Recognising the key signs of GP stress and burnout
Professor David Peters summarises GP burnout in four stages, explains the signs and points out ways to seek treatment and protect yourself at any stage
Burnout is a process. Think of it as a ‘burnout spectrum’ with an end stage where no GP would want to land. The fundamental hallmark of burnout is exhaustion – running out of ‘oopmf’ – physically, mentally, and emotionally.
We need to be on the lookout for ourselves and for our colleagues if we start to see signs of lack of concentration, poor timekeeping, poor productivity, difficulty in comprehending new procedures, lack of co-operation, irritability, aggressiveness, withdrawal behaviour, resentment, increased tendency to make mistakes and resistance to change.
If this applies to you or your colleagues then customer service is probably taking a nose-dive, but the need for watchful awareness isn’t just a matter of health and safety, because research suggests that people can increase their resilience if they are shown how, which is obviously good news.
On the other hand maybe you are burning out because you are the canary in the coal mine. Many of us already feel that the NHS isn’t getting any easier to work in, especially if your are in a practice or organisation that’s poorly managed, where there’s low morale and effective leadership is lacking. If this is ringing any bells then action on burnout (let alone compassion fatigue) may mean doing more than just giving your own resilience a boost.
There are four levels of burnout profiled in this article, to help give a clear picture of the signs, how to deal with the problem, and the consequences of non-treatment.
Stage zero: Engaged and enthusiastic
Signs of the stage Burnout isn’t an issue for you. Being at work (on the ‘good days’ at least) you feel ‘engaged’: you have energy, you get involved and you feel as though you’re achieving something.
At your surgery, morale is good and so is job satisfaction (two factors known to offer relative protection against burnout).
Sometimes you’re a bit over-enthusiastic or wound up but you have effective ways of discharging tension and you can relax when you need to. You sleep well.
You get on with patients and colleagues well, and you’re coping even though you seem to be attracting more than your fair share of the practice’s difficult and chronic patients.
Your capacity for hard work and enthusiasm are obvious to those around you. Your standards are high and you believe in what you’re doing. Maybe you’re thinking that just being a GP isn’t enough for you – you might be interested in becoming a provider or commissioner, for instance.
In autonomic terms, you’re running on adrenaline some of the time but it’s because you’re excited and driven, not because you feel threatened.
Dealing with the signs You’re well now, so use your good health to focus on what motivates you.
Also, perhaps colleagues are looking to you to keep up morale and provide leadership. Do you need to brush up your leadership skills, get some coaching, find a mentor or a therapist? Could it be you don’t always recognise your own boundaries or the limits of your own energy?
Consequences and worst case scenario Perhaps you’re a bit of a hero figure and maybe you set the bar unrealistically high for yourself (and others). Work is exciting but make sure you keep the home-fires burning and have yourself a life outside of it.
Stage one: Tired and disorganised
Signs of the stage You attend too many meetings, but dutifully keep trying to pull your weight. You sometimes over-run your sessions or make prescribing errors.
Professionally, you’re not having ‘good days’ any more. You drink at home regularly, but not to excess. If colleagues, friends or family express concern, you are sceptical. You feel you’re ‘OK really’ and assume this over-pressure exhaustion is bound to pass.
In autonomic terms, your decision-making cortex is less efficient, and it’s harder for the all-important ‘relaxation response’ to kick in.
Dealing with the signs Doctors are scared of labelling themselves as ‘not coping’ and too often they avoid getting professional help until a full-blown crisis hits.
Still, as a GP you know the early symptoms that signal stress: difficulty sleeping, tension headaches, appetite change, poor concentration, feeling anxious, irritable or low in self-esteem.
Imagine then what you would say to yourself if you were your own patient: change your lifestyle, get a life outside practice, take time out, exercise and eat better, get support from others. If you have stopped having good days you could already be on the road to burning out.
Consequences and worst case scenario This is the point to take upstream action. The chances are that more serious mistakes will be made, or that your tiredness will lead to irritability and more upset.
The subsequent guilt and distractedness will tend to spiral down into stage two.
Remember that though alcohol is a traditional ‘coping method’ in the medical culture, long-term it causes more stress, poor well-being and under-performance.
Stage two: Grumpy and distant
Signs of the stage You’re regularly aggressive or short-tempered. You find yourself retreating into hostile withdrawal when you can’t have your say or your own way. Patients’ endless demands are getting to you; to get by you feel forced to become more detached and less involved. Too many consultations end up with crossed wires, or a sense of having missed the point.
Professionally, you begin to feel training in general practice was a mistake. You perhaps wish you had gone into another branch of medicine.
You’re pretty wound up by the time you get home and have considered taking something self-prescribed to help you relax or sleep.
In terms of your autonomic nervous system, you are flopping between fight and flight; sometimes you feel like you’re struggling at other times, or as if you’re trapped. In this mode the ‘compassion’ circuits just won’t turn on: at an instinctual level patients are beginning to trigger a threat response.
Dealing with the signs Is it you, your dysfunctional practice, or the incessantly shifting NHS goalposts? Possibly it’s all three, but somehow you have to deal with the here and now.
Talk to a colleague you can trust or call a helpline (see the sources of help article). All the stage one issues and your advice to yourself still apply, plus the research evidence for stress management techniques that benefit healthcare staff such as mindfulness, relaxation, cognitive behavioural skills.
In reality you will have to go with locally-available expertise. At practice level, does someone need to improve management, make appointments longer and shorten lists (easier said than done, admittedly). How much control do you have of your workload anyway?
The Marmot research points to low control being a major risk factor for stress-related disease. Maybe it’s time to get a coach or team consultant in to get people talking about the practice’s problems.
Consequences and worst case scenario If some patients have complained to receptionists about you there had been nothing formal, yet. Perhaps the practice as a whole is underperforming because of perverse incentives and unrealistic targets, with arguments and angry meetings about money or staffing levels.
A century of mortality statistics show that doctors’ risks of marital breakdown, cirrhosis, accidents and poisoning are the higher than other professions’.
Stage three: Can’t be bothered; burnout
Signs of the stage Feelings of hopelessness and lack of motivation are now obvious to you and others. Now you’re increasing inconsiderate or lacking in interest in patients or colleagues; poor communication and crossed-wires are becoming the norm.
Increasingly you’re withdrawn and isolated, and the relationship problems inside the practice are mirrored at home.
Autonomically speaking, you’re shifting from a failing fight and flight response into the freeze mode, waiting for the ‘overwhelm’ to go away.
Dealing with the signs All the previous observations and interventions apply, but at this stage professional help is essential. An awful lot of GPs don’t have a GP themselves though, and it’s unlikely that your colleagues have let you get this far down the road without comment: either someone in the team has tried and failed to steer you towards help already and you have resisted, or they too are on the burnout spectrum.
Either way, collusion has to be challenged. So if you’re reading this and recognise the picture, ask if you are still capable of reaching out for help.
Consequences and worst case scenario Some GPs can be this burned out yet tolerate their desperation, soldier on and still somehow keep up an acceptable standard of work. Yet it seems more likely you already have a problem with patient satisfaction, and could be a GMC hearing waiting to happen.
What’s more, you could be facing the prospects of practice break-up, marital meltdown, litigating patients, depressive illness and the likelihood of a chronic stress-related disease.
GPs are people too and sometimes need help.
Ask yourself; take an honest look; take a break; call a doctors’ helpline as soon as possible.
Professor David Peters is clinical director in the School of Life Sciences at the University of Westminster. He leads the Westminster Centre for Resilience (email@example.com) and the Self-care Faculty at the College of Medicine. He is a professor of integrated healthcare at the University of Westminster.