Addressing burnout in GPs

Burnout among doctors has never been higher: a recent survey published in the British Journal of General Practice found that as many as 80% of medical students and GPs reported symptoms of burnout, a figure that rose to 90% in junior doctors. It should come as no surprise that burnout in doctors decreases the quality of care offered to patients, but it may be news to some that the risks associated with overworked and unwell doctors are significant and concerning, both to patients and to doctors themselves, To mitigate these risks, the General Medical Council (GMC) in the UK  has published a report, Caring for doctors, caring for patients, which includes the results of an independent review of the causes of poor wellbeing among doctors and recommends several ways in which these issues can be addressed.

As a GP appraiser, I have become increasingly concerned in recent years about the wellbeing of my peers. Appraisal meetings often begin on a positive note, as GPs present their achievements over the previous year. These are usually considerable, with many finding new ways to tackle increasing demand with dwindling resources. I am astounded by how many stay well by exercising on top of a 12-hour day. However, not everyone is superhuman. The relentless negative feedback we receive from the media and general public, in combination with poor communication with our secondary care colleagues, have led to low morale. The number of GPs leaving the role is increasing, and of those who stay, many are demoralised. Quite often, there are tears in the appraisal discussion; although this provides catharsis, it does not lead to the difficulties being resolved.

We have heard politicians promise many times that we will have more GPs. It sounds good to the public, but in reality increasing the number of GP training places, or stepping up the recruitment of doctors with equivalent qualifications from overseas is unlikely to attract the number needed. Our daily tasks are so often thankless and endless – so very much needs to change. In the GMC’s very detailed review, the authors have identified three core workplace needs that impact the wellbeing of doctors. These are the ABC of doctors’ core needs: autonomy and control, belonging, and the third, competence. I particularly like the section on compassionate leadership which is not just the responsibility of GP partners and practice managers, but the joint responsibility of all in the practice team.

The culture change described in the GMC document is already present in some GP practices – those that make time each day to discuss problems together, and those that have open doors to each other however busy the day is. These practices also learn and participate in social activities together. However, not all GPs can be part of such practices. Some GPs work in places with poor infrastructure, or face workplace bullying. And some need help for domestic issues: GPs are as likely to have relationship or money problems as their patients. Many areas have set up mentoring schemes. This is not new: local medical committees have been proactive in providing support in several areas. At last, we too have recently established a mentoring scheme in the practice in which I work. During this process, we were able to find out what has worked elsewhere and what has not. Not being an early adopter was not our choice, but it has been advantageous in this respect.

Some innovations can help all of us. Pharmacists are now working in many practices. Their training makes them skilled at reviews of medications and long-term conditions. Primary Care Navigators are too. They have the skills to advise patients and their families about available resources, both in social care and in the voluntary sector, and they work closely with social prescribers who can help patients by focusing on what matters to them, and by taking a holistic approach to people’s health and wellbeing. They connect people to community groups and statutory services for practical and emotional support. Nurses, paramedics, and physician associates are already providing valuable help in GP practices, most commonly by offering minor illness clinics.

All these things are happening now, before we even mention e-consults and video consultations. Using information technology (IT) alone may promulgate the inverse care law, in that those who are more fluent with, and have better access to, IT may receive more GP attention than those who are less IT savvy. However, using new IT approaches alongside more traditional ways of communicating with patients can extend the services offered to patients. It can improve access to care to those at work or those at home with caring responsibilities. The future can be bright if we are willing to look at different ways to provide care. It will be even better if we consider the wellbeing of those we work with and listen more, so that we understand each other better.

Reading C: text 1: questions 7-14

Read the text and choose the answer (A, B, C, or D) that you think fits best according to the text.

7. In the first paragraph, the writer says that burnout in doctors is…

8. The writer expresses surprise that some GPs…

9. In paragraph three, the word thankless is used to suggest that…

10. In the third paragraph, the writer says that…

11. In the fourth paragraph, the writer says that…

12. In paragraph four, the word it refers to…

13. In paragraph five, the writer says that progress has been made by…

14.According to the writer, the use of IT in general practice…

Writing about patients

The tradition of the physician-writer is a long one. We often talk about the art of medicine; like writers or artists, doctors rely on training and experience along with intuition and perception to accomplish their work, whether rendering a diagnosis or determining a treatment plan. The subject matter of the clinical encounter – which includes moments of intense human drama, like birth, suffering, and death – puts healers in a unique position to articulate universal truths about our humanness and our limitations. It is no surprise then, that Apollo was the Greek god of both medicine and poetry. Or that Anton Chekhov, the 19th-century Russian writer and physician, cohabited promiscuously with the two crafts: “Medicine is my lawful, wedded wife, and literature my mistress,” he wrote.

If writing about patients has ancient roots, however, so does the imperative to protect their privacy. More than 25 centuries ago, the Hippocratic Oath forbade physicians from sharing family secrets of their patients. As the ethical standards of biomedical research have placed increasing protections on the rights and dignity of research participants over the last century, similar rights – privacy among them – have been codified for patients outside of research too. Historian of medicine Susan Lawrence argues, however, that concerns over privacy have swung the pendulum too far. In her recent book, Privacy and the Past, she suggests that our concern about harm occurring from the release of patient information exceeds evidence of harm actually occurring. In fact, she writes, if historians hide their subjects’ identities because of potential stigma generated by their medical and social vulnerabilities, “then the historian becomes complicit in perpetuating stigmas that she may actually want to try to reduce by bringing understanding and compassion to the complex lives of historical actors.”

Consider the cases of Johns Hopkins surgeon William Halsted, who popularised, among other operations and techniques, the radical mastectomy in the 1880s. When historians studying the patient experience and representations of the body wanted to use photographs of his surgical patients that included their faces, their heads were often lopped off in the name of privacy. Phoebe Evans Letocha, collections management archivist at the Alan Mason Chesney Medical Archives at Johns Hopkins, saw the effect of this first-hand. “You lose that emotion,” she told us. “Then she’s just the disease, just the scar. You don’t see the human experience of the disease.”

Telling a patient’s story, particularly if conclusions are drawn or an agenda expressed, raises thorny ethical questions. Anna Reisman, an internist at Yale who directs a writer’s workshop for internal medicine residents, suggests that asking for permission does not eliminate the power differential between doctors and patients. In an essay in The Atlantic, Should Doctors Write About Patients? (2015), she shares the advice she gives to students: “I urged them to think about the power in the doctor-patient relationship, and whether asking for permission to share the patient’s story in a personal essay is enough to remedy the moral ambiguity.” No matter what the individual circumstances, it always involves an act of appropriation: the physician is opening a closed door, looking into a soul, revealing truths that may be generalizable but are profoundly personal as well. Reisman, unable to provide a universal answer to this dilemma, often suggests her residents put aside nonfiction essays and turn to fiction instead.

Writing about patients becomes particularly complicated when doctors try to publish. There are no industry standards as to how privacy issues should be handled, and guidelines vary considerably among journals, blogs, and presses. The murkiness extends to in-house publications. Individual health care institutions apply their own rules and regulations, explains Audrey Huang, director of media relations and director of marketing and communications for research and education at Johns Hopkins Medicine. Patient stories, she says, are a powerful means of conveying to the public important advances and discoveries at Johns Hopkins. “Our patients are our greatest advocates,” she offers. At the same time, if a privacy suit arises, the hospital is legally implicated. “We’re very careful about not revealing too much.’’

Patients also have a voice in illness narratives – the stories of illness spoken or written by patients, family members or caregivers and published online or in journals and books – and some argue that these are more important now than ever. In her 2012 book Illness as Narrative, Ann Jurecic, English literature scholar at Rutgers, attributes their growing popularity to “the profound need people have to tell these stories in an era when religious and folk explanations no longer give a satisfying and complete meaning to their experiences, and when biomedicine largely excludes the personal story.” In addition to giving meaning to personal experience, patient stories can also provide clarity and colour to descriptions of biomedical breakthroughs, or arguments for policy change. One aspect of patient narratives though that has yet to be explored to any considerable degree is the matter of privacy: should the illness narratives of patients give doctors and other healthcare professionals the same level of anonymity as patients themselves expect when healthcare professionals write about them? Should the rules be any different?

Reading C: text 2: questions 15-22

Read the text and choose answer (A, B, C, or D) which you think fits best according to the text.

15. In the writer’s opinion, the phrase the art of medicine refers to…

16. In the second paragraph, the phrase swung the pendulum too far is used to suggest that…

17. In paragraph three, the writer uses the example of the photographs of William Halsted to…

18. In paragraph four, the word it refers to…

19. In the fourth paragraph, Anna Reisman often advises her students to…

20. In paragraph five, the writer says that…

21. In the final paragraph, what reason is given for the growing popularity of patient narratives?

22. The writer believes that patient narratives…

That is the end of Part C and the end of the Reading Test