Dr Daniel Goodare: What I've learned from working in ultra-remote medicine
Dr Daniel Goodare, a GP in western Kazakhstan, explains the tough lessons he learnt
Name Daniel Goodare
Location Atyrau, western Kazakhstan
Having left school at 16, I returned as a mature student to become a doctor. Thirteen years later, in 2010, as the relieved owner of the necessary MRCGP, I was free to pursue my original goal to practice rural and remote medicine in the most interesting places possible.
With that ambition in mind, I had ensured that my training had the full range of ‘traditional’ posts, such as obstetrics and gynaecology and paediatrics, as well as as much emergency and acute medicine as possible.
I also still continue to work part time in emergency medicine to keep my acute skills up to date.
My first years as a GP have been spent in utterly beautiful locations around the coast of Scotland, in lowland, highland and island locations, working as a sessional single-handed GP for a handful of the most lovely practices imaginable.
I was about to commit to a tiny Highland practice for a permanent post but out of the blue, I was offered the opportunity to work on a locum basis in western Kazakhstan, for a company providing medical services to the oil and gas industry - definitely on my list of ‘interesting places to work’.
The clinic is a surprisingly well equipped mini-hospital with a small emergency room and two resuscitation beds, as well as a two-bedded short stay ward. It is in a small city in the middle of a particularly flat and uninteresting desert, which continues for nearly 2,000 kilometres with barely a single hill, though the north Caspian Sea is not far, under which lies the world’s biggest potential source of new oil, surrounded by a lot of enthusiastic Texans and their European equivalents. These are the people I am paid to look after.
Like other small communities in remote locations, the expat community is close, being intimately aware of one another’s social, emotional and health problems. This brings with it a refreshing openness, and a greatly increased difficulty with patient confidentiality. Having been used to deflecting questions about Mhairi McDonald or Angus McDuff (not real people – I hope) in tiny post offices and pubs in other remote areas, I was well prepared for this.
We and another similarly sized western clinic in the town provide virtually all the medical care for the 5,000 or so expats working in the oil industry in and around Atyrau, Kazakhstan.
The nearest quality medical service provision is a choice of Istanbul, or Dubai, both about 1,500 miles away as the crow flies.
GPs in remote areas are expected to be emergency doctors too
There is plenty of chance to practice acute medicine – two weeks ago I spent four days looking after an apparently uninsured Polish speaking patient with malignant hypertension, multiple seizures, and confusion, who didn’t know he was in Kazakhstan. It took four days to organise the finances to allow us to evacuate him back to his home country and proper specialist medical care. I spent the first 36 hours of his attendance at the clinic, sleeping on my examination couch. There is simply nobody else available.
You’re essentially a single-hander - even in a team
There are two doctors, myself, and a local doctor, who is available to sign all the requisite forms. Knowledge of western medicine is more limited than I had anticipated amongst the Kazakh-trained doctors I have worked with, as is the ability to speak English. Essentially, therefore, this has to be seen as another single-handed role.
Grow a thick enough skin to deal with close scrutiny
The part of remote medicine that is less anticipated by those not involved in this kind of work, and much more of a challenge, in my experience, is the tremendous amount of exposure your practice and clinical decisions get. Any medical event equal to or greater than an ingrowing toenail, will be scrutinised, often publicly or on social media, and compared to the decision that patients imagine the last doctor – invariably an absolute hero, or a complete charlatan – would have been made. Apparently none of us are simply normal human beings. Develop a skin thick enough to deal with this public scrutiny, while maintaining clinical independence and not forgetting to love the people you work with, is possibly the biggest challenge of remote single-handed medicine.
Have a break in a bigger team
For those hoping to work entirely single-handedly in remote or ultra-remote locations, spend some of your time each year working with other doctors in a larger setting. For me, this is the best protection against the professional isolation of single-handed practice, gives me a chance to talk things through, and allows me to experience the joys more easily.