For all those who’ve never been on this blog before, a very warm welcome to you. I used to post regularly on fairly random subjects, everything on life, love, and the universe. Of late I’ve been feeling that I want to look in the direction of my fellow professionals and offer my thoughts on what’s been happening and what the future may hold. I’ll also throw in some glimmers of hope in these dark days, like this video of a cat playing the piano
I challenge you not to smile!
There was a speech made by the chair of the Royal College of GPs in July 2017, suggesting that GPs and especially GP trainers should avoid scaring off new trainees from primary care by being negative about the profession. Now, there are a number of ways you could look at this. I think it is fair that we don’t want to put off young colleagues entering GP-land, especially since we’re not exactly flush with doctors at the moment. At the same time, suggesting that GPs should sugar coat the current issues and pressures of primary care, or try and put a positive spin on a very hard job, did not go down well with many GPs.
What makes a good job?
If you look at what factors play the biggest part in job satisfaction, they are consistent across the board of professions, from white-collar high finance to domestic worker. The key features are
- Ability to influence outcomes
- Ability to make decisions
- Atmosphere of good teamwork
- Support of ‘bosses’
- Feeling of contribution
- Feeling valued
Notice that pay does not play a significant part in this formula. In fact, the data shows that the greatest source of job dissatisfaction is not the pay packet, but the feeling of not being appreciated. It used to be the case that we doctors were held in high regard by those we serve i.e. our patients, and that there was a high level of autonomy in primary care, that we were trusted enough to make the best decisions we could in light of the knowledge and resources available to us. For many of us, this has changed quite dramatically.
The Shipman enquiry has probably had the biggest effect on how the profession is perceived. Almost overnight, a feeling of distrust in GPs was cultivated, then actively encouraged. Politicians in particular found that they could make great capital by dumping on GPs, as well as using the popular press to sensationalise the whole affair. The fact that Dr Shipman was a well respected GP who hid a monstrous appetite for murder made for huge and unwelcome publicity. As humans and as doctors we wonder what could drive such urges and can only offer sympathy to those whose relatives suffered at his hands. Some feel that if he had never been discovered, the profession wouldn’t have undergone such a crisis of trust, but I think this is unlikely.
There has always been a strong element of jealousy from the political classes, consistently the least trusted of professions, of the medical profession. The Shipman affair was merely a catalyst that provided the opportunity to ‘rein in’ those pesky uncontrolled GPs with their bloated (and imaginary) pay packets and 4 hour lunch break. What has happened in the name of ‘public safety’ is that the authorities rushed to remove all 6 factors of the job satisfaction ‘formula’ from primary care.
A deliberate elimination of GP Job Satisfaction?
Support from those in Health Boards or LMCs, whose previous role was to ensure that we were effectively resourced to carry out our jobs, suddenly became the police force of primary care. Regulations multiplied overnight. Suddenly guidelines and protocols were ruling our professional lives, providing nothing more than cover for those in management to hide behind when things go wrong. Quick and easy tools of finger-pointing; ‘Dr _________ didn’t follow the guidelines and the patient died/ got cancer/ lost a limb/ (insert adverse outcome)’. But even if guidelines are followed to the letter, they are of no benefit to us the doctor in the event of a complaint:
‘Oh but they’re just guidelines, not a replacement for clinical judgement.’ Unfortunately this is the refrain from those in the ivory tower offices, far from the realities and uncertainties of current primary care. Guidelines are ropes that either are formulated to make us tow the line, or to be hanged with. Distrust and suspicion are now the primary instincts of management and it has smashed morale. We GPs are no longer trusted to make decisions that we feel are in the best interest of our patients, or that if we did, we are not supported in those decisions. Why would anyone, much less a highly trained professional, want to continue in such a manner?
The most successful GPs understand and nurture the team connections about them and they know that without the team pulling in the same direction, and supporting one another, the job becomes immeasurably harder. The literature is clear on this, the organisation needs to be clear on its goals and focusing on making sure every team member gets to contribute and thrive. Dysfunction at a practice can easily be sensed. I’ve worked at practices that function very well as a unit, and at practices where it seems everyone is at loggerheads. It is obvious which ones get the work done and with least stress.
As stress grows, the instinct to close ranks and take a self-protective stance is understandable. We all know how when the going gets tough, communication becomes strained, finger-pointing is more common, people look to dig their heels in and focus on their own priorities. This is human instinct, but it is self-defeating behaviour. And there is very little resource for GP practice to work on team building skills. Some forward thinking practices have taken this on board and followed the example of corporate structures that undergo regular team-building work. Examples of this include workshops, to weekend retreats to re-establish the central ‘mission statement’ of the practice.
Such activities have often been fodder for comedy in the past (paintballing, anyone? Who can shoot the practice manager in the nether regions most often?!) and yet it has been shown that the building and maintenance of strong inter-personnel relationships has been vital in the success in private enterprises, public bodies, and the military. In case anyone feels this is not relevant to primary care, just ask some of your colleagues who will freely admit that every day they’re in a battle. The problem is, many of them are losing because there’s no battle plan to follow, and no back-up when they’re wounded. The military term for a soldier left unsupported and unarmed in the face of an overwhelming force is ‘cannon fodder’. Don’t think for one second that we don’t have colleagues who feel they face this every day.
Are we still valued as a profession?
For the most part our patients do value what we provide. I find most of my patient contacts will end in a ‘thankyou’ and it’s very gratifying. Not just in an ego stoking way, but because it’s a natural human instinct to want to feel appreciated for the efforts we put in. Studies show this is one of the biggest contributors to job satisfaction. Of course there will be exceptions, and unfortunately we tend to remember the ‘bad’ contacts long after the good, even though the latter numbers far outweigh the former. This is not new for the profession. What seems to have changed is the overt contempt that has developed from those that ought to know better. We see increasing resentment from secondary care that we as GPs have become less likely to act as community house officers for hospital teams.
Complaints are on the increase, but what pushes the boundaries of the resilience of our GP colleagues is the fact that other health professionals seem much more willing to act as though we are there to do there every bidding, and feel aggrieved when we point out that this is not why we are here. When I return a request for some various test or follow up that should be done by the hospital team, phone calls or letter follow with increasing levels of anger and disdain. Cries of
‘How can you do this to the patient?’
‘They will suffer if you don’t carry out x, y, or z action’
And the famous
‘All the other GPs do it!’
Having been in healthcare for 20 years I don’t think I have seen as many deliberate assaults on our professionalism from within the NHS as there have been in recent years, and this has been a significant strain on the ethical and moral compasses within the profession. Should I or should I not just do this ‘for the sake of the patient’? Of course this actually translates as ‘should I or should I not do this for the sake of a quiet life?’
These requests need to be seen as nothing more than that – requests. They are not within our requirement or contract to carry out, and I have always advised a politely worded refusal letter should be in everyone’s toolbox. It needs to clear that we are not trained monkeys and that our professionalism needs to be respected once again. Since we have little or no representation within the hospital setting, we have no voice when it comes to the decision making processes in secondary care. Work that should be completed in the hospital is increasingly fobbed off to the primary care setting. What needs to be recognised is that the culture of ‘I sent a letter to the GP to do it therefore I have washed my hands of responsibility’ will only end when every GP is comfortable with the following phrase.
“I’m NOT here to do YOUR job.”
This has been traditionally a hard attitude to take. We instinctively want to help, and we want to further our patients’ cause by getting things done for them. We are also aware that secondary care has its own personnel and funding problems and are overstretched. But we cannot fix a poorly designed system by making the individual parts take on more strain. We have to value ourselves, our time and sanity and make those values clear, before those outside of primary care begin to value us as fellow professionals rather than servants. This might not have been an issue in the ‘olden days’ of general practice (and I have been around long enough to remember those days!) when we had the leisure of being able to go that extra mile to get things done because it was possible to do so. The sheer volume of work in modern medical practice has made that impossible.
We could complain that patients are too demanding or not resilient enough, or now live in a consumerist culture where everything should be available immediately for free, but the main issues come from within the profession. An undervalued and underappreciated workforce will not work to full productivity for any length of time. It has been shown again and again in organisations of all sizes and functions.
Which brings us back to how we see ourselves and the future of the profession. It is difficult not to feel pessimistic when changes do not occur at a systemic level that will make primary care a sustainable long term career for a junior doctor. Thus the trainee’s exposure to general practice becomes a far less positive experience because we GPs are not actors. If we are a tired, stressed and weary workforce, this will be evident to anyone who sees us. Trainees are not stupid. We don’t need to tell them that it’s very hard to be a GP, they can see it for themselves. No amount of positive spin or gloss can change that. They don’t want to be like you, because you can’t articulate what it is that would make them want to do what you do, be who you are. Which means, it’s quite likely that you don’t want to be you either. I can understand this, because when I suffered from burnout, the last person I wanted to be was me.
So what can be done?
The picture looks distinctively pessimistic as falling numbers of doctors and many who are left suffering issues of mental illness and substance abuse. Burnout rates are climbing. It will take a long time to replenish the pool and the appetite for ‘importing’ doctors to fill the gap appears to have lessened over the years.
I believe that we do have the option of creating a great future not only for the profession but for ourselves as the sustainers of the service. This doesn’t happen by big policy changes or dramatic steps, although a large shift in funding to follow the workload would be very beneficial and is essential to recognise that the NHS of the past is unsustainable. However what is needed most is a mindset shift to move away from the old patterns of workload. Primary care is at the coalface of healthcare provision in the UK and the vast majority of that provision occurs in our offices. That will never change. It is true that we need more resources to meet the challenges ahead, but we can follow the examples of those who are creating successful futures for themselves, their teams and their patients to channel our current resources more effectively.
- Setting a very clear vision and intention for the future. Instead of grinding out each day and hoping to make it to Friday, we need to establish clearly what we want to achieve as successful GPs. What should be the objectives to aim towards? Everyone within the team must have a stake in this, otherwise it just becomes someone else’s dream. There is nothing less fulfilling than making someone else’s dreams come true while ignoring your own.
- Valuing our skills. We have a very powerful set of skills as GPs and we can only refine them by concentrating on them. Spreading ourselves too thinly will mean losing the very essence that makes us invaluable. Being able to articulate clearly, ‘This is what I do. This is what I’m good This is why I do it.’ Only when we stand up and recognise our core values will other people outside (and within) the team start doing the same.
- Valuing our time. We have the same 24 hours in the day as everyone else. How to make sure those hours are used effectively? By focusing on the activities that provide the most value. This means cutting out the unimportant ‘tasks’ and the agendas foisted upon us by others. Learning to say ‘no’ effectively is one of the top 3 skills of the most productive people. As individuals and as a team, our priorities have to take precedence otherwise nothing will get done, or will only get done badly.
- Self-betterment. If we want any chance of a long and bright career which we can look back on with pride, we need to upgrade our skills constantly. This doesn’t mean go to every CPD meeting that appears in the inbox. Instead we must keep time aside to grow spiritually and develop our interpersonal relationships in the workplace (team building) but most importantly at home. Quality of home life directly and inextricably affects quality of work. Ignore the first and both will suffer. Instead of reading about the latest wonder inhaler for COPD, read about how to strengthen your relationships and put that into practice. This job cannot be done alone.
- Relish the complaints. People will complain about you no matter what you do or don’t do. Accept this will happen and relish it. Don’t hope that is won’t. The amount of time wasted in dealing with complaints pales in comparison to the amount of time and energy wasted worrying about them, especially the ones that haven’t happened yet. Be thorough, but accept that you can’t cover every angle every time.
- Find ways of making the job a little bit more fun. Get your team to cheer you up when you’ve had a tough clinic. Put entertaining videos on in the staff room (see cat video above). The only way to thrive in an environment is if you enjoy it. It’s also the only way that upcoming doctors will want to be you.
For those who want to know more about what it takes to lead a long and successful career, check out my ebook ‘Superdoc – the 4 core competencies of successful GPs’ on Amazon.co.uk today, and don’t forget to subscribe to the blog.
Wishing you love, health and success on your journey,
Dr Mithu Rahman