Investigation: A profession on the brink of burnout
As Pulse launches its Battling Burnout campaign, our survey of almost 1,800 GPs reveals 46% are at high risk of burnout. Madlen Davies reports
‘I was getting ill much more frequently, two or three days every month. I lost teeth because I didn’t have the time or energy to look after myself. I was working long days, never finishing before 7.30pm or 8pm.’
That is how London GP Dr Dominique Dock describes the burnout that led to his early retirement from his partnership last year – and he is not alone.
As Pulse launches its Battling Burnout campaign, figures from the largest recent survey of burnout among British GPs show that 46% of the profession is classified as being at a high risk of developing burnout, with GP partners and those in deprived areas particularly badly hit.
Almost all the GPs surveyed are classified as being at risk of burnout in at least one area, in results described by the GPC as ‘hugely concerning’. A fifth say that they do not think they are positively influencing other people’s lives – a result GP leaders say demonstrates the damaging demoralisation of the profession over recent years.
The survey of 1,784 GPs was conducted on the Pulse website and at the Pulse Live conference last month, using a validated questionnaire – the Maslach Burnout Inventory tool – adapted for GPs.
The survey contains questions assessing three key areas that signal a high risk of burning out – emotional exhaustion, depersonalisation and a low level of personal accomplishment. It was drawn up with input from RCGP chair Professor Clare Gerada and the College of Medicine.
Although providing only a snapshot of the state of the profession, the results are stark. Some 46% of GPs score highly in two of the three areas – signalling they are at high risk of burning out. This compares with a previous US survey published in the Archives of General Medicine last September that found symptoms of burnout in at least one area in 38% of doctors, and in 28% of the general public. A study of Italian teachers carried out in 2010 showed 19% scored highly in the domain covering emotional exhaustion.
The most recent comparable survey of British GPs was published in BMJ Open last year. The survey of 564 GPs found 46% were emotionally exhausted, 42% were depersonalised and 34% felt they were not achieving a great deal. This compares with rates of 74%, 43% and 20% in the Pulse survey.
But it is the human stories thrown up by the survey which are perhaps most shocking.
I couldn’t express my care for patients how I used to
Dr Dominique Dock
Dr Dock says burnout made him resent patients and colleagues and made daily life unbearable: ‘The stress would pile up and by 10am you’ve already reached rock bottom.
‘I was very sad I couldn’t express my care for patients how I used to. I didn’t like what I was doing any more. I thought “What’s the point?”
‘I didn’t want to become one of the doctors who doesn’t listen to their patients any more and reaches for the prescription pad.’
At a time when working hours have become longer, consultations more complex and patients more demanding, GP leaders say the risk is that burnout will end up undermining the future of the profession and endanger the whole drive to shift more care into the community.
GPC deputy chair Dr Richard Vautrey says Pulse’s findings are ‘hugely concerning’.
‘It’s alarming that so many GPs are burnt out. It underlines what we’ve been saying for years,’ he says.
‘The current level of work is unsustainable. I hope enough alarm bells are ringing in the Department of Health, in NHS England, Health Education England and all the devolved nations for them to say “we need to tackle this”.’
I hope alarm bells are ringing in the Department of Health
Dr Richard Vautrey
Burnout is categorised by the World Health Organisation as a ‘state of vital exhaustion’ and doctors working on the frontline often have higher rates of burnout.
Dr Michelle Drage, chief executive of Londonwide LMCs, says among professional groups GPs are particularly prone to burnout because they have ‘the ultimate responsibility’ for the wellbeing of thousands of patients.
She says: ‘Rising levels of burnout are causing a deterioration of general practice as a profession. I’ve never seen it so bad.’
‘No one else deals with life and death on that scale. Accountants and lawyers certainly don’t.
‘The impact of a GP being burnt out isn’t only on their own families, but on the 2,500 people they care for.’
Some 74% of GPs find they are emotionally exhausted, scoring highly on statements such as ‘I feel fatigued when I get up in the morning and have to face another day on the job’ and ‘I feel like I’m at the end of my rope’.
GPs who rate their practice populations as ‘deprived’ or ‘very deprived’ have a higher prevalence of emotional exhaustion than GPs who rate their practice populations as more affluent. Those working in practices in inner cities, city suburbs or towns are more emotionally exhausted than those in villages and rural areas.
Dr Vautrey says this is because cities tend to have a more complex mix of social and medical problems – problems which are often outside GPs’ control. He says: ‘Education and housing are wider determinants of health. Patients bring these social problems to the GP, which adds to the workload. Their medical problems may be treatable, but social problems are still there so often patients will come back.’
Most worryingly, 43% of GPs reported high levels of depersonalisation.
Dr Arup Paul, a GP in Tower Hamlets, east London, says burnout is ‘devastating’ general practice and that the pressures of the job affect relationships inside and outside his work. He says: ‘There is a depersonalisation with patients from burnout. I care about patients less now – people used to say I cared too much.
‘It affects my whole life. You go home and you find it difficult to speak to your elderly mother, because you know you’re going to get whinged at. You come home and you don’t want to speak to your partner because all you want to do is check your emails and eat.’
The most startling statistic revealed by the survey is that almost all of the GPs who responded – 97.2% – do not feel they are positively influencing other people’s lives or achieving something worthwhile as part of their job.
Dr Arup says that this is leading to many GPs retiring or seeking to reduce their hours: ‘There are frustrations with the system that you can’t do anything about. You make an outpatient referral, the patient gets seen, but you don’t get a clinical letter for four months.
‘You can’t move forward with the care management plan. The patient has all their anxieties. So what should be a linear process becomes convoluted and your frustration increases, because the system isn’t working and there’s nothing you can do.’
All the signs, though, are that the pressure on GPs is going to increase. LMCs are complaining of a ‘shocking’ rise in the number of GPs seeking support, with one LMC reporting a doubling in presentations to pastoral care services in 2012 compared to the previous year. The BMA Counselling service also saw an 80% rise in calls from doctors regarding work-related stress in 2012, compared with 2010.
Dr Mike Bewick, deputy director of primary care at NHS England, acknowledges the burden on GPs, and insists NHS England is ‘committed to working with the profession to help address the growing pressures on practice workload’. But the signs on the ground are less promising.
At the LMCs conference, Cornwall LMC’s Dr Francesco Scaglioni reported that one GP in 17 in his area presented to local occupational health services in 2012 – a third of them ‘frankly suicidal’ – but claimed the service was being cut.
‘Last month, we received a letter from the local area team saying funding was withdrawn, with no provision for the users of this service,’ he said. ‘This is callous, dangerous and heartless.
‘Funding for occupational health services must be provided – for the good of our patients and the good of ourselves.’
Please note: This article was updated with new figures that showed 46% of GPs were at high risk of burnout, not 43%.