Tag Archives: burnout

General practice in Scotland and Australia: the experience of two GPs

Jane Gall and Derek Wooff, are both general practitioners who worked in Stranraer, Scotland for 26 years and have been working in Shepparton Medical Centre for the last 6 years.

General practice is a good job. It uses knowledge, experience, judgement and intuition to provide appropriate care and this complex process is both stimulating and rewarding. Currently with rising patient expectations and decreasing investment, solutions to workload issues may benefit from broader thinking and looking to other models of care.

We wish to reflect on our experience of translating care from the NHS in Scotland to Medicare in Australia.

We became emotionally exhausted attempting to continue providing the level of care expected by the population. 

Our background was working as general practitioners (GPs) for 26 years within the NHS model of care based in Stranraer, a small town in Scotland. We knew our patients and their families extremely well. We were truly part of a team with practice nurses, linking with district nursing staff and being part of the community hospital. This involvement provided professional satisfaction and support from a multidisciplinary team. There were many changes over the years and the team structure of General Practice allowed moulding and restructuring to changing demands. However, we became emotionally exhausted attempting to continue providing the level of care expected by the population with decreasing resources and increasing clinical governance. It was hard to manage workload and demand as well as fulfil the QOF (Quality and Outcome Framework) criteria and paperwork. It seemed the fun of the job had decreased with the doctor agenda rather than the patient agenda driving the consultations. We were concerned about moving out of our comfort familiar zone and working elsewhere without the ‘safety’ of background knowledge of patients and relationships that had developed from years of continuity of care.

Could we re-establish our professional satisfaction and feel the fun again of general practice by moving continent?

In 2010 we moved to Australia and took the opportunity of developing a medical student teaching GP clinic, which was a new development for the University of Melbourne. This challenge was growing a general practice business in Shepparton, a regional town in Victoria, Australia, within the Medicare system. When this opportunity arose for a ‘sea change’, we decided to take the plunge. Interestingly we found change and new beginnings are normal in the Aussie culture.

Adapting to a new model of care has been refreshing and interesting. Firstly, we realised that the therapeutic relationships with patients we value so much and had felt were partly built on years of continuity of care can be established quickly within a consult. This may be aided by years of experience although I do believe that active listening skills are the key. Trust can be felt at the consultation and so it can be a surprise when despite this patients do move around for care. The GP model of care in Australia allows patients to go to any GP practice at any time, so ongoing relationship care is viewed differently by both the patient and the professional.

We have considered the impact of this fundamental difference between the NHS and Australia primary care. The Australian system does encourage patients to take more ownership of their own care although it may result in over servicing and unnecessary repeat investigations. However, the GP is freed from the trapped feeling of patients being dependent on him or her as an individual. Patient autonomy and ability to seek second opinions is almost encouraged and facilitated in Australia. This can be releasing and helpful, although potentially confusing and may result in patients searching for the response desired by the patient. As there is little effective transfer of information or central data base to connect patient information, decisions can be made within silos of thinking.

Perhaps care could be considered in different contexts; acute and chronic. Acute consults sometimes including incidental task oriented requests like forms or repeat prescriptions and ‘chronic’ for more complex ongoing illness review. It appears that some patients seem to value continuity of care for chronic disease, while attending different ‘convenient’ practices for incidental or acute care. In some regard this does make sense as good background knowledge of medication tried and pathology results may be more important for management of chronic conditions.

The flexibility of provider of care allowed to each patient does alter the fundamental role of GP as the hub of the wheel and ‘gatekeeper’ that is strong in the UK model of general practice. The GP is part of the care, but not the truly essential coordinator in Australia. As stated, the care may then be inappropriate or with duplication at times but it can also provide appropriate convenient care, for example, antibiotics for a UTI in a timely and accessible manner at a consult near the where the patient may be shopping. However, there is no real way of stewardship of the public purse which will be providing Medicare back up payments for many visits.

In the NHS… some shift to patients accepting some accountability for their own care would be good to see.

Currently there are ‘care plans’ and ‘team care arrangements’ under the Australian Medicare scheme. These are used for ongoing complex illness and team care is for co-ordinating allied health referrals. This model applies well to some cases – for example patients with diabetes. It does encourage goal setting for individual patients with their ‘regular’ GP and review can be three monthly. The emphasis is focused on the individual patient in contrast to the QOF points in the NHS model which is doctor agenda and population care driven. Also there is current discussion regarding the ‘my medical home’ model in Australia to further incentivise care by one GP. This may help address some of the duplication and rationalise ongoing responsibility. I believe this may be of benefit particularly to the most vulnerable such as mentally unwell patients who may slip through the net. The responsibility by the GP in the NHS can be over-burdensome and some shift to patients accepting some accountability for their own care would be good to see, particularly given the current recruitment crisis of GPs in the UK. This requires understanding from society and a change from people feeling that totally comprehensive care is a right to encouraging capable individuals to play a more active part in their healthcare. GPs may then feel less trapped in impossible positions within the NHS model of care.

A huge learning area for us has been understanding the business financial differences within general practice in the two countries. The curious bit is considering how this affects care delivery both from a patient ‘consumer’ perspective and from the professional point of view. Our practice in Australia followed a ‘bulk billing’ model until recently. This model survived on Medicare rebate income from item of service and was effectively free to patients. Translating across from the NHS, this model fitted our beliefs of having no barriers to accessing primary care. However, we have now a deeper understanding of Australian Medicare and appreciate this government support is essentially present for those who have healthcare cards and so fit the criteria for free care. Interestingly, others often wish to pay their way as part of their expectation and own feeling of self-worth, not misusing the ‘free’ system. This seemed to us an interesting cultural shift from the British feeling of their rights as they have paid taxes to the Australian view where they feel it is appropriate to contribute and often have a higher regard of value when linked to a higher cost. However, there are some patients on the borderline for ‘healthcare cards’ which is the entitlement to free care and so are charged for consults thus may find cost a barrier to seeking appropriate primary health care. Using judgement to allow bulk billing could allow discretion to the most vulnerable but still lacks the guarantee of access to primary care for all. We do believe access to primary care is a fundamental right and it is a professional duty to manage this demand supported by broad discussion with society.

Our view is that there is value in adopting the best of both models of care.

The concept of ‘my medical home’ with continuity of care for patients with chronic illness while still allowing patients to access convenient care for acute problems may be a hybrid that could be considered. Ideally some linkage of electronic health records would support some mobility of patients and safety net patient care, while helping to reduce duplication and unnecessary investigations. This is truly a challenge for health care everywhere.

Moving to Australia has refreshed us professionally and allowed us space to reflect on and appreciate the robust system of general practice in Scotland.

Within the consultation, a focus on patient driven agenda with individual patient health goals is important. This may result in more engagement and accountability by individual patients and some of the dependency which exhausts individual general practitioners would be alleviated. One challenge is how to maintain clinical governance and standards of care within such a wide scope of work. Measuring outcomes can miss valuing the skills of navigating multiple co morbidities and providing appropriate holistic care. Knowledge and skills that are hard to define or measure are key to implementing appropriate individual care.

The engagement with individual patients resulting in improved professional satisfaction is still possible and the fun can certainly bubble up again. Recognition of the importance of primary care and managing public expectations are key to helping the bubbles rise up again. Moving to Australia has refreshed us professionally and allowed us space to reflect on and appreciate the robust system of general practice in Scotland. However, general practice in Scotland would benefit from review to alleviate the exhaustion of unrealistic patient demands and impossible society expectations. General practice is a complex job so any adjustments are complex but without recognition of the value of the job along with adaptation and changes to the job, there is a risk of loss of the essence, fun, effectiveness and professional satisfaction for the next generation.

General practice is still a wonderful job.

BJGP Open: adapting primary care for migrants

Photo by shawn at Morguefile.com

The aim of this paper was to provide some insight into how primary care is managing to offer care to migrants. In particular they were interested in looking at the challenges and the ways in which practices and practitioners were adapting to meet this need.

The first phase was an online survey. During this they surveyed 70 primary care practitioners. They then used responses to select eight case studies for a further qualitative phase. They had a mix of mainstream GP practices as well as specialist services that offered tailored services to refugees, asylum seekers and other migrants. There was one group interview (with three GPs from the same city) and seven further in-depth interviews. The descriptive analysis was structured around the principles of equitable care that drew on the framework from Browne et al.

They found that practitioners tended to focus on working with community and external agencies and adapted their own processes in order to avoid care. This was particularly evident in areas such as screening, vaccination, and health checks. The biggest barrier was the lack of funding and this was cited in 73% of cases. The organisation and partnerships were regarded as particularly important to ensure there is an awareness of wider social determinants, the impacts of trauma and violence, and all this had to be wrapped up into culturally-competent care.

Opinion: There is a small section in this paper that caught my eye in relation to burnout. Just over one-third (34%) cited personal fatigue/burnout/capacity as a barrier to developing services. The additional workload ramped up the stress for some healthcare professionals and in one of the services they had introduced life coaching. In another they had adopted debriefings that are similar to those used in conflict areas.

“I think in terms of values, everyone sees the work that we do in serving vulnerable groups as a privilege.”

I’d put a positive spin on the burnout angle – it can be enormously re-invigorating to get involved with marginalised groups. As one ‘mainstream’ GP stated: “I think in terms of values, everyone sees the work that we do in serving vulnerable groups as a privilege.”

There are some fine examples in this paper on how primary care can be developed to give a more “equity-oriented service”. It showcases how, despite all the appalling strain on the system, there are still ways for primary care to innovate to reduce health inequalities. More than anything we should be driven by the principle that we need to reduce health inequalities to improve our societies. And sometimes we need to hunt these people down. Whether it is people with learning disabilities, or the mentally ill, or people who inject drugs, the homeless or as in this case migrants and refugees – these are the groups of people that need our attention.

ResearchBlogging.orgSuch, E., Walton, E., Delaney, B., Harris, J., & Salway, S. (2017). Adapting primary care for new migrants: a formative assessment BJGP Open DOI: 10.3399/bjgpopen17X100701

“Too big to talk about”: Organisational momentum and its paralytic wake

David Zigmond was a small practice GP in south London 1977-2016. You can
read Obituary for St James Church Surgery here.

Corporatism often enlarges and entrenches itself by increasing demands for compliance. Eventually though, unchecked, this will sicken any organisation. Such is now evidently ailing our NHS. A brief glimpse from a small conference provides a sample.

November 2016, London. A small conference of (mostly junior) doctors. The brief: to better survive the increasing stresses of their work. They are being mentored, guided, enabled and reassured by evidently concerned and sympathetic senior clinicians and cohort managers.

Supportive, ventilatory and distracting strategies are suggested: these may palliate, encourage and help endurance.

Discussion turns to appraisals: how tiring, gruelling, dispiriting and stressful they are.

Discussion turns to appraisals: how tiring, gruelling, dispiriting and stressful they are. An older patrician-clinician, Dr O, is able to reassure with statesmanlike knowledge and know-how. Yes, appraisals are an unpleasant, inordinate and major stress for many doctors, Dr O agrees. But he can personally help with this: he knows how the system operates, and who operates it: Dr X, for example. Dr X is very senior in the appraisal hierarchy and wants to be helpful to our many needlessly and haplessly struggling doctors. He can pass on many tricks, feints and shortcuts to neutralise the formidable administrative obstacles and find easier ways to demonstrate the compliance now essential for professional survival. Yes, Dr O continued, these are testing and perilous times but there are those – like Dr X – who will provide sanctuary, ‘a safe house’, help with ersatz documentation. The important thing is that we find ways to tender what we must: to survive.

As I listen to these exchanges I recall heroic stories from World War II: of resistance movements stealthily sheltering, then smuggling to safety, downed allied airmen; of Oscar Schindler duplicitly providing false documentation and work to protect those otherwise doomed. Dr X seemed, to me, like Schindler and Dr O his discrete emissary.

All these efforts, albeit unintentionally, perpetuate a bad and destructive system.

I admired all these caring and protective seniors and the responsibility they showed for the welfare and survival of their juniors. Yet I was doubtful of the larger benefit that would come from these sincere and substantial efforts: to help these tired and craven doctors to pass muster, comply to regulations they experience as draconian, and then survive-by-adaptation with the mandatory documentation. All these efforts, albeit unintentionally, perpetuate a bad and destructive system. Adaptation via obedience can easily turn to collusion.

I attempted, with respectful diplomacy, to say this. I summarised briefly: “I really like the comforting care, support and healing that’s being offered between you. But something much bigger is being ignored: the unsustainable, toxic and oppressive environment we all have to work in. These forces overwhelm and fatally undertow all our attempts to mitigate or repair…”

I had wanted to offer a brief profile of the component-agents of our pathogenic healthcare culture: how the 4Cs – commercialisation, commodification, corporatisation and computerisation – are driving out the human and vocational heart of our work; how our erstwhile (mostly) humanly gratified professional ‘families’ are displaced by managerially driven and depersonalised systems of ‘factories’; how our health services’ administrative devices all drive the larger system that is so ailing and alienating us. The entire Internal Market, Commissioning and Inspection cultures, in their many guises, all contribute: autarkic NHS Trusts, financially-based competitive commissioning; burgeoning performance-related targets with their necessary machinery for monitoring, data, negotiation and penalties; the resulting, ever-increasing need for compliance, surveillance, policing, documentation and (to mop up any surviving outliers) strictly regulated professional appraisal and validation …

But the chairperson arrested the beginning of this flow. She judged it well beyond the scope of this meeting: how may clinicians now best survive?

***

During a short break a veteran manager approaches me. “I know what you want to say. Almost everyone here would agree with you. But there’s nothing we can do about these things: they are far too big for us to influence them”, she says with fraternal commiseration. “In any case, this is not the right forum”, she adds with cautioning advice.

“Well, there never is a ‘right forum’ for discussion of these crucial things now. This recurrent exclusion is not accidental. It is the tip of a systemic iceberg: it tells us much about the size and nature of our problems. Paradoxically, our lack of open discussion indicates why we must talk candidly. And if not now, when?”, I replied.

The manager seems attentive to this but says nothing. She meets my gaze and offers me a brief smile. To me this seemed unjoyfully complex: contrition, appeasement, fear, alliance, apology, irony and respectful pity. I smiled back, wondering what she saw.

She turned to join Dr O. They re-entered the conference room.

—–0—–

Interested? Many articles exploring similar themes are available via David Zigmond’s home page on www.marco-learningsystems.com

 

Time for the old guard to join the social media fray?

Adam Staten

Adam Staten

Adam Staten trained at Cambridge University and Kings’s College London School of Medicine. After serving a short service commission in the Royal Army Medical Corps he returned to the NHS and is now a salaried GP. He lives in Surrey with his wife and children and likes to bang on about general practice, the future of medicine, and saving the NHS.
Adam Staten

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OLYMPUS DIGITAL CAMERAThe news is everywhere. I don’t mean this in the way that I might if I were a dewy-eyed aspiring journalist, seeing fascination and potential scoops in everything around me. I mean that news coverage seems to be literally everywhere; on the TV, on the radio, on the computer, on the phone in my pocket, on a big screen in Waterloo train station. It’s inescapable. And when it comes to health news, or more particularly doctor news, it never seems to be good news.

Headlines such as: “1 in 4 cancer cases missed: GPs send away alarming number of patients” (Daily Mail, 1st March 2011), “These overpaid doctors must stop whingeing” (The Times, 28th May 2014) and “Study reveals scale of errors on doctors’ prescriptions” (The Guardian 2nd, May 2012), are depressingly commonplace.

Even when we try to recruit the help of mainstream media it seems to get turned against us. The BMA tried to make the point that ten minute appointments are potentially dangerous for patients so that general practice might get the support it needs to provide longer appointments.  To convey this message the ticker feed of the BBC news channel informed the viewer that “GPs are putting patients in danger with ten minute appointments” as though it is out of sheer contempt for our patients that we refuse to give them any more of our time.

It’s not just us. The junior doctors were subject to The Sun’s ‘Moet Medics’ smear campaign and, when the consultant contract negotiations re-opened recently, the BBC obligingly ran a story entitled “NHS consultant paid £375,000 in overtime” to point out that it isn’t only GPs who are workshy and overpaid.

I thought it was just me making my wife feel uncomfortable by screaming at the TV in the evenings, but a recent study in the BJGP exploring why younger GPs are leaving the NHS found that 63.4% of them are also pretty miffed at this continual public abasement.1 Thus far, shouting at the TV seems to have achieved relatively little but there is an alternative. The junior doctors used social media pretty effectively to counter a lot of the negative media coverage during the last round of strikes. The noise on social media outlets revealed widespread public support for the juniors, which helped to strengthen their resolve and legitimise their cause.

Unfortunately, I suspect that many GPs, dare I say many older GPs, are wary of being too vocal on social media, with a hint of concern that opening a Twitter account is akin to giving your patients a key to the back door and painting a target on your back for the GMC to aim at.
This is a shame because social media is our best tool for getting across our side of the argument and it is also a fantastic way of opening up a dialogue with the public. These arguments would be well explored by the reluctant older generation of GPs who have earned experience and gravitas by passing through the mill of the NHS over the last few decades and who can spot the same cycles of mistakes re-appearing over the horizon.

Having a good rant on a blog is incredibly cathartic, I can feel myself relaxing as I type, but it is also a way to reach thousands, potentially tens of thousands, of people in a matter of hours which is exactly what some successful GP bloggers do.

Social media is an effective means to counter the denigrations of our profession and, so dependent has the mainstream media become on social media that, if we make enough noise, we might even begin to influence them. And that might even mean the occasional positive headline.

Reference

1. Doran et al. Lost to the NHS: a mixed methods study of why GPs leave practice early in England. Br J Gen Pract Feb 2016, 66 (643) e128-e135

The merits of time off from practice

Thuvaraka Ware

Thuvaraka Ware

Thuvaraka Ware is a GP Registrar working in Camden. She tutors medical students at UCL in community medicine and believes primary care research will shape clinical and public health policy over the coming years.
Thuvaraka Ware

photo-1460398495418-62c9b5d79fbfAlthough we would otherwise think and hope it, there remains a culture within medicine that disincentivises time off for anything, from parental leave to sabbaticals. The reasons for this are myriad, from concerns about de-skilling to the fear of the unknown and coming off the conveyor belt of speciality training.

There is, of course, security and contentment in knowing where you are heading and following a chosen and well-trodden path, weathered by many before us. But what are we denying ourselves by racing to the end without exploring the diverse options available to us? Despite being a motivated, intelligent and compassionate workforce, with many transferable skills, it sometimes feels like our choices are limited.

During my maternity leave, I did not have the time to do much more than nurture my children, both of whom are intent on removing themselves from the gene pool in interesting ways. But the time away from clinical practice let me breathe, reflect on my career so far and derive meaning in my role as a doctor. I was able to explore ideas I would not have normally, like writing; I also got back to doing art, using skills developed during the warm haze of my grammar school years, but left languishing in some part of my mind not regularly used for analysing blood results and honing consultation skills. I optimised this period of reflection further by making use of a fantastic mentor, who helped me realise my strengths and the aspects of my work that gave me real satisfaction. On my return to the practice, I felt better able to direct my training with purpose and creativity.

I do not think that I would have achieved this without the time off, as the emotional and mental strain of work leaves little room for fanciful ideas at the end of each day. It is no surprise that the mental health of medics is one of the poorest of any professional in the country, as we so rarely give ourselves a break. Taking time off may be very useful to check in with our inner id, to ensure we are happy on the path we find ourselves – or give us a stimulus to find another one.

This experience has also spilled over into other aspects of my life. By feeling like I am doing something meaningful at work, I am able to take this personal sense of value and make the limited time I have with my family richer and more colourful. And the newfound purpose adds to the feeling that hopefully I will leave behind something grander and more significant, than the day to day tasks of reassurance, negotiation and docman reviews.

So be brave and take a break from work! Take pause and stock of your place in it all. You only get one chance at this and after all, as they say, its all about the journey.

The importance of self care for GPs: tackling burnout through comedy

doctor in the house photo 2smallAhmed Z Kazmi is a doctor and stand-up comedian. If you would like to see his show ‘Doctor in the House’ he will be performing at Brighton Fringe 20-24th May 2016, Hollywood Fringe 19th-26th June 2016 and Edinburgh Fringe Festival 4-14th August 2016. For lots more information and to purchase tickets please go to www.doctorahmed.net

At my medical school interview I was asked what I did to relax, I remember thinking that was an odd question. My GP training curriculum included lectures entitled ‘How to avoid burn out’ and I remember sighing and rolling my eyes. It was not until I was in the role of qualified GP for some time that I started to feel a drain on my wellbeing. Then in 2015 my father died from cancer and I really struggled to remain the empathetic and attentive doctor I had prided myself on being. The presence of grief and mourning added an additional ball to the juggling act of clinical duties, professional development tasks, administrative tasks, family and friend obligations and the banal tasks of daily living, and I found myself struggling. I suddenly saw the relevance of the question asked of me at my medical school interview and the rationale for the lecture on burn.

I think it is fair to say general practice is a high intensity occupation. The high volume of patient contacts per day plus the short consultation duration coupled with often unrealistic patient expectations create a sense of panic and unrest during the working day. The relatively frequent rearrangement of service structure and health policy combined with a constant media flurry around the NHS and general practice can produce for many GPs a gloomy atmosphere within which to work. This environment was sadly a contributing factor in my decision to move from the UK in 2014 and practice in Australia.

As mentioned earlier, it was not until last year that the importance of non-academic outlets and self care became evident to me. I used to consider exams or diplomas or courses a leisurely parallel to my role as a GP. I loved to learn, enjoyed keeping up to date and saw an update course as a luxury activity. With social media being inundated constantly with healthcare politics I found myself almost totally unable to switch off from the job, even in my personal time,  and for the first time decided to temporarily reduce my working hours and take up a hobby unrelated to my vocation. But alas the apple never falls far from the tree. I decided to try my hand at stand up comedy (not after an unsuccessful attempts at becoming a pole dancer and instagrammer respectively) and quickly had to embrace that my work as a GP was in fact my largest source humour. I decided to make a stand up show about the funny side of being a doctor. I wished to create something that would be playful and entertaining whilst remaining respectful to patients and the profession. I took a few months to write and rehearse the cabaret comedy show ‘Doctor in the House; What your doctor really thinks’ and made my comedy debut at the Perth Fringe Festival in February 2016. All my shows sold out and I received positive reviews from critics, colleagues and spectators. I managed to raise over $5000 AUS for a local cancer charity from ticket sales and donations. In addition to this I used the show as a vehicle for some more serious subtexts including patient responsibility, cancer awareness and bereavement. Above all the experience did renew my empathy and interest in my vocation.

The experience taught me that even in this current climate we can create opportunities for fun and laughter around our work. It is all too easy to become stationary in a vehicle stuck in mud where the wheels are turning but the car is not moving forward. Several of my friends had hobbies during medical school: music, art, fitness but sadly these were made redundant as general practice and family pressures grew. I would encourage the reader to gently reflect on the following questions:

  1. Do you feel content at work?
  2. Do you feel you are nearing burn out?
  3. If you are content, well done, how can you ensure that continues? If not how might you address it?
  4. Think of one or two hobbies/interests/activities (big or small!) you would like to do more of or have never tried and would like to sample.
  5. Lastly think about how you might actually start to undertake the activity and create room for it in your life.

I am not suggesting everyone take a four month sabbatical and go on a world fringe festival tour of their solo stand-up comedy show… But I think now more than ever it is imperative for GPs to become good at self-care. Yoga? Swimming? Mindfulness meditations? Reduction in sessions? Cookery class? Or, yes, even stand-up comedy. What would you say to your patient in a similar position, need I say more!

BJGP Book Review: Out of Chaos Comes a Dancing Star

F1.large-2Out of Chaos Comes a Dancing Star: Notes on Professional Burnout by Chris Ellis. OpenBooks Press, 2014, PB, 95pp, £18, http://www.lastoutpost.info

This book review was written by Ami Sweetman and was in the April 2015 issue of the BJGP.

The author of this book has a fellowship and doctorate in family medicine, and from 2005 to 209 was an associate professor of family medicine at the University of the United Arab Emirates. He is now back home, semi-retired, and doing family practice in Pietermaritzburg, South Africa.

The opening quote from the philosopher Friedrich Nietzsche sets the tone, ‘Out of chaos comes a dancing star’, which in its fuller context reads: ‘One must have chaos in oneself to give birth to a dancing star.’

The text derives from his collection of notes taken from experience, workshops, and courses on the management of stress and burnout in medical doctors, and those involved in the healing professions, although he says it applies to all professionals whether in law, business, or driving the school bus. Stress is a common theme risking progression to burnout. His work shows that understanding another person’s trials and tribulations can be a source of inspiration. Although the text has a serious undertone it sparkles with wit throughout.

Insights into some of the struggles experienced by healthcare professionals are revealed, creating an awareness of the similarity of concepts and conditions encountered by all doctors. The book offers advice and motivation to see past the common despairs of working life and provides comfort in the knowledge that you are not alone when times can get tough.

Topics included are: how we see patients, attitudes to medicine and the practice thereof, the organisation of our work, and conflicts. There are quotes from attendees at the workshops, and excerpts from ‘iconic texts’ scattered throughout the book for contemplation.

Even the list of contents is intriguing. For example; the wounded healer; long hours and no sleep; the character of the doctor; management of acute burnout; guilt and loneliness; the Mr God complex; the angry doctor; the doctor–doctor relationship; credentials needed for burnout; know thyself; and finally, the Phoenix Phenomenon.

Fundamentally the problems are of time, or rather the lack of time, overwhelming obligations, anxieties over making errors in diagnosis, the increasingly informed, uninformed, and misinformed patient, and, of course, the burgeoning administrative and management problems. There are numerous splendid quotes and example situations placed throughout the text.

I would encourage you to dive into this treasure trove of medical wisdom and take away those insights that mean the most to you personally. Although many of the concerns are the products of extreme circumstances, it’s fascinating to see how the messages relate to the NHS or similar systems all around the world, no matter how sophisticated we may think our version of health care to be. We all, save a few of us, appear to suffer stress in trying to fulfil our role.