INTRODUCTION
The tipping point that led to this article being written was the publication in the Lancet of data unequivocally demonstrating the remarkable increase in pressure in the last few years on primary care and particularly on GPs.1 There have been other times when pressure on GPs has been notable — the new GP contract of 2004 was a response to similar circumstances. But with resources for general practice falling in real terms as a proportion of the total NHS budget2 and GP recruitment difficulties as bad as they have been for many decades,3 both authors felt some guiding principles might help in these difficult times.
Inspired by other ‘commandments’,4,5 these are an honest and heartfelt attempt to be supportive to colleagues. They are undoubtedly not perfect.
1. Thou shalt look after thyself as well as thy patients
Workdays are long and filled with many complex and insoluble problems. Take time to eat good food and drink fluids at sensible intervals. Use that time to rest for a few minutes rather than trying to be superhuman and working without breaks. Make sure you get some exercise regularly and prioritise finding time for outside interests, an early night, and some relaxation whenever you can.
2. Thou shalt keep a sense of perspective
The arc of history is long. This is a difficult time now, perhaps the most difficult. But being a doctor, especially a GP, will always involve challenges and there won’t be many times when you have it easy. But the lesson from history is that it will, in time, become more manageable again. You may need to make changes to your work and to your life to retain or regain perspective and it is legitimate to do so.
3. Thou shalt treasure thy time away from work
Home should be a sanctuary, protected and safe, away from the stresses of the surgery. As much as possible try to avoid taking paperwork home. Use every single day of your holiday entitlement, because you’ve earned it and you need it. Plan and book your holidays well in advance so that you have a period for recovery in place. A holiday on the horizon will boost your resilience.
4. Thy main role is to support individual patients to make the best possible decisions for them at this time
You are not infallible, you cannot foretell the future, and you should not feel obliged to meet externally imposed clinical targets that are not appropriate for individuals. You are not obliged to impose unwanted but ‘recommended’ health promotion or apply ‘the evidence base’ without considering whether it is appropriate for this patient at this time. Consultations work best if we ‘Shut up, listen, care, and know something.’ 6
5. Thou shalt not be too hard on thyself when thou maketh mistakes, as long as thou learneth something from them
It is inevitable with the volume of patient contacts, short consultation times, and workload pressure that sometimes you will get things wrong. This is unfortunate but it is inevitable. You are a human dealing with humans. Punishing yourself mercilessly is self-destructive and not helpful. Mistakes are painful experiences but can also be valuable feedback. Making an error will make you feel bad — use that emotion to analyse why you made that particular mistake and ask yourself, ‘What can I learn from this?’ If you can learn something, the risk of repetition is reduced and a positive outcome ensues. Look for patterns in the situations where your mistakes tend to occur. Identifying these is the most important step in figuring out how to avoid them in future.
6. Thou shalt accept that on some days being adequate is acceptable
Some days in general practice can push you to the absolute brink and the job can feel overwhelming at times. When your surgery is running late, packed with patients with complex needs, and your receptionists are bombarding you with extras and urgent questions, you need a strategy to get through it. On days like these it’s about surviving without making serious errors, not about practising perfect, textbook medicine. You need to get your head down and plough through the work as best you can. In these situations, understand that you will need to prioritise. You may need to defer examination of a patient for another day, choose not to explore some cues, or ask fewer open questions. Understand that it’s all right to do this when absolutely necessary as long at it doesn’t happen every day. Bad days pass, and in a few hours the sanctuary of home will be yours again.
7. Thou shalt sit down and talk with thy close colleagues every day
It’s a wonderful opportunity to learn, discuss cases, exchange views, ensure fairness of workload, and support each other.7 Share your success stories. It feels great to highlight an achievement. It’s not showing off; it’s spreading good practice! Do this often and allow others to share their successes with you. Nurture your relationships with colleagues and staff. Sometimes it may help to share your feelings one-to-one with a trusted friend, someone who understands you and who understands general practice. Use them for support when you need it and support them when the situation is reversed.
8. Thou shalt learn how to say ‘no’ sometimes
The enormity of workload can feel insurmountable. No doctor is an inexhaustible resource so it is essential to be able to say ‘no’ at times. This applies to colleagues, employers, commissioners, secondary care, and sometimes to patients. Accept that you cannot be everything to all people and ask yourself, ‘Where can I be most effective?’ Target your energy wisely; your appraisal documentation may feel burdensome too and it should be good enough, rather than perfect.
9. Thou might find it helpful to develop an interest within medicine
Although it can feel like extra work, it may help to keep you sane. Consider developing an area of clinical expertise, become a trainer, or get involved with medical politics, commissioning, research, the RCGP, or writing. Expose yourself to enthusiasts; their passion is infectious and energising.
10. Thou shalt not ignore early signs of burnout
Every GP is at risk of burnout. Warning signs include: a sinking feeling on a Sunday night, anxiety and apprehension before work on a Monday morning, using alcohol to de-stress, losing the ability to think clearly, becoming less efficient, procrastinating, over-investigating, and over-referring. If this is happening, take action and do not delay. Put aside time to share these feelings with a trusted colleague, a loved one, or your GP. Reflect on where this is heading if things don’t change. Early recognition and an action plan may restore your happiness and relationships, enable you to avoid complaints, and even save your career. If you don’t act it will probably get worse, so don’t wait until you reach the point of no return.
Acknowledgments
The authors are grateful to the members of the RCGP’s overdiagnosis e-mail discussion group for their comments and advice on earlier drafts of this paper.
- © British Journal of General Practice 2016
