Burnout in the Medical Profession

This is a syndrome of emotional exhaustion, depersonalisation, low productivity, and feelings of low achievement. Although it can occur in a range of occupations, burnout has been found to occur most amongst professional people in the caring professions of medicine, nursing, social work, counselling and teaching. It is typically associated with the prolonged and cumulative effects of emotional stress and pressure that arise from personal interaction with members of the public on a daily basis. Burnout may seem to have two apparently conflicting elements. One is an apparent daily trudge of a dull, monotonous and tedious routine. The other is sheer exhaustion from years of struggling through demands and change.

There are three components to burnout:

1. Emotional exhaustion leads to an inability to engage fully with many aspects of the job but particularly with those aspects involving interaction. Speech may become flattened and body and facial gestures diminished as the person becomes less responsive to the demands of the situation of a professional interaction.
2. Depersonalisation means a tendency to depersonalise those with whom one is forced to interact so that patients are seen less as individuals and situations become simply part of a routine.
3. Lack of personal accomplishment accompanies burnout. The individual will tend to feel little sense of achievement in relation to the job even if the reality is very different.

Burnout may be associated with the development of depression and this is seen to be linked most clearly to the degree of emotional exhaustion. The condition may go through three stages as indicated by groups of symptoms below:

• Poor concentration
• Insomnia
• Poor productivity and more mistakes
• Guilt
• Denial
• Loss of Libido
• Depression

This may be followed by:

• Becoming uncooperative and resistant to change
• Resentment
• Frustrated, bored
• Feeling isolated
• Paranoia
• Irritability
• Aggressiveness, short temper

This may progress yet further to:

• Poor timekeeping
• Indecision
• Avoidance behaviour
• Apathy
• Amnesia
• Withdrawn
• Alcoholism, drug dependence or other inappropriate behaviour

The temptation to "cope with stress" by drinking more is to be avoided most strenuously. If consumption is rising and drinking is occurring at times when it would not formerly have done, these are signs of trouble. Self medication must also be avoided. If there are mental health issues, consult a colleague. This is not an area to treat yourself.

Much has been written about stress, burnout and dissatisfaction in general practice and many sources of difficulty and conflict have been identified. Over-demanding patients fed by the claims of politicians who tell them what they may expect, aggression, abuse, unscheduled care, keeping up to date, practice management and new ways of working are all contributory factors. What they boil down to is difficulty in coping. The new contract of 2004 was the most radical reform to the profession since the GP Charter of 1964, if not since the inception of the NHS in 1948. The greater flexibility of the contract may aid satisfaction and give back a sense of control. On the other hand the greater demands for performance related pay and rejection of the old concept of leaving doctors to perform to their own level of satisfaction may be a source of further anxiety and stress. There were increased problems after the reforms of 1990¹ but it is too soon to ascertain if things are better or worse after the more radical reforms of 2004.

Change is a source of inability to cope and resistance to change is a symptom of failing to cope. Mao Tse Tung fostered a system of perpetual revolution to make everyone feel insecure and in doing so to cement his position. The NHS may feel like that today and in the present political climate, perpetual change is the one aspect that will not change for the foreseeable future. Of course the problem of burnout is not limited to the NHS or the British health system.²

We start with enthusiasm and altruism. The newly qualified doctor or the recently appointed GP is keen, vivacious, excited by the challenge and eager to make an impact. When does this all change? When does a young Turk become an old fart?

It is said that 40 is the age when a broad mind and a narrow waist change places but it is not simply a matter of years. Indeed, age is not related to burnout. ¹ Age is no excuse for either a narrow mind or obesity. People get settled and perhaps too comfortable in their ways. One of the earliest features is resistance to change. We all have a degree of resistance to change and this is nothing new. Around 2,000 years ago Ovid wrote, "Nothing is stronger than tradition."
About 500 years ago Nicolo Machiavelli wrote words to the effect that, "There is no more arduous task that can be given a man than the initiation of change."
Perhaps the most profound of such wisdom comes from about 30 years ago from the unexpected source of Frankie Howard in the words, "People don't know what they like but they like what they know." This truth is applicable to absolutely every aspect of life.

In past centuries adherence to tradition was often regarded as a laudable asset rather than a sign of incipient senility. Conservatism was regarded as so desirable that a major political party called itself The Conservative Party although nowadays, like all other parties, it wishes to present itself as a radical party of change. Entry to general practice could be summed up with the words, "Here's your gold watch and shackles for your chain." Continuity and long service were admired. Little changed over the years and moving from one practice to another was exceptional. Nowadays many young doctors prefer to accept a salaried post rather than commit themselves to a much more lucrative career as a principal with the implication of commitment and duration of tenure. The whole world is changing at a pace that was formerly unthinkable and the National Health Service is changing as fast as anywhere. This is partly due to rapid changes in science and technology but also there is political pressure to implement untested and unproven ideas if only to demonstrate that the politicians do not lack vitality

Resistance to change is often seen where competence is questionable. Coping with the status quo is just manageable. Coping with change too is not. It is amazing how many people in various walks of life regard their jobs as stressful. "Stressful" usually means an inability to cope or borderline competence. What some see as stressful, others would view as challenging and exciting.

Practice management is often cited as a source of stress and dissatisfaction with life. Nowadays everyone has a practice manager and the calibre is excellent compared with the secretaries and senior receptionists who were masquerading under the title 20 years ago. Nevertheless, a doctor should understand the business that he owns. He does not need to have all the skills that his manager possesses any more than he needs to be able to perform nursing duties or type like a secretary.

We are taught how to practice medicine but often business management is expected to be acquired by instinct or perhaps the sordid world of business management is an unseemly topic to teach a doctor.

• Can you write a business plan?
• Do you know the theory of project management?
• What are the principles of the management of change?
• Why does your accountant list a positive bank balance as a debit in the accounts?
• Do you have a reasonable grounding in employment law?
• If yours is a dispensing practice do you understand input and output VAT?

Perhaps some managerial rather than purely clinical components are required in your next PDP. Do not be afraid to delegate to your practice manager or management team what they will do better. Doctors are often bad at delegation and this was an impediment in the early days of introducing skill mix. Nevertheless, it is good practice to have an adequate overview of what is done on your behalf just as you have a reasonable idea of what a consultant will do when you refer a patient.

Not everything can be delegated and there comes a time when the buck stops here. Practice meetings are important to make everyone, especially the partners, feel empowered and to contribute to the direction and achievement of the practice. Partnership relationships are very important.³ If there is friction between individuals it needs to be brought into the open so that it may be rectified and the practice may continue in harmony. The senior or lead partner needs to take a firm hand. Perhaps there is dissent about work loads or time taken for non-clinical work. An equitable and acceptable solution must be found. No one must feel impotent or exploited. Policy decisions need to taken after full discussion. If there is still dissent then "cabinet responsibility" dictates that a unified approach is taken and everyone "sings from the same hymn sheet". A house that is divided against itself cannot stand. (Gospel according to Matthew, chapter 12, verse 25, also cited by Abraham Lincoln in June 1858 when accepting the Republican nomination for the Senate).

• How can we prevent burn out?
• How can we continue to see the many changes we face as an opportunity rather than a threat?
• How can we ascertain that we face each day with vitality and excitement rather than yearning for the day when our superannuation contributions will summate to a satisfactory pension?⁴
• What is the secret of eternal youth?

A personal development plan is no longer an optional extra but a necessary component of compulsory reaccreditation. This should not be seen as yet another burden for the hapless doctor to bear in the endless struggle with bureaucracy but as a useful and valuable tool for personal fulfilment. The trouble with an unguided PDP is that there is a tendency to pursue one's personal interests. There is nothing inherently wrong with this provided that it is not the only avenue to be explored. Personal interests are probably what is already done well. What a mentor will also ask is, "What aspects of your work do you do not so well?" If there is reticence in admitting to any shortcomings the next question may be, "What aspects of your work do you find stressful? What do you hate most about the job?" These are almost certainly the aspects that are done not so well. It may be ENT, ophthalmology, heart sink patients, over-demanding patients, trying to understand the literature or practice management. These are the fields that require some attention in the forthcoming year. Improving competence in these fields serves two purposes. In terms of being a good doctor, it is more important to address shortcomings than to improve isolated areas of excellence. If competence is improved then these areas will be less stressful and life will be much more fulfilling. The doctor, the patients and the practice all benefit.

It is not just the individuals but the practice as a whole that requires a development plan. This addresses needs, future developments and engenders a team spirit of enthusiasm and pride in achievement:

• Perhaps individuals need more protected time for audit or practice management.
• Perhaps more emphasis should be placed in skill mix with training of nurses to take some of the load off doctors and training of others to take some of the load off nurses too. Skill mix can increase rather than decrease stress. It is inefficient that a person should be routinely performing tasks that are well below his competence and this can lead to low self-esteem but if they are removed he will be functioning nearer to the edge of his ability all the time and this may increase anxiety and self-doubt.
• Doctors may wish to develop personal interests and practice based commissioning may be a suitable route. The concept of GPs with special interests was greeted with antagonism by Council of the RCGP when it was first mooted some years ago but the concept is likely to be a valuable part of practice based commissioning. It is essential to talk to the PCT or Health Board before embarking on extra training as there is much to be considered and embarking on a fruitless project will multiply, not reduce frustration and burnout.
• The Primary Care Research Network provides an opportunity to get involved in clinical research, perhaps at the level of a participating practice rather than as a project leader.
• "He who can does. He who can't teaches," wrote Oscar Wilde but perhaps we should turn instead to the words of Alexander Pope, "Let such teach others who themselves excel and censure freely who have written well." Becoming a trainer may reinvigorate a flagging career. Teaching medical students is another option. Teaching others necessitates being self-critical of one's own practices but the vitality of the young is also infectious and can be most satisfying. Training may be especially beneficial in areas where it has been traditionally difficult to recruit as there is a great tendency to stay in the area after training and there can be no more thorough assessment of a potential candidate than to have had him as a registrar.
• Interests outside of the practice may also help to add a spark of zest to life.

Profession is a very important and very time-consuming aspect of life but it is not all of life. It is essential to have a life outside of the practice.

• We advocate a healthy life style and physical fitness to our patients and we should practice what we preach. Mensa sana in corpore sano (a healthy mind in a healthy body). This does not mean persisting with rugby well after the days when it ceases to be judicious but appropriate and enjoyable recreation that puts a certain degree of stress upon the cardio-respiratory and musculo-skeletal systems.
• Never neglect the family. They are young for far too brief a time and that time is gone for ever.
• Have interests and friends outside of medicine. It is a great career but it is not the whole world. This will make you a more rounded person, capable of seeing life in perspective and less likely to make rash judgements.

• Maintain a lively interest in all things new to be able to welcome change as a opportunity rather than a threat
• Use your PDP to maintain vigor and to help cope with the more demanding and stressful aspects of practice. Do not look solely at clinical components.
• Make sure that the practice is healthy with good and harmonious relationships, a feeling of equity and a pride in belonging
• Control unreasonable and unrealistic demand
• Have outside interests
• Talk to others. Seek help if necessary. Do not be afraid to approach someone else to ask for help. They will not see you as a weak, pathetic and inadequate but they may be able to offer help and advice as well as moral support.
• As with so many diseases, early diagnosis and treatment gives the best prognosis
• Prevention is even better

If you recognise these features in yourself, take action. If you recognise them in a colleague, have a friendly chat and point in the right direction. Effective action can make an enormous difference to a person's quality of life and the quality of service that he or she can offer to patients and the practice.