The independent medical practitionerBMJ 1997; 315 doi: https://doi.org/10.1136/bmj.315.7101.2 (Published 19 July 1997) Cite this as: BMJ 1997;315:S2-7101
Most doctors in Britain have worked for the NHS since graduation, and probably expect to do so until retirement-but not all. Richard Colman, an independent practitioner in Yorkshire shares the personal insights from a different approach
A general medical training is a most flexible friend and valuable asset. Doctors trained as general practitioners have the potential to develop an independent medical career offering differing degrees of variety and flexibility. I put forward the example of my own career, not as a model of perfection, but to illustrate some of the opportunities, requirements, and difficulties faced by the independently minded doctor.
Facing the financial reality
First the downside. There is financial insecurity. Having a partner prepared to live with that-and forego any preconceived expectations of life as the doctor's other half-may reduce problems arising at future times of doubt and uncertainty. Continuing education, holiday pay, and pension contributions must be paid from your own pocket. NHS principals have an easier financial ride in these areas, and also have more status and respect-the lack of which is perhaps most keenly felt by my mother. Independent doctors must also suffer the connotation, held in the minds of more conventional colleagues, that they are somehow irresponsible, weak, or failed-sentiments which are often surprisingly reversed in a quiet moment by the admiring GP who privately expresses the wish that he or she had done what I have. Working relations with colleagues can be strained: they may resent your presence. You can be perceived as a threat to their ego, their medical skills, and can seem to offer a test of their patients' loyalty.
During my last year of vocational training in general practice, instead of looking for a practice as my colleagues were doing, my wife and I had been looking for an environment and potential life style. We found it in North Yorkshire: we took on a repair lease of a National Trust farm house in Bransdale, a dale owned by the Trust in the middle of the North Yorkshire Moors National Park. The roofs and walls were bare, we had no water or electricity, but we could afford the rent.
Developing a broad range of skills
Doing all the work ourselves we tapped a spring some 600 meters away, laid the drains, damp proofed the flagged floors, treated the timbers, plumbed the house and repaired the worst dilapidations, all without power. Our evenings were spent enclosed in the comforting light emitted by paraffin lamps and the glow of a wood fire. We cooked on a paraffin stove.
I found occasional locum work to pay for materials as we went along, believing that the definition of being well off was spending one penny less than income, and that the reverse-being in debt-was (and still is) more horrendous and constricting to us than the fear of famine.
When my wife became pregnant (shortly after we had secured a copious supply of hot water) I began to plan the electrics and we had a rudimentary source of power and light by the time of the birth. The wiring was refined and completed over the following year. I also gained mechanical skills as I wrestled with a weary and aging Volkswagen Polo which eventually died after 250 000 miles and one rebore. I have now developed the knowledge and skills to be virtually free of the services of a plumber, electrician, or mechanic.
As life began to ease and settle a bit and with an expanding family I diverted more time in to my medical career. I had continued with local locum work punctuated by three short spells in Saudi Arabia. I was developing an interest in holism, by which I mean the idea of stress as an underlying influence in many physical and emotional conditions, rather than any particular allegiance to complementary or alternative medicine. I read, learnt more, attended meetings, and mastered hypnosis. I decided to set up my own practice as an independent doctor in York to satisfy a need that I perceived for this sort of approach.
Direct competition with the NHS won't pay
Common sense had lead me to believe that there was no point in trying to offer a comprehensive general practice service comparable with that offered by the NHS. Who would pay for something if they could get exactly the same for free? The independent doctor can't compete with the NHS because the cost of rooms, equipment, and staff make it unviable. The independent doctor must offer those things which are not universally available on the NHS: principally time, explanation, education, second opinions, and special interests. My initial special interest was stress and the interface between the physical and the emotional, but it could have been sports medicine, complementary therapies, psychotherapy, or less practice-based pursuits like occupational health or media work.
Overheads must be kept low. I have a small consulting room and waiting area in York, no fancy equipment, and I don't have a receptionist. All of my consultations are by appointment: my wife takes the phone when I am out, and with a call diversion service and an answering machine she can be based at home, 34 miles away.
Patients value service
I base my work on the belief that people come for my opinion and expertise, not fancy trimmings. Mine is not the image of private practice as portrayed by BUPA and specialist practice, which is insurance based. I charge what I am comfortable with and see as good value, (which is well below BMA recommended rates). My initial unease at charging patients was soon quelled: patients did not see it as a problem, but as a reward for my efforts. Patients pay at the end of the consultation, and there is a mutual respect and honesty about having one's time and effort rewarded so quickly and directly. I vet all enquiries before making appointments to ensure we are not wasting each others time. This leaves me without complaints, impossible demands, or unreasonable expectations. I am not in the game of offering miracles or of telling people I can give what I can't-I am a coach not a magician.
Expanding and advertising the practice
Experience leads me to believe that you are unlikely to survive solely on one special interest unless you open rooms in various locations. When I set up my practice in the mid-eighties I was unable even to inform the public of my existence. My legal action against the General Medical Council's restriction of advertising and the subsequent involvement of the Monopoly and Mergers Commission caused the GMC to change their guidance a few years later. My concern about the plight of the non-conformist, and my developing interest in ethics, led me to seek selection to the GMC, at which I was successful on the second attempt. I offer a perspective that the Council sorely needs (though not all may agree with this).
Rather than diversifying geographically, I worked as an adjudicating medical practitioner for the Benefits Agency and was involved with assessments of industrial injuries, prescribed diseases, and war pension claims. This work exposed me to a lot of disability and pathology. I performed many thorough physical examinations and functional assessments, which helped maintain my clinical skills and complemented the rest of my practice, which was mainly counselling based. My work there led me towards occupational medicine, and I began to do work for various companies. The need to consolidate my knowledge led to the formal study of occupational medicine, and I sat and passed the Diploma examination of the Faculty of Occupational Medicine this year.
Diverging from the medical curriculum
The independent doctor needs to move into areas not well understood or covered in the medical curriculum. I studied the philosophical nature of man in evening classes to broaden my understanding of human nature. My battle with the GMC led to an interest in ethics and I gained a certificate in moral philosophy from the University of Hull after studying for 2 years. Both topics have turned out to be useful in therapeutic situations where moral dilemmas can often be a source of great anxiety. Resolving them can be helped by a discussion of different perspectives. I think I can look back over my career-now perhaps more than two-thirds done-with satisfaction. Mary and I now have 5 lovely children, I have enough work to feel financially comfortable, a small pension fund, and the flexibility that allows me to work a basic 4 day week. I retain a thirst to learn more about my special interests and to develop others. I choose not to work in general practice because the daily rate for locums is derisory-less than paid by the Benefits Agency Medical Service, of which the BMA is so critical.
Alternatives are possible
The world continually changes, and the world of medicine is no different. Many of my generation felt let down by a model of general practice wrapped in dogma and false ideals that was current in the early ôeighties. Some left medicine altogether. Since then some problems have eased, others remain, and new ones emerge. Independently minded doctors may still not trust the establishment to ensure that a medical career is a satisfying and worthwhile way of life but they can choose the option of taking their destiny in their own hands to carve out an alternative.
The life offered by independent medical practice is uncertain but never dull, and allows for differing interests and life styles. You are directly responsible to your clients, customers, or patients but your free time can be your own. In return you need not be subservient to the whims and wishes of a government or the dogma of a medical establishment. People will not pay for services they do not value but neither do you have to deal with people who do not value you. Above all I found I could be myself.