Ruth Stewart: Leaving town

WHEN we pulled up in the driveway of our first rented house in Camperdown, south-west Victoria, a woman’s face appeared over the fence.

“Hello”, she said. “Who are you? What are you doing here?” I explained that we were doctors and would be working in the town.

“Oh, you got any family here?” I proudly named my great uncle who had been a general practitioner in the town for 20 years.

Yes, she knew him.

“One of their boys married a local didn’t he?” she said. I wondered how long it would take to be considered a local.

My husband, Anthony, and I lived and worked in Camperdown as procedural rural generalists for 22 years — for a generation.

Then we left.

What follows refers to our experience.

We know there are other doctors in other towns with different stories. Camperdown has about 3500 residents and serves an agricultural community of around 6000 people.

We had gone there because we wanted to be procedural doctors providing “cradle to grave care” for a community. We initially went to fill a short-term locum position, and then decided to return for the first part of our general practice training because we found that we liked the doctors, the health service and the town.

Many Camperdownians have been born and have lived their whole life in the area. The 2 years that we had promised to stay in Camperdown came and went. We worked hard at learning our trade and raising a growing family.

We realised that knowing our patients helped us give them better care. We found that when we knew a patient, we didn’t need to spend time in each consultation establishing rapport; that we could anticipate things that may happen for them.

The patients who chose to come back and see us again trusted that, with skills and beneficence, we would guide them to health. But the interaction was not one-way.

Their trust in us increased our confidence in our existing skills and our willingness to practise new skills and to continually expand our scope. It was not uncommon for our patients to choose a simpler local treatment option precisely because it was delivered locally.

So we focused on our professional development in Camperdown. We sought to learn any skill that could be used safely within the equipment and teamwork parameters of our health service. Between us we wanted the necessary array of skills to meet our community’s needs.

As we came to know patients, they also came to know us. Our patients would describe our flaws to visiting medical students in cheerful detail; but they would also heap lavish praises on our heads.

With such frequent positive reinforcement from our patients, we rarely wondered whether it was all worth it. We worked very hard and at times came close to exhaustion, but we were careful to take time for family, friends, exercise and relaxation.

Some of the toughest clinical experiences were also the most satisfying ones — a brush with joy or terror in the midst of routine, but there were challenges and even tragedies. These experiences pushed us to our limits clinically and emotionally, but we maintained our engagement with our patients, whatever the distress, and negotiated appropriate care.

In Camperdown we were always meeting our patients and their families whether their outcomes were good or not so good. We saw the grieving widower slowly emerge to establish a new relationship, suicidal patients learning new ways to express their anger or contain their distress.

We had private opportunities to talk of the horror of trying to resuscitate a dead baby. People supported us when we were vulnerable.

If you remain in a community, you must learn to cope with failure. The longer you stay there, the more likely it is that you will be asked a question that you cannot answer, or make a mistake that you cannot right. You will meet the people affected by your error.

It is awful to look someone in the eye and say that you have erred, but I found that, having breached that barrier, it became possible to attempt reparation and reconciliation.

Camperdown became our home. Our children grew up there and had their primary and early secondary education in the town.

We developed strong friendships with many people who supported us through the years. We engaged in medical politics and worked hard to defend health care in the community. We fought passionately because we were defending our own.

However, there is a season for all things. In September 2011, we announced to our colleagues, our friends and the community that we would leave Camperdown in 4 months’ time. We had spent the past 4 months wrestling with the idea.

Clinical and medical education roles in medically underserved Far North Queensland beckoned, and it was time to move on.

We knew that our decision would affect our family, our friends and indeed the whole community. The hardest part of the decision to leave was telling our colleagues.

The number of procedural rural GPs in the vicinity of Camperdown has more than halved in the past 10 years. If procedurally skilled doctors do not come to join the Camperdown team, it is not possible to sustain the scope of medical service in the region. So we felt that we were abandoning our colleagues and our community.

As the farewells gathered pace, I worried that the more accolades we received, the more we heaped insult on our long-serving colleagues. Medical services would not cease in Camperdown with our departure. Our small number of colleagues remained, and would be doing what they could as long as they could.

Our hope is that the federal programs designed to increase the numbers of rural doctors will deliver appropriately skilled doctors to Camperdown. But we are not certain that this will occur.

Anthony and I decided that the time of farewells was rather like being at our own funeral. People were saying really lovely things to us about what we had done for them and others. But rather than feeling flattered by these comments, when someone told me how much we would be missed by the community, I felt distressed.

When I thought about it, I realised that my sense of self-worth as a doctor has been closely tied to my ability to work with people to solve their problems. I realised that by leaving town we were creating a problem for people that we could not fix.

Although this realisation was gut-wrenching, it enabled me to listen to the stories people told. In our work we had touched the lives of many people.

Some accused us of abandoning them when they needed us, but fewer than we expected. Most people thanked us for our services over the years and talked of what we had done well.

Stepping out to buy a coffee became an hour-long excursion as I listened to stories of our exploits. We were given many cards and presents; there were dinners and parties in our honour, and even a public farewell, where moving speeches were made.

It was quite overwhelming.

I am uncertain whether our first neighbour had decided we were locals, but many other locals had.

I had expected grief in farewelling dear friends; but I felt bereft because I was saying goodbye to crowds of people for whom I had cared medically. Anthony and I discussed that if we reversed the decision to leave, this burden of grief would be lifted from our shoulders.

It was tempting. To stay would have been easier in the short term. We had been in a familiar environment, and now we were facing great uncertainty.

We don’t know whether our staying on in the town would mean that the medical service in Camperdown would continue, or if our leaving means that it will not. We can only hope that we are making room in that wonderful community for other doctors to start a new career.

In the end, the same tenacity that enabled us to stay in the one community for the long haul meant that we stuck to the plan for change. We are leaving one area of need for a community of greater need.

On one of my last days at Camperdown Clinic, a patient came in, looked at me and asked, “Who’s going to know my story now?” I could not answer.

I have since come to feel that this was the essence of our effectiveness in the community. We knew their stories.

I can only hope that other doctors will follow us and will listen to the old stories and learn some new ones.

Dr Ruth Stewart is associate professor of rural health and director of rural and clinical training and support at James Cook University, Cairns.

This article is reproduced from the MJA with permission.

Posted 8 October 2012