Dr Mulka has written an excellent and stimulating article.1 He certainly demonstrates a difference in workload between the years. I believe it demonstrates primarily a change in perception, not increased workload.
Numbers of patients seen are less. Time spent seeing those patients is similar, if one factors in time for visits. If one assumes 20 minutes per visit, he spent 34 hours in 1982 and 13 in 2002, or if 30 minutes, then 51 and 20 hours respectively. Added to the hours in surgery, this equals 92 or 109 hours in 1982, and 97 or 104 hours in 2002.
He sees a different type of patient. As he says, he has grown older with his patients, so they have more complex problems, but does a new doctor have a different workload to an established doctor? The type of patient he saw in 1982 was the sort a GP registrar could expect — more single problem patients, more who needed a sick note — patients who did not feel that continuity of care made a significant difference to their current problem. I certainly felt that the complexity of work increased after a few years in practice. Would the type of patient Dr Mulka saw a few years after starting general practice be much different from the patients he saw in 2002?
Waller and Hodgkin in General practice: demanding work mirrored Dr Mulka's finding — that of no objective measurement of increased workload other than an increased number of repeat prescriptions and results.2
If one looks at out-of-hours workload, the situation is not clear cut. Salisbury found ‘evidence that levels of provision of out-of-hours care have risen considerably, but the wide variation between areas, and differences between studies … make it difficult to confirm this finding.’3 Data from my practice show variation but no increase in night visiting in the period 1995–2002 (Table 1).
Subjectively, the workload was lighter. Early in my career a night on call without visits would have been inconceivable, 15 years later and it was not rare. In terms of time commitment, the majority of GPs have worked fewer hours on call, as Hallam noted, ‘25 years of decreasing personal commitment and increasing reliance on rotas and commercial deputising services’.4
If one looks at total out-of-hours contacts for our local GP cooperative, the figures for 1999–2002 (Table 2) show a 2.6% change (that is, approximately 1.25 more calls a day in 2002 than in 1999), despite the increasing population of Burton upon Trent, and our practice joining the cooperative in September 2000. The sharp rise in 2003 is owing to all of the local practices shutting on Saturdays and the cooperative taking over Saturday morning surgeries.
If one cannot say with certainty that workload has increased to a major extent, what has happened? Undoubtedly out-of-hours time burden per GP has decreased because of the rise of GP cooperatives, yet the pressure to opt out of on call work has increased — almost in inverse proportion to the number of hours worked (an inverse workload law — the fewer hours worked on call by an individual GP, the more stressful those hours are perceived to be?). I believe GP attitudes have changed, as has the society of which we are part.5,6
We should be more honest with the public and ourselves. Our perception of our work has changed fundamentally, not the workload. It is not wrong to say that the hours and conditions we readily accepted 20 years ago are no longer right for us or our families. To blame significantly increasing workload for our woes does not fit the evidence.
From blaming workload for our low morale, it is a short step to blaming patients. Not only is this perversely biting the hand that feeds us, it also encourages us to see the patient as at best, a consumer and at worst, the opposition. When we cease to work alongside our patients we risk losing the two core aspects of our professionalism identified by Heath — the biographer of our patients, and the interpreter of their symptoms.7
As a GP, I love my job, feel I am well paid and do not think I am working significantly harder than before. Is there is something wrong with my perception?
Acknowledgments
Thanks to staff of Burton Doctors On Call Cooperative for providing figures for the cooperative contact rates.
- © British Journal of General Practice, 2004.