Supporting GPs to remain mentally healthy: What works?

Abstract

Doctors are some of the most resilient members of society; they have to be, so as to be able to survive not just a long and gruelling training, but also constant exposure to disease, distress and disability. They must be able to bounce back after adversity, and get on with their job. All the evidence is that healthcare professionals, particularly doctors, do tend to ‘tough it out’. Doctors tend to be stoical, denying their vulnerability, slow to ask for help, and working on long after they should have taken sick leave. However, they are not invincible and they can, and do, suffer from the same stresses as the patients they treat. This article will explore the causes of mental ill-health among GPs, the concept of resilience and initiatives that can improve a GP’s ability to survive in turbulent times.

The GP curriculum and maintaining a healthy workforce

Core statement 1: Being a GP states that GPs should:

Develop the attitudes and behaviours expected of a good doctor

Know yourself and relate to others: the development of professional expertise throughout training is underpinned by your ability to understand yourself and to relate successfully to other people

Manage the factors that influence your performance

General practice and mental ill-health

Burnout is an important and increasing problem among GPs. Burnout is part of a spectrum of mental health problems, and if left unaddressed can lead to escalation of mental distress, including depression, anxiety or ‘self-medication’ with alcohol. For doctors, national statistics are not available for these conditions, but estimations can be made through examining survey data (with its limitations of sample sizes, bias in responding, and so forth), treatment data, such as that from a specialist London-based practitioner health service the Practitioner Health Programme (PHP) and data from other sources, such as the recent suicide report by the General Medical Council (General Medical Council (GMC), 2014).

Other information can be gleaned from national surveys; for example, the British Medical Association (BMA) has been conducting a survey on GP job satisfaction and other variables associated with their work. The latest report, published in 2014, identified: the lowest levels of job satisfaction among GPs since before the introduction of the new GP contract in 2004; the highest levels of stress since the start of the survey series in 1998; and a substantial increase over the last 2 years in the proportion of GPs intending to quit direct patient care within the next 5 years (BMA, 2015). The National GP Work–Life Survey, which surveys GPs following any major contractual change, has also reported declining numbers with respect to job satisfaction, workload and stress (Hann et al., 2013).

GPs, despite only making up around 25% (60 356/235 134) of doctors licensed to practice by the GMC, make up over 40% of the approximately 1500 doctors presenting to the specialist practitioner mental health services, such as the PHP, with the modal age of all doctors seen being between 29 and 30 years old. Nearly two thirds (60%) of the GPs accessing the service are female, reflecting the higher proportion of females in the GP workforce. In particular, younger female GPs and older male GPs are accessing the service at times of stress and difficulty, when they might otherwise consider an exit from delivering primary care. The PHP service has also seen a six-fold increase in training grades accessing the service since 2008.

We acknowledge these figures from PHP only provide a snapshot of struggling practicing doctors, and they may not be representative of the wider medical professional population. Women may be more likely to seek help due to societal expectations relating to vulnerability or more women work part-time, and therefore have the time to seek help that others do not. There may also be generational differences in help-seeking behaviour, which could go some way to explaining the rise in younger doctors presenting to services.

Risk factors for mental ill-health

Doctors suffer from the same life events as the patients they treat, for example, loss, physical illness and domestic issues (such as marital breakdown, births, moving home). They also have additional risk factors, associated not only with their close proximity to suffering, but also to occupational and personality issues. These can be broadly divided into: occupational risk factors, individual risk factors, and barriers to seeking help (Table 1).

Table 1.

Risk factors for mental ill-health among GPs.

Risk factor and barriers	Cause	Examples
Occupational risk factors	Related to clinical aspects of the job	• Emotional demands of the job, such as breaking bad news, dealing with infertility • Unrealistic patient, public and political expectations related to the capacity for GPs to deliver desired outcomes • Easy access to prescription medicines • Need to keep constantly up to date, against ever changing clinical guidelines
	Related to structural aspects of the job	• Heavy workload • Long hours • Lack of support within practice
Individual risk factors	Exaggeration of personality traits	• Caring can lead to denying one’s own needs • Concern can lead to perfectionism • Excessive sense of responsibility
Barriers to seeking help	Lack of knowledge about where to find help	Although this might not be so relevant to GPs, for trainees, frequent moves during training and placements makes it difficult to know where to seek help
	Professional implications	• Worries that admitting to a mental illness (especially addiction) might impact on their professional career and risk involvement with the regulator • Worries about taking time off work to seek help • For GPs in small or rural areas, finding a GP who is neither a friend nor a colleague can be difficult
	Difficulties with disclosure	• Associated with stigma, embarrassment and shame • Reluctance to take on the ‘patient’ role

Source: Brooks, Gerada, and Chalder (2011).

GPs and resilience

The predictors of mental ill-health and factors related to resilience are closely linked. Resilience means flexible, strong, sturdy, tough and quick to recover: it is the capacity for a substance or object (or person) to spring back into shape. It is the ability to not only survive but also to thrive and adapt in the face of adversity.

Box 1 identifies some common characteristics of resilient individuals. Resilient individuals approach obstacles with the belief that they can make a difference, that challenges are unavoidable, but do not need to cause excess anxiety, and that ultimately persistence results in success (Howe, Smajdor, & Stockl, 2012). The belief that increased effort enables achievement of goals and enhanced performance is encouraged through consistency in feedback and rewards for achievements, fostering an individual’s faith in their ability to affect outcomes, sense of control, and decreased fear of failure. Reflective practice encourages individuals to see positives and learn from their mistakes, thus encouraging a constructive view of poor performance.

Box 1.

Resilient individuals tend to have the following characteristics.

• Confidence (self-efficacy)

• Co-ordination (planning)

• Control

• Composure (low anxiety)

• Commitment (persistence)

• Ability to make adversity meaningful (learning from errors, managing emotions, seek help)

Source: Martin and Marsh (2006).

Staying resilient

The authors of this paper have recently undertaken a systematic review on what factors or interventions can enhance resilience (Balme et al., 2015). Although this review addressed the general medical workforce, there are many aspects that are pertinent to general practice. It is important to remind ourselves that resilience is always contextual, it is a complex and dynamic interplay between an individual’s environment and sociocultural factors, and interventions must therefore address not just the individual, but also organisational issues.

Individual

Dunn, Iglewicz, and Moutier (2008) proposed a conceptual model of medical student wellbeing describing a ‘coping reserve’, whereby students’ own dynamic aspects of personality traits, temperament and coping style form an internal structure within the reservoir, which can be replenished or depleted with adaptive or maladaptive strategies (Fig. 1). The model can be used beyond medical school and can be applied to the lifelong career of a doctor. However, this model is overly simplistic, the relationship between burnout and resilience is unlikely to be as dichotomous as suggested; the opposite of burnout is full engagement (Maslach & Leiter, 2008), whereas resilience is a dynamic process influenced by internal, external and environmental factors.

Figure 1.

A conceptual model of medical student wellbeing the ‘Coping Reserve Tank’. Reproduced from Dunn LB, Iglewicz A, & Moutier C. (2008) A conceptual model of medical student well-being: promoting resilience and preventing burnout. Academic Psychiatry, 32(1), 44-53, with the permission of Springer.

GPs who maintain intellectual interest and high levels of job satisfaction have greater levels of resilience. Although this might be a confounding factor (more resilient individuals chose jobs that are more interesting) it does suggest where doctors have career progression or job-variability, or are able to develop additional areas of special interest, retention rates will improve and the risk of burnout will be reduced. General practice lends itself to variability and is perhaps one of the most flexible careers in medicine (Box 2). The nature of work, either as partners or salaried doctors, allows portfolio careers to be more easily created, and for diversification at different times throughout an individual’s career, enhancing their ability to remain resilient.

Box 2.

Areas where a GP can work.

• Clinical (GP, GP with special interest)

• Research and development

• Education and training (for example, appraiser, trainer, mentor)

• Medico-legal

• Journalism

• Management

Engaging in Continuing Professional Development either structured (conducting research/academic role) or unstructured (reading journals) or related to group activity (practice-based small groups, Balint groups, trainee groups) promotes resilience.

Self-awareness and reflective practices ensure individuals engage with the limitations of their skills, enabling adoption of a realistic approach, developing self-compassion and self-forgiveness for medical errors. These practices can help to enable individuals to recognise the symptoms of burnout and, when it is necessary and important, to seek help or make a change.

Although it probably seems obvious, ensuring a work–life balance and having time away from work will help to maintain resilience. This means:

Taking holidays

Hobbies, interests and other pursuits outside medicine

Putting aside time to spend with friends

Self-care (exercise, regular meals)

Support from others helps provide a buffer for work-related stress (Lee, Stewart, & Brown, 2008). Fostering personal support (family, friends and significant others) can provide stability and understanding, and professional support from peers and colleagues can help share the burden of complex cases, reduce isolation, and enhance enthusiasm and knowledge. Mentors are helpful throughout ones career, and they can help doctors find the pleasures in their work and find ways of dealing with stress and adapting to change (MacLeod, 2007).

Organisational

General practices are busy places; they often focus entirely on the need to deliver care to patients, rather than on the needs of those who provide the care (GPs, nurses, other clinical, managerial and administrative staff). Good practice management can help to ensure that there are systems, practices and procedures that allow time for reflection, team-working and for good communication throughout the organisation, as well as ensuring that the workload is manageable. A resilient organisation is a learning organization; it learns/grows from problems and adverse events (which are not uncommon in general practice) and develops the skills and knowledge of the individuals working within the practice.

GPs and specialist practitioner health services

Given that many healthcare professionals, especially doctors, are reluctant to seek help when they suffer from symptoms of mental disorder, it is important to ensure that barriers to accessing appropriate and timely care are addressed. The PHP (www.php.nhs.uk) is a confidential service for doctors and dentists resident in London who are experiencing mental health and/or addiction problems. Over the last 9 years, it has had around 2000 patients access the service. It is a GP-led, specialist integrated mental health service, providing a wide range of treatments, including assessment and case management, care planning, talking-therapies (individual and group), inpatient and residential care, drug and alcohol rehabilitation, relapse prevention, mindfulness, prescribing, monitoring, and much more. The team of GPs, psychiatrists, psychologists, specialist nurses, and administrative and management staff are co-located, share an electronic medical record, have weekly multidisciplinary team meetings, and share the care of patients in the service (PHP, 2014).

Independent analysis has shown that the patients attending PHP are as ill as other patients attending ‘normal’ NHS mental health services, and that PHP saves lives, improves outcomes (sustained at 12 months), saves money for providers, educators and the wider NHS, and enables doctors to return to training and/or work (Brooks, Chalder, & Gerada, 2011; Brooks, Gerada, & Chalder, 2013). The number of referrals to PHP has increased considerably since it opened; this is in not only due to increased awareness of the service, but also, and importantly, because the rate of mental ill-health in doctors is increasing.

Around 10% of the patients approaching PHP suffer from alcohol and/or drug addiction, the rest from mental health problems, such as depression, anxiety and complex mental health problems. Over the years, there has been a change in the make-up of the PHP patient population. When first opened in 2008, most of the cohort consisted of older male doctors, with younger doctors representing around 20% of the patient group. This has now reversed. More than half of all new patients are under 30 years old. In 2008 and 2009, 42% of the 195 patients presenting to the service were aged 46 years or over, and a quarter were aged 25–35 years. In 2012 and 2013, conversely, just over half (55%) of the 242 patients presenting to the service were 25–35 years old, and 22% were 46 years or older. To put these figures into perspective, under-35-year olds represent 28% of those on the GMC register.

Once doctors enter treatment, either for mental health or addiction, they do remarkably well, with over 80% of alcohol-dependent doctors and 90% of drug-dependent doctors remaining abstinent at 5-year follow-up. In addition, most (75%) doctors who were not in work or training when they became patients, returned to work.

At the time of writing, NHS England is committed to expanding the PHP across England for GPs. This will give all GPs access to such a service.

Finally

A simple questionnaire for GPs to complete is provided in Table 2. Based on the well known and used Alcohol Dependence Questionnaire using the acronym ‘CAGE’, the authors have created one for doctors based on examining whether they might be at risk of, or developing burn-out. If you score more than two then you might need to stand back, seek support and take time away from work.

Table 2.

A simple questionnaire for GPs.

1	Has anyone close to you asked you to Cut down your work
2	In recent months have you become Angry or resentful about your work or about patients
3	Do you feel Guilty that you are not spending enough time with your friends, family or even on yourself
4	Do you find yourself becoming increasingly Emotional, for example, crying, getting angry, shouting or feeling tense for no obvious reason

Key points

Resilience refers to bouncing back after adversity; it is a feature of the individual within an environmental context

Doctors are some of the most resilient individuals in the workplace

Doctors who experience burnout or depression should not struggle alone

Doctors who enter treatment services for mental health or addition problems have excellent outcomes

References

Balme, E., Gerada, C., & Page, L. (2015). Structural, environmental and individual factors that promote or impede the development of resilience amongst training grade doctors in the NHS in England. [Unpublished report]. Brighton and Sussex Medical School.

BMA. (2015). National survey of GPs: The future of general practice. Retrieved from www.bma.org.uk/working-for-change/negotiating-for-the-profession/bma-general-practitioners-committee/surveys/future-of-general-practice.

Brooks

S. K.

Chalder

Gerada

(2011) Doctors vulnerable to psychological distress and addictions: Treatment from the Practitioner Health Programme. Journal of Mental Health 20(2): 157–164. doi: 10.3109/09638237.2011.556168.

Brooks

S. K.

Gerada

Chalder

(2011) Review of literature on the mental health of doctors: Are specialist services needed? Journal of Mental Health 20(2): 146–156. doi: 10.3109/09638237.2010.541300.

Brooks

S. K.

Gerada

Chalder

(2013) Doctors and dentists with mental ill health and addictions: Outcomes of treatment from the Practitioner Health Programme. Journal of Mental Health 22(3): 237–245. doi: 10.3109/09638237.2012.734647.

Dunn

L. B.

Iglewicz

Moutier

(2008) A conceptual model of medical student well-being: Promoting resilience and preventing burnout. Academic Psychiatry 32(1): 44–53. doi: 10.1176/appi.ap.32.1.44.

GMC. (2014). Doctors who commit suicide while under GMC fitness to practice investigation. Retrieved from www.gmc-uk.org/Internal_review_into_suicide_in_FTP_processes.pdf_59088696.pdf.

Hann, M., McDonald, J., Checkland, K., Coleman, A., Gravelle, H., Sibbald, B., & Sutton, M. (2013). Seventh National GP Worklife Survey. Final Report to the Department of Health. Retrieved from www.population-health.manchester.ac.uk/healtheconomics/research/reports/FinalReportofthe7thNationalGPWorklifeSurvey.pdf.

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Smajdor

Stockl

(2012) Towards an understanding of resilience and its relevance to medical training. Medical Education 46(4): 349–356. doi: 10.1111/j.1365-2923.2011.04188.x.

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(2007) The challenge of providing mentorship in primary care. Postgraduate Medical Journal 83(979): 317–319. doi: 10.1136/pgmj.2006.054155.

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A. J.

Marsh

H. W.

(2006) Academic resilience and its psychological and educational correlates: A construct validity approach. Psychology in the Schools 43(3): 267–281. doi: 10.1002/pits.20149.

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Maslach, C., & Leiter, M. P. (2008). Early predictors of job burnout and engagement. Journal of Applied Psychology, 93(3), 498–512.

14.

PHP. (2014). Annual report 2013/2014. Retrieved from http://php.nhs.uk/wp-content/uploads/sites/26/2012/04/Six-Year-Report.pdf.

15.

RCGP. Core statement 1: Being a GP: Core capabilities and competences. Retrieved from www.rcgp.org.uk/training-exams/gp-curriculum-overview/online-curriculum/1-being-a-gp/core-capabilities-and-competences.aspx.

16.

RCGP. Core Statement 1: Knowing yourself and relating to others. Retrieved from www.rcgp.org.uk/training-exams/gp-curriculum-overview/online-curriculum/knowing-yourself-and-relating-to-others.aspx.