Tag Archives: GP 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.

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!

“I am sorry”: Burnout, bad day or normal general practice?

London11Dr S Vashisht qualified in Cardiff, trained in London and is a GP in Nottingham.

It will be our 30 year re-union soon and I will be travelling to Cardiff to reminisce with my classmates of 1985. That Class of 1985 is now full of fifty-something-year-old doctors. Thirty years is a long time in medicine.

I can remember that as a newly trained GP, my non-medical friends would tell me their tales of experience with the health service and with their GPs.  “I have phoned my GP for an appointment and I have been given an appointment in two weeks’ time. Two weeks’ time! I am ill now, and I could be dead in two weeks” one friend told me. I tried in vain to explain about the system of appointments. My friend didn’t understand that most flu-like illnesses are self-limiting. She felt unwell and wanted to feel better as soon as possible. Surely her GP should be able to prescribe something that would make her feel better?

Thirty years later I have a similar conversation with many patients. They do not want to take time off work, because of the strict monitoring of ‘sick time’ off in most work places. They have been unwell for three, five or seven days already. I examine them and tell them that it may take up to 3 weeks to get better from their flu like viral illness.  “There’s a new virus going around,” I explain.

Some are reassured, others are not convinced and yet others think they have wasted their time in coming to see me. “That doctor is no good, a complete waste of time. All doctors do is just tell you to take paracetamol.” The message about self limiting viral illness has not got across to the general public. Which forms of education, communication and skills could improve this scenario?

I have increasingly noted that my consultation starts with the patient telling me “Doctor I have been trying to get an appointment for 4 weeks and there are no free appointments” or “I phone at 8am and I can’t get through. When I get through there are no appointments left, so they just tell me to phone the next day”.  I often work as a locum, and this conversation with patients takes place in the inner-city practices, in the middle class areas, in those practices with stable long term staff, those practices that frequently use locums and in practices with a high turnover of staff.  “I am sorry about that. What can I do for you today?” I ask sympathetically.  “Well I have a few things I want to talk about.” My heart sinks a little… I have about 7.5 minutes of the consultation time left.  “Can you tell me the problems and we can can deal with the most important one today? I am sorry.” The consultation continues… I was already running a little late and by the end of this consultation I am running more than 15 minutes late.  I call the next patient in. “I am sorry to keep you waiting,” The patient is very understanding. “What can I do for you today?”  “Well doctor, I don’t know where to begin.” I realise this is not going to be a seven or ten minute consultation.

The next patient is called in and tells me: “Doctor I have been to outpatients and had a scan, but have not got an appointment for the results”.  I tell the patient “I am sorry about that. I will ask the secretary to chase up the clinic appointment.”

It seems that the next patient has not arrived. So I feel a sense of calm. I call the following  patient in and conduct a consultation and deal with two problems.

The patient who I thought had not arrived has now arrived. An elderly patient has come with her daughter. The patient has had a recent bereavement of her spouse and there are concerns about living alone, memory impairment, insomnia and low mood. I often wonder if we have researched how long it takes to do an MMSE. It takes me at least six or eight minutes to do.  I check that the address details are correct on the computer system. I note the patient’s daughter’s name and contact detail in the computer system. I think that consultation took  about 20 minutes. I am really running late and a little agitated. It’s at this point that I know I am going to continue to run late, and that I will be starting all subsequent consultations by saying “I am sorry to have kept you waiting”.

I realise that maybe I have had a little crisis today, or is it the beginning of professional burnout?

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.

Introducing GPs Anonymous

photoPeter Aird is a GP in Bridgwater, Somerset.

Is it just me or is being a GP increasingly being portrayed as something for which one ought to be ashamed? If so, then perhaps we should consider if we need some help.

With the latest suggestion that patients will be able to bypass their GP and refer themselves for cancer investigations, perhaps it’s time to face up to an uncomfortable truth. We’ve been told enough times by enough people – perhaps the implication is true: we’re not up to the job. It’s all the fault of we GPs.

We mustn’t  go on denying it any longer – convincing ourselves we’re OK – after all, until we acknowledge our problem how can we expect anything to be done to help us. We will just go on making everyone’s life a misery.

We all know how embarrassing GP behaviour can be – you know the kind of thing, spoiling everything for everybody on Christmas Day by turning up at a family gathering rather than opening our surgeries as normal – and thereby compelling people to waste hours in A&E departments with their sore throats and itchy toes. And then, of course, there is the wilful ignoring of our patients who clearly have cancer whilst, at the same time, putting an unnecessary burden on secondary care services by admitting patients to hospital just for the fun of it.

So let’s all face up to our problem. I’ll go first by introducing myself:

My name is Peter – and I’m a General Practitioner.

There that wasn’t so bad -to be honest it’s a relief to have it out in the open – I hope you can find it in your heart to accept someone as shameful as me – after all the hurt I’ve caused. If you’re similarly afflicted, come and join me – I’m setting up ‘GPs Anonymous’ in the hope that together we can support all of us who are stricken with the affliction that is ‘being a GP’.

But perhaps you’re still unconvinced you have a problem. Can I urge you then to ask yourselves these four screening questions? Answer two in the affirmative and you may have a problem – answer ‘Yes’ to all four and you’re in real trouble.

C – have you ever felt you wanted to cut down how much general practice you do?

A – have you ever been annoyed by criticism of your actions as a GP?

G – have you ever felt guilty for what you have done as a GP?

E – have you ever started early in the morning doing your ‘GP thing’?

Extra phone lines will be installed should demand for this new service prove overwhelming.

[bctt tweet=”BJGP Blog: Peter Aird is joining GPs Anonymous. Try the CAGE questionnaire.”]

So why do people fall into the destructive behaviour patterns of general practitioners? Well there seems to be a genetic component in some cases – seeing your parents behaving as GPs seems to predispose some to follow a similar path – though, thankfully this is becoming less common. Others experience a little bit of general practice early on in their medical career and naively imagine that it’s a good thing – something they can control. After all, just one attempt at a ten minute consultation can’t hurt can it? But before long they’re out of control – only in it for the extortionate pay, long hours of ‘off duty’ and the kicks one gets from the systematic mismanagement of those who thought they were there to help.

It’s a tragic condition but, with the arrival of ‘GPs Anonymous’ at last there is some real hope for change. Perhaps together we can rid the country of the blight that GP’s have become.

And then won’t everyone be happy?