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Sad and confrontational patients 'key source of stress' for GPs

Emotionally draining patient consultations are a key factor contributing to GP stress and burnout, a study has found.

The research, carried out by researchers from the University of Birmingham, looked to understand the sources of GP stress and distress, as well as the barriers and facilitators to getting help.

They found that the reason behind high levels of GP burnout could not solely be put down to rising workloads.

Encounters with sad or confrontational patients, dysfunctional working relationships, unsupportive or bullying colleagues, the fear of making mistakes, complaints and inspections also caused stress.

The findings, published in the BMJ, were based on in-depth interviews with 47 GPs in England, including some who had experienced burnout or mental distress.

They come as the NHS England-funded GP mental health service was inundated with demand upon its launch one year ago.

Researchers said: 'The sources of stress and distress cannot solely be attributed to increases in workload and occupational stress linked to the work role demands of being a GP.

‘Doctors, including GPs, are not invulnerable to the clinical and emotional demands of their work nor the effects of divisive work cultures - culture change and access to informal and formal support is therefore crucial in enabling GPs to do their job effectively and to stay well.’

They said GPs should have ‘a safe space’ to deal with these causes of stress.

Doctors who got support from colleagues fared better, the research found.

Dealing with emotional demands of patients can mount up.

One doctor explained: ‘People bring in and they park with you their problems and their sadnesses, and they feel better for that and you feel worse.’

Doctors also confided that it was distressing to deal with confrontational patients.

One salaried GP said: ‘I’ve had situations where I’ve felt say physically threatened and had to ask someone to leave.’

They said that collegial support, talking about feelings of vulnerability and illness and open communication channels help GPs feel less isolated and able to cope better.

One respondent said that there was no time for reflection at her practice following a colleague’s suicide after a bout of depression.

She said it was: ‘Really devastating to the practice. But it was a bit like, ‘Well, we’ve just got to carry on. We’ve got this job to do,’ and there was no time to (pause) even really acknowledge it, you know, beyond having the usual things like funerals and stuff.’

Many interviewees said they felt isolated which made it harder to get support. One salaried GP said: ‘You don’t really leave your room or talk to many other people.’

Doctors also reported stress from ‘internal politics’ at their practice, or a feeling of being ‘over-ruled’ by colleagues.

Being at the brunt of bullying by colleagues or partners was ‘a key source of distress’ for some interviewees.

One disclosed: ‘This is like an abusive relationship, where I’m unwell and I’m being shouted at at work. I hate coming into work.’

Researchers called for medical training to tackle the ‘culture of invulnerability’ so doctors felt able to discuss feelings to protect their mental health.

Dr Clare Gerada, the medical director of the GP Health Service and who helped with recruitment to the study, said: ‘The cause of distress is fundamentally that we are unable to meet the demands.’

She added that it is because 'GPs care so much' that they 'are trying to constantly deliver and make up for a system that’s undeliverable and pushing themselves way beyond what’s healthy for them'.

Regarding colleague support, she added: ‘When you are stressed and have got too much work the first thing that goes is the time to talk to people, the coffee break, the meeting colleagues for lunch.'

Dr Robert Morley, who is a member of the BMA's GP Commitee and chair of Birmingham LMC, said doctors do need space to deal with the causes of stress, adding: ‘There is absolutely no slack in doctors’ working day.

‘The underlying issue is the unsustainable workload and the stresses of the job.’

GP support services

More than one in four GPs regularly work more than 50 hours a week, a Pulse investigation revealed last year.

An investigation by Pulse publisher Cogora found that two thirds of GPs experienced abuse from their patients and a recent Pulse survey revealed that one in seven GPs has turned to drunk or drugs to cope with stress.

The GP Health Service, commissioned by NHS England, had a ‘rush’ of GPs contact it when it launched last January, with 981 GPs referring themselves in its first ten months.

In November the BMA offered GPs a mindfulness app to encourage them to take time out from the winter crisis.

And a peer mentoring scheme in the East Midlands has helped nearly 100 burnout-beset doctors to stay in the profession.

Readers' comments (10)

  • The sheer volume of work and a failing health system leave no joy in the job at all.More eurocrats than you a shake a stick at with meaningless task cap it off.Thanks UK.

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  • A lot of these problems have been made worse by the response of the system to these sources of stress. The complaints culture changed so the 'the customer is always right.' In practical terms this means that patients can behave pretty threateningly without fear of redress and it is very difficult to remove abusive people from a list.

    The complaints systems is fundamentally designed to escalate problems with good money to be made by GMC/NHSE/PAG/CCG/CQC/Ombudsman and so on by putting doctors through processes that are stacked against them. Some of these regulators have crossed a line of ethical probity that is beginning to look like human rights abuse. This makes practising medicine in a measured, proportionate way with personal boundaries almost impossible.

    Most professionals involved in counselling have some sort of supervision and support to but we are expected simply to cope with whatever is thrown at us and shut up. If we challenge the system we are labelled as lacking 'insight' whilst the NHS has a long history of hanging whistleblowers out to dry. It's therefore hardly surprising that with so little control over their working lives that some doctors are prone to getting depressed.

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  • absolutely agree with the above. The complaints system is heavily biased with the poor doctor regarded as guilty until proven otherwise. Why is there no sanction against abusive or time wasting vexatious complainers? They never are asked to apologise for wasting time causing stress etc...

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  • Burnout is a euphemism for PTSD-type symptoms. Traumatised patients (sexual abuse, torture, domestic violence, rape) talk to their GPs, who don't/can't talk to anyone. GPs then, over months and years, develop anxiety/depression symptoms due to vicarious trauma. GPs need emotional/psychotherapeutic support. The fact they're not getting it might explain their fatigue with mental health problems. The people providing the support are themselves struggling. You've got emotionally damaged people supposedly caring for emotionally damaged people.

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  • David Banner

    The chronically sad crawl into your surgery, grab a tissue, then plug into your sympathy socket. Over the next 20 minutes they syphon off all your empathy reserves, then leave rejuvenated whilst your drained husk remains slumped in the chair. Eventually I had to annoy these emotional leeches enough so they would prefer to pester another poor GP instead. (On a serious note, we are not trained counsellors, they clearly need more than 10 minutes, and it’s unfair on both you and the waiting room, so direct them to a professional listener and save your own sanity)
    As for the confrontational? Take no BS, zero tolerance, ‘nuff said. And don’t sweat on the complaint letter, just add it to your appraisal folder, job done.

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  • It is not the patients that cause the stress. It is the system, inappropriate workload dumping, CQC, complaints, appraisals etc etc.

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  • doctordog.

    It’s the system AND the patients.

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  • I feel as a profession we are unsupportive to other colleagues. We are just expected to just suck it up and carry on, day in, day out. There is no support from colleagues, BMA, RCGP, GMC, etc.

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  • Stress? What stress? Banging my head against a brick wall is just a hobby.

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  • Unhappiness is not a medical problem, despite the RCGP's determined attempts to make it so. Doctors are not Social Workers or Counsellors, despite the best efforts of the RCGP to tell us we are.

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