Reasons for sessional general practice
Gender and the pressures of general practice were mentioned by the majority of participants and will be discussed shortly. Smaller numbers also mentioned the desire for variety in their working life. The flexibility of sessional work allowed many of the GPs to use their medical training in a non-clinical setting doing research or working to improve health policy, and in other clinical subspecialties, such as prison work, indigenous health, family planning and dermatology.
So with the variety, and the flexibility, and the sort of sub-specialisation which happens in this country, I was able to do what I wanted to do. (♀GP25_40s)
According to these GPs, sessional general practice is sufficiently flexible that it allows them to pursue complementary career goals. All found that “life’s less boring” (♀GP6_50s) and “more clinically sustainable and interesting” (♀GP18_40s) with flexible work practices. Several GPs found working with vulnerable or special needs communities a satisfying complement to mainstream general practice. The GP quoted below, for example, was drawn towards helping an under-serviced population.
That was the year that the World Health Organization report came out about Aboriginal health, and I thought “That is pretty appalling!” … I discovered there was an Aboriginal health service here, so I went and got a job there and worked there. (♀GP15_40s)
Gender strongly influenced female participants’ decision to work less than full-time. Thirteen female GPs and one male GP had dependent children, but only the man did not mention his children or family during the interview. Three of the mothers commented that their spouse’s employment required them to work sessionally in order to manage the household and caring responsibilities. A further two women with adult children had significant caring responsibilities. Several male GPs acknowledged that the impact of having children was felt more keenly by women, but only two men mentioned that family commitments played a role in their decision to work sessionally.
Caring responsibilities were universally viewed by the mothers in the sample as personally important and rewarding. They wanted to be involved in parenting and their children’s school activities, and felt it was important to fit work around school hours. None resented or regretted the need for flexible hours around children. One GP even attributed an improvement in her practice skills and knowledge to motherhood.
I learned an awful lot by having babies. I give much better breast feeding advice after I had babies than before [sic]. (GP♀14_50s)
Several women stated that the capacity to both train and work less than full-time drew them towards general practice. A few female GPs mentioned that they were increasing or expected to increase their hours as their children became more independent. This was borne out in our sample with the four older women in full-time paid employment, but notably still only working sessionally in general practice.
The pressures associated with general practice were keenly felt by our participants.
Frankly I find general practice extremely stressful at times and that is one of the reasons I went to teaching. (♀GP13_50s)
I had just had enough of the burden of it, I was worn out. (♂GP24_50s)
It got tiring and that’s about it really. (♂GP11_50s)
The nature of general practice … influenced my decision [to work sessionally] more than anything. Just that it’s very full on and very relentless and [it’s] an onslaught of humanity at times. (♂GP19_30s)
These quotes refer to the emotional and physical consequences of general practice. The last quote talks about the “nature of general practice” and one could easily argue that this has always been so. However, the majority of our participants felt that something had changed over recent years, in part because the balance of conditions within the consultation had altered. They perceived a shift away from traditional “disassociated problem solving” (♀GP20_40s) involving a mix of semi-acute and chronic care, towards the management of multiple, chronic diseases.
The nature of the demographic of the patients is such that they’re often older. They’ve got complex medical conditions. You can’t see them in 15 minutes, especially if they’re new. (♀GP3_50s)
I think all general practices are finding that we’re seeing more and more complicated work. … I don’t get many of the things that we would say are simpler. Most of the people who are booked up are people with chronic mental health issues from pain, compensable issues, elderly people with complicated diabetics. (♀GP14_50s)
Many GPs expressed the tiredness that results from this style of work with complex patients.
I think they [patients and the College] expect that you go and look at it in a more holistic way. I think it is extremely hard to do that full-time. I just think it is hard to maintain that focus. (♀GP27_50s)
To attend to a person properly, and to listen to them and make them feel listened to, and to deal with their physical problems, all in fifteen minutes, is tiring. (♀GP26_40s)
Additionally, the participants felt that their patients’ conditions increasingly required psychological management, which had consequences for the treating doctor.
It doesn’t matter what the consultation is about, it can still end up turning into some emotional issue… I find that quite exhausting. (♀GP7_40s)
General practice is intellectual work all the time, with a huge emotional overload. (♀GP1_40s)
For the GPs in this study, the prevalence of complex, chronic illness and the increasing need for psychological management meant that consultations were time consuming and exhausting.
It’s hard to, you know, [appreciate] the complexity of managing multiple health issues in individuals who [you have] known for a long time.... Knowledge of what someone’s done before and why something might impact on them, and I think it’s hard to define how much time and energy goes into that sort of thing. (♀GP14_50s)
Increasing patient expectations were also perceived to define current general practice. Patients appeared to be more demanding and hold unrealistic expectations.
Most of my patients … wouldn’t be happy if you just printed out a script and handed it to them … What might happen if you do take antibiotics? What might happen if you don’t take the antibiotics? [What are] the reasons for taking it? [What are] the reasons not for taking it, you know? I think that takes up a lot of time and I think that’s quite exhausting. (♀GP7_40s)
On the one hand they are saying you should be home with your babies and on the other hand they want you there 24/7. (♀GP1_40s)
The GPs we interviewed felt these expectations keenly.
What sessional general practice offers
Sessional general practice was compared favourably to full-time general practice. The strain of full-time clinical practice strongly influenced many GPs’ work decisions. Sessional clinical practice was seen to offer “downtime” (♀GP18_40s), the opportunity to “recharge your batteries” (♀GP3_50s). It kept them “fresh,” (♂GP11_50s) provided time to “catch your breath” (♂GP19_30s), and allowed GPs to “maintain good mental and physical health” (♀GP14_50s). Therefore, many of the GPs felt that a mix of clinical, non-clinical and unpaid activities attenuated the tiredness one might otherwise feel. Time away from clinical work also gave one GP the opportunity to think about complex clinical cases (♂GP11_50s).
Many of our participants felt that full-time general practice did not allow them to be the best GP they could be.
[Like] most GPs I want to do a decent job, and I have actually always found that if I go beyond a certain number of sessions I don’t think I am doing a decent job anymore. (♀GP27_50s)
I think I’m a better GP by not doing it all day. … By Friday afternoon I’m not really that interested in people’s small petty problems. (♀GP20_40s)
If you are doing general practice well clinically, it is quite challenging. I have seen a lot of lazy GP’s that palm things off. (♀GP23_60s)
Our participants recognized that “inner resources” were central to providing good quality care.
If you’re part-time you’ve got more [inner] resources to be able to offer that particular type of [patient]. (♀GP18_40s)
The level of compassion and I think … the care factor would diminish. … Doing it less than full-time gives you the capacity to, I guess, rebuild yourself, so that you can do your job well. (♀GP12-20s)
These rhetorical claims were buttressed by their actions. For example, dedication could be expressed through thoroughness, as below.
I tend to review all the records before I write a complex referral say to a cardiologist or a physician. I will attach lots of information, because… I have a duty to give them all the information, and say “Well the question I really want you to answer is this.” (♂GP17_60s)
Commitment to patients was also revealed in the way several participants had chosen to spread their sessions across more days to ensure continuity of care, rather than the same hours across working fewer days
“I needed to have some continuity of care with my patients. … While it would be preferable to just do … two and a half days … it ends up being easier, in terms of seeing people again. … It works better … if you work more days. (♀GP12-20s)
The remuneration for sessional clinical work was generally seen as modest, particularly due to the number of patients GPs saw with chronic and complex diseases and the associated unpaid paperwork. Continuing medical education was seen as important but several GPs found it slightly more difficult to keep up to date clinically.