There is an art to boiling a frog. If you drop your frog directly into boiling water it will leap out with some haste and no little dissatisfaction. However, if you start with cold water and slowly crank up the heat the obliging poikilothermic amphibian will allow its body temperature to rise to the point where it is, quite literally, cooked. Actually biologists squabble in coffee rooms over the reality of this but no matter; it is a powerful metaphor that highlights the risk to GPs working in healthcare systems that are increasingly heated.
GPs are, if nothing else, homeotherms and we are feeling the heat. Doran and colleagues’ mixed methods study of why GPs leave practice early in England delves deeper. In essence they have spoken to the ‘frogs’ who realised they were being cooked but who retained the presence of mind to leap to safety. It highlights much in the system that needs to be addressed. For the individual one answer to the management of stressors and avoidance of burnout perhaps lies in the practice of mindfulness. A Dutch pilot study from Verweij and colleagues suggests it is feasible and could be incorporated into CPD programmes.
I hardly need to tell those in practice of the prominence of mental health in the daily workload. The editorial by Thomas and Morris sets it out in lucid terms and the challenges of mental health feature throughout this issue.
The articles this month also have many direct clinical messages for practice. Wondering how best to identify depression in adolescents? Haugen and colleagues looked at three straightforward questions in a validation study published in this issue. Are we missing bipolar disorder? Yes, quite a lot, and we need to look harder at patients not responding to antidepressants as these may well be the people with bipolar who need a different treatment plan. Hughes and colleagues suggest trying the Mood Disorder Questionnaire to pick up bipolar disorder in these circumstances.
For many GPs the suggestion of using questionnaires is met with some degree of hostility and the PHQ-9 is unlikely to promote feelings of nostalgic warmth. Many felt its role in QOF was the worst kind of box-ticking, paint-by-numbers medicine that did nothing to damp smouldering burnout. Malpass and colleagues emphasise the importance of clinical judgement when interpreting the PHQ-9 as it can miss symptoms that are meaningful to patients. Still struggling with a cohort of patients on long-term benzodiazepines? The study by Vicens and colleagues reports on the 3-year follow up of a cluster randomised trial for long-term benzodiazepine use. The primary care-based interventions were effective and manageable enough to give options for GPs and patients alike.
There were 6233 suicide deaths registered in the UK in 2013.1 Many more are affected by these deaths and Nic an Fhailí and colleagues have explored the role of the GP in the experiences of suicide bereavement; their recommendations will prove invaluable to clinicians.
We are also covering stroke prevention in atrial fibrillation and the barriers to effective management of type 2 diabetes. Perceptive editorials on the NEJM/BMJ spat about conflict of interest and the Accessible Information Standard will keep readers up to speed.
If you suspect you are being cooked in the system or burnout beckons then turn to the Debate & Analysis and Out of Hours sections to be provoked, informed, and stimulated in equal measure. They feature earworms, eye-related SSRI complications, care farming, and the art of Bedlam among other things. And, finally, if you need a further cooling tonic then turn to Sharon Spooner’s research on what is still good about the NHS and great about general practice.
- © British Journal of General Practice 2016
