conflicts of interest.

This research project was supported by the Royal Australian College of General Practioners, with funding from the Australian Government under the AGPT program.