INTRODUCTION
Medicine is an immensely stressful profession and it is therefore hardly surprising that research has consistently shown that doctors all over the world experience significant levels of stress and the adverse effects of this, such as depression, anxiety, addiction, and burnout.1,2 The picture in the UK is no different.
The recent General Medical Council (GMC) report, published in December 2018, The state of medical education and practice in the UK,3 highlighted that doctors in the UK report considerable work pressure, poor psychological wellbeing, and impaired work–life balance. A third of the 2600 doctors studied said they plan to cut down their work hours in 3 years; a fifth plan to go part-time; and a fifth plan to leave the UK to work abroad. Furthermore, 21% of doctors in the 45–54 years age group and 66% of those in the 55–64 years age group said they plan to take early retirement by 2021.
GPs included in this study highlighted some of the specific work pressures compared with other doctors, such as: working beyond rostered hours; a significant proportion of high pressure days; feeling unable to cope with workload (as a specialty, GPs do more face-to-face patient contact as core to their expected work than any other specialty, adding to the risk of burnout and exhaustion); poor satisfaction with work-life balance; and an increase in the number of referrals to manage workload pressures.3
Similar observations have been noted previously. In a systematic review of the prevalence and associated factors of burnout and psychiatric morbidity among doctors in the UK, Imo found the prevalence of psychiatric disorders to range from 17% to 52% and that GPs and consultants had the highest rates.4 Furthermore, Imo found that low job satisfaction, overload, and increased hours worked to be significantly associated with increased prevalence of burnout and psychiatric morbidity. Similarly, a pan-European study of family doctors across 12 European Union countries found that GPs in the UK had high rates of burnout and the only other countries where GPs had higher burnout rates were Turkey, Italy, Bulgaria, and Greece.5
Psychological wellbeing of GPs is especially important in the delivery of good quality care to patients in the NHS, as GPs are at the forefront of the bulk of healthcare delivery in the UK.
TIME TO ACT
Now, more than ever, it is time to act. Failure to do so would have significant negative consequences on the present and future generations of our doctors and in turn the service they offer to patients. For a more psychologically healthy medical work force, there needs to be a comprehensive stress management strategy; this involves actions for the ‘system’ to take — organisational changes or systemic ‘culture’ transformations — and measures for individual doctors to adopt.
Medical practitioners themselves should bring about a radical paradigm shift in their own perspective, that is, how they view the medical profession, their role/s within it, how to cope under pressure, and when and how to seek help. All along, bearing in mind the mantra:
‘Grant me the courage to change the things I can change, the serenity to accept those that I cannot change, and the wisdom to know the difference’.6
WHO CAN DO WHAT?
Doctors are reluctant help seekers, and stigma and lack of self-awareness/recognition of the signs of stress are important barriers to seeking timely and appropriate help. We are not in the least abdicating employers and other responsible bodies (for example, Royal Colleges, GMC, Trusts) from their responsibilities, such as making the work environment as stress-free and emotionally supportive as possible, ensuring no extended and unsupported work hours, enforcing regular rest periods, no ‘out-of-the-job’ extra responsibilities, having ‘protected’ learning time, supportive colleagues, opportunities to have mentors, advice on career progression, flexibility in taking leave entitlements, and focusing on work–life balance. However, all this has been said before, and so, while we wait for these systemic changes to set in, we place one key responsibility on their shoulders — to destigmatise mental health issues among the medical profession. These measures should target all doctors (and medical students). Examples of prevention strategies targeting doctors, doctors in training, and medical students, include awareness raising campaigns about various aspects of work stress and other mental health difficulties, its potential for harm, the signs and symptoms, how to seek help, and adequate and appropriate advertising and promoting of support services. Such awareness raising campaigns need to start early on in a doctor’s careers and there should be regular booster sessions. Such stress awareness raising programmes need to focus on explaining what stress is, what its symptoms/manifestations are, how to cope, when to seek help, what help is available and where. There also needs to be effective advertising about where to seek help, in confidence, should the doctor or student experience psychological difficulties. Provision of confidential and independent (outside hospital settings, and delivered by independent professionals) and/or anonymous help is crucial to break down barriers to help seeking.
STRESS MANAGEMENT FOR GPS
We have suggested adopting a prevention paradigm where both the individual and the ‘system’ are equally responsible. Some of these, as will be clear, are up to the individual and some are beyond the individual’s scope. Such an approach should be viewed alongside the general understanding that there are five key components/aspects of stress management: remove the stressor; withdraw from the stressor; change stress perceptions; control stress consequences; and receive social and/or emotional support.
‘Do–It–Yourself’ is an effective stress awareness programme that should get the attendee/doctor to self-reflect and self-assess; that is, they should assess their own work pattern, their own coping mechanisms, sources of support, what can change, and so on.
In our view, doctors need to own more responsibility for their own psychological health and wellbeing. This starts with being more aware of what stress is, what its manifestations are, and what can be done, including where to get help. And for all this, finding time for self-reflection, ideally with peers, is crucial. Every doctor needs to have their own repertoire of strategies to de-stress: this includes understanding one’s own perspective (or how one views work, life, and events) and making necessary changes (cognitive re-framing) for the better, and putting in place adequate positive coping strategies. William Osler, widely regarded as the father of modern medicine, said:
‘The young doctor should look about early for an avocation, a pastime, that will take him away from patients, pills, and potions … No one is really happy or safe without one.’7
The need for doctors to have passions and/or serious hobbies (or a ‘life outside work’) cannot be over-emphasised — work should not be your life!
Doctors should inculcate in themselves (with or without outside help) some essential life skills, such as, assertiveness, problem solving, communication, and to challenge procrastination. For a more fulfilling professional and personal life, doctors need to incorporate regular relaxation exercises into their daily routine. These could include deep breathing exercises, yoga, mindfulness, or other ways of mental relaxation. Having sources for social and emotional support helps immensely in positively coping with stress. Problem focused, rather than emotion focused, coping often provides a better solution. All the above will ensure that doctors find time for themselves and their families, ways to relax, time outside of work and a good social life.
There is an ongoing debate about whether doctors need specialist psychological support services or whether they ought to access mainstream services. Although research has been inconclusive, our experience suggests that the former is more effective in attracting and retaining psychologically disadvantaged doctors.8 In our view, the most crucial aspect of any such service will be the assurance of confidentiality; only then will doctors access this service. It also needs to be seen as ‘independent’ of the doctor’s employer and regulatory bodies such as the GMC. An easily accessible (including out-of-hours access) telephone or text helpline, confidential one-to-one, or group-based psychological support service, ought to be integral parts of such a service.
CONCLUSION
In summary, one thing is clear, doctors, and in particular GPs in the UK, are under considerable stress and risk burning out if they do not receive appropriate and timely help. As the main source of stress is work, workplace interventions are key, and many strategic changes can only be brought in by employers, regulatory bodies, and related organisations. That said, we argue that doctors need to be more aware of their own psychological wellbeing and signs of stress, and should seek help at the earliest opportunity. Doctors should take more responsibility for their mental health.
Notes
Provenance
Freely submitted; not externally peer reviewed.
Competing interests
Dr Sanju George has assessed, supervised, and treated sick doctors for the General Medical Council. Dr Clare Gerada runs the Practitioner Health Programme.
Footnotes
Support available
Please see https://www.rcpsych.ac.uk/members/supporting-you/psychiatrists-support-service/further-help and www.php.nhs.uk for a list of support services for doctors with psychological difficulties.
- © British Journal of General Practice 2019