I’m fascinated by shows such as The Island with Bear Grylls, where ordinary men and women who normally work as car mechanics or hairdressers are abandoned on a Pacific island and have to fend for themselves. Some of them, of course, thrive. Others are on the first boat back for a beer and pizza.
UK general practice is currently littered with analogies to military-style ‘resilience’, which is unsurprising considering the huge pressures we are facing. But what can we really do to help ourselves in these difficult times? How can we ensure survival?
I asked colleagues in Bristol and the Resilient GP Facebook group for their ideas, and I would like to offer you the Ten Commandments for general practice survival, based on a survey of 100 GPs’ coping strategies.
1 Get peer support
There’s something comforting about strength in numbers and the knowledge that others can also experience days from hell.
Whether we chat to our colleagues in the practice, or join a First5 or Balint group, we all need somewhere to vent our frustrations. Sites such as Resilient GP, Doctors.net and Tiko’s GP Group offer much-needed support in the virtual world.1
I know a GP who had a weekly lunch with a GP friend for many years, which had to end when she was asked to work an extra session due to staff shortages. The combined effects of the increased workload and losing her peer support pushed her to the point where she was signed off work with stress. She had underestimated how vital these lunches were to her professional survival.
2 Learn to say ‘no’
Why do we have so much difficulty uttering those two little letters? The answer lies is a complex blend of psychological and behavioural factors, but it is possible for assertiveness skills to be taught.
When workload is mushrooming, we have a choice of either working all hours or saying ‘no’ to some of it. For many GPs this will seem like an unrealistic aspiration. But here’s how you do it.
Say ‘no’ to patients
There are many things we do within consultations that reinforce a patient’s attendance, from issuing a script to writing a letter for housing. If we prescribe lots of antibiotics and other placebos for self-limiting illnesses, we send out a message that the patient needs to see us again for these ailments.
Similarly, if we write the numerous letters that are requested of us, rubber-stamping anything from parachuting to TV appearances, not only are we taking clinical and legal responsibility for it, we are also sending out the message that we are the fall-back position for anyone in a spot of bother.
You can adopt policies as an individual, but it is far easier and less confusing for patients if they are adopted by the whole practice.
Say ‘no’ to other healthcare professionals
When I was working in hospitals, I would always be amused by the number of times ‘Dr informed’ would be recorded in patient notes, as if that would magically absolve nurses of responsibility for a patient. Now I’m in a GP practice, I know it’s not just nurses that do this, but physiotherapists, psychologists, social workers, health visitors and paramedics.
I have enormous respect for all these professionals, who know far more about their specialist area than I do – which is why it is sometimes frustrating to be asked to take responsibility for their roles.
We have recently seen a huge shift of work from secondary to primary care, without the resources to match it. We can either passively do it all, under the pretext that it is easier for the patients, or we can return the work whence it came.
Many practices have standard letters to manage some of these secondary care requests. The GPC and Londonwide LMCs have produced excellent template letters to assist with this.2
Say ‘no’ to colleagues
Whether we are a GP partner, salaried or a locum, we all need to identify when we are being shafted and do something about it. The perception that we are working harder than anyone else may or may not be true, but without discussing the issues, we will never know.
I needed to reduce my management workload, so I discussed it with my partners and reduced the number of sessions I worked, and arranged for some of it to be redistributed. Likewise, if salaried GPs feel they are doing a disproportionate amount of on-call work or visits then this needs to be questioned.
3 Take breaks
To quote Glasgow GP Dr Margaret McCartney: ‘Coffee time is about much more than coffee’.3 It is a time when we can interact with colleagues and discuss anything from the latest NICE guidelines to who will be the winner of the next reality TV show.
My day is punctuated with short ‘time-outs’, which involve snack breaks, reading Pulse or going on Facebook (don’t tell my practice manager). I know many GPs who will go for regular short walks or enjoy a few minutes of mindfulness in between patients. It is a false economy to forge full steam ahead without ever stopping.
Likewise, annual leave should not be used as a chance to catch up with work, but really to switch off, ideally in a remote area with no wi-fi or mobile signal. If you can’t manage to be marooned on a deserted island, it is still possible to cut yourself off, but you have to be organised enough to clear the decks before you leave and disciplined enough to maintain the distance.
At least one career break is also essential for survival. Although I was sleep deprived and hormonal, my three maternity leaves have still been breaks from work. The last one was nearly five years ago now, so I am starting to think about a sabbatical.
4 Develop a portfolio career
Many GPs have found that working fewer practice sessions helps them to stave off burnout. But the irony is that, with six practice sessions, I am considered to be part time, when I am easily clocking up 37.5 hours per week. I would recommend anything that takes you away from long days at the coalface, if you can afford it, as it is likely to keep you sane.
What sets general practice apart from other specialties is its versatility. You can combine practice work with education, appraisal, CCG duties, GPSI work, medicolegal work or sports medicine, to name a few. Admittedly, if all GPs had a portfolio career, this would worsen the GP shortage, but your primary responsibility is to yourself. If you burn out, you are no use to anybody.
5 Go home on time
My three children attend a lovely primary school where emotional and social development is valued as highly as academic achievement. They are taught that everyone has an invisible bucket: if you are mean to people, you empty their bucket and if you are kind, you fill it. When I come home from work feeling frazzled, the children often ask me if my bucket is empty and offer to fill it with hugs.
We all know patients that can drain our buckets in the space of 10 minutes. Whether it’s through emotional connections or hobbies, we all need our buckets filled at the end of a long day.
We all need to create deadlines for ourselves. This could be leaving work on time to do the school run, attending a language or dance class or, like me, getting home to eat dinner with my kids.
6 Join a great team
As a newly qualified salaried GP in London, I worked in a practice where I was earning less than the average salary, but had an excellent work-life balance and a fantastic team of GPs, nurses and receptionists. Similarly, my current partnership role in the inner city is not in the highest-earning practice, but I am working with partners I like, respect and trust.
In order for everyone to work together there needs to be a shared practice vision. It requires dedicated time, good communication and a certain amount of compromise. There is nothing worse than having your decision-making undermined by another clinician. With written practice policies in place, patients are far less likely to make unreasonable complaints, and if they do, you will have the full support of your team behind you.
As a partnership, we have an annual away weekend when we discuss vision and strategic policy. After all, as US entrepreneur Jim Rohn said, it is the set of the sails, not the direction of the wind that determines which way we will go.
7 Take care of yourself
Do we practise what we preach when it comes to our health? Do we exercise and drink less than the recommended limit for alcohol? Do we seek help when we are stressed or depressed? Or do we soldier on? One of the biggest causes of psychiatric morbidity and suicide among doctors is that we fail to seek help when we need it. There are now many more LMCs offering free support and counselling for GPs. I personally found Dovedale counselling (now defunct) invaluable following a relationship breakdown many years ago. You can find your local counselling service via the BMA’s Doctors for Doctors service.4 To find out whether you’re at risk of burnout, take Pulse’s survey.5
8 Improve your time-management skills
Which other profession has to assess, formulate a shared management plan and explain it within just 10 minutes? Without effective time-management skills, both in the consultation and generically, we cannot survive. The irony is that by adding breaks to our surgery or offering longer appointments, we are likely to finish earlier. If we keep a patient waiting, our guilt makes us feel we ‘owe’ them time in return, even for simple problems. Every GP needs strategies to cope with the ‘shopping list’ patient, the rambling patient, the demanding patient and the complex patient. Time management can be learned and is about being able to plan, prioritise, delegate and avoid procrastination.6 Learning how to touch-type helps too.
9 Log off your email after work
Most GPs hate remote working but I have to confess, I love that it allows me to get home in time to have dinner with my kids and put them to bed. The downside is that I often log in remotely at 9pm. Although this allows you flexibility, it means you don’t leave work behind. This permanently ‘switched on’ state of mind is thought to be unhealthy, so unless you have very young children, it’s probably best to avoid it.
I have been impressed by GPs who set clear boundaries between weekdays and weekends. Some have multiple leadership roles and huge workloads, but they keep their weekends totally free.
10 Avoid over-servicing your patients
Have you ever wondered why some GPs breeze through the day with minimal effort, while others are constantly busy? The latter group is likely to be ‘over-servicing’ their patients. This involves an inability to manage risk and uncertainty (with the resulting increase in investigations), excessive ‘hand-holding’ of patients and a reluctance to signpost them to non-GP services. We all have patients who come to us with huge baggage, which they place on our laps to deal with. The skill is subtly to place it back on theirs, while offering support, for instance by encouraging them to chase their own appointments or self-refer if allowed. It is important to foster personal responsibility in patients, even if it seems easier just to take over.
It is important to remember we are physicians and not counsellors, social workers, life coaches or priests. In the words of Star Trek’s Dr McCoy: ‘I’m a doctor, not a magician.’
Dr Shaba Nabi is a GP in Bristol, director of the GP training programme at the Severn Deanery and an appraiser in south Gloucestershire
3 McCartney M. Coffee time is about much more than coffee. bmj.com/content/348/bmj.g3444
4 BMA. Doctors’ well-being. Tel: 08459 200169. tinyurl.com/docs4docs
5 Pulse. Battling Burnout survey. Pulsetoday.co.uk/burnout