Why are doctors so unhappy?
BMJ 2001; 322 doi: https://doi.org/10.1136/bmj.322.7294.1073 (Published 05 May 2001) Cite this as: BMJ 2001;322:1073
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As long as we carry on with our individualist-based "doctor knows
best" paternalism and the institutional arrogance that the BMA and others
promote, we are swimming against the tide. As well as being left feeling
unsupported, under attack and hopelessly vulnerable.
We do have unique training and skills - something to do with taking
responsibility for uncertainties (that managers and ebm hardliners often
fail to understand), but not for knowing how the show should be run. That
must be negotiated and shared nowadays: it's the only way accountability
isn't a persecutory burden on us.
Wilke has just written an interesting book on it for GPs ("How to be
a good enough GP"), where he talks about doctors regaining a sense of
personal and professional agency by participating in group analytic
seminars. Balint did something similar 30 or 40 years ago of course, but
this brings in the modern dimension of managing the complex network of
relationships that we rely on, which is all around us. And managing it in
an open and creative way, where we can find fulfilment in exploring our
differences rather than angst and stress in interminable conflict and turf
-wars.
Only when we make authentic contact with each other through means
like this can we challenge Smith's "bogus contract", and speak with any
sort of meaningful unity.
Rex Haigh
ref Wilke G (2001) "How to be a Good Enough GP" Radcliffe Medical
Press: Abingdon
PS I think your online questionnaire is rubbish and doesn't address
what really matters. It's full of system errors (like what's behind what,
and trains of causality) and will produce arid and meaningless statistical
"evidence". I prefer the ones in Cosmopolitan - at least they're funny.
Competing interests: No competing interests
GPs are squeezed between patients’ expectations for instant remedies
without risk or error, and government pressures to speed the conveyor and
tighten quality control. Extending the strategy initiated by the
Conservatives in 1990, New Labour’s Alan Milburn is developing an
industrialised, consumer-led NHS. Meanwhile bureaucracy marches on: as a
proportion of spending on healthcare, administrative costs have doubled
from about 6% before the 1990 “reform” to about 12% now. This is still
behind USA at about 25%, but the modernisers are on course to reach that
target.
The driving force behind this strategy is perception of the NHS as an
industry producing clinical interventions as discrete commodities,
episodically consumed by patients. In the programme espoused by New
Labour, innovation will come from State-assisted corporate investors, for
whom public service will be subordinated to pursuit of profit. Motives
for this electorally unpopular(1)strategy were explained by Richard Smith
in 1996(2)and Allyson Pollock in 1999.(3) New Labour’s devotion to
creeping privatisation of the NHS starts from its conversion to classical
economics, the World Trade Organisation, the World Bank, and its
commitments to the General Agreement on Tarrifs, Trade and Services to
open all public service to global competition and investment. None of
these has any mandate from the Party membership or the electorate.
To prepare for this, all NHS activities are so far as possible being
parcelled into commodity units, suited to profitable provision by traders
in public service. But how far is possible, without impeding effective
and efficient care? Conservative governments tried and failed to create
market competition between hospitals and between GPs. New Labour tries
and will fail to get private investors to build new hospitals and develop
new primary care where there is greatest need for improved care, not where
these investments would be most profitable. As with other privatised
national services, investors will make the profits (mainly by reducing the
number, pay and security of staff), while the NHS and its patients keep
the risks.
Things would be easier if New Labour could proceed directly to North
American solutions. If the NHS didn’t have to provide the most difficult
services for the most difficult people, but just let them pile up in
hospital Emergency Rooms, we could concentrate on high quality care for
easy people, and heroic salvage for the rest. But in the UK, according to
opinion polls, a substantial majority even of conservative voters
continues to believe in a socialised NHS, based on neighbourhoods and
devils they know, not on shopping around between competing providers.(4)
Doctors either don’t know this, or let themselves be persuaded by the free
medical tabloids to forget it. The professional optimism of the 1970s has
gone. Sons and daughters of professors of medicine no longer grieve their
parents by “throwing their lives away” in general practice, and GPs now
curse their patients as they did in the early 1960s. They see them as
insatiable consumers, not potential partners in production of health gain.
Successive governments have imposed a new consensus that clinical
production must follow an industrial model, enforced by tight management.
This violates the continuity, solidarity, and locality that made for
satisfying work in the past, and promotes mistrust. Like patients, a
large majority of doctors remain loyal to the original principles of the
NHS, but also like patients, their hopes diminish that these principles
will be upheld by any political party in office. On this hopelessness
industrialisers and commercialisers depend.(5)
Richard Smith rightly describes as bogus the assumed contract between
doctors as providers and patients as consumers. Instead he proposes an
honest contract between doctors and patients as equally valuable and
essential co-producers. This needs to be spelled out as a material
foundation for post-industrial production of socially useful value,
beyond, outside, and eventually alternative either to commodity trading
for profit, or to the old authoritarian pattern of State paternalism.(6)
Clinical medicine is effective, and more so than ever before.(7) Its
efficient delivery depends on continuity, social solidarity, and locality,
all of which impede and confuse trade in care as a commodity, but meet
profound human needs. This is something health professionals could
understand very much better than career politicians, if only we were
prepared to take a few infant steps toward critical social and economic
literacy. Over the past 50 years, first the Lancet, then the BMJ, have
developed into an increasingly effective dissident press, able to see that
the New Emperors have no clothes, and daring to say so. To restore
professional morale, we need a much clearer, bolder, and more independent
perspective, recognising that we can gain the initiative whenever we dare
to accept it. In the early 20th century doctors got themselves a special
relationship with rulers. In 1990 they lost it. This loss made possible
a more dignified and rational alternative, a working alliance with
patients, both able to see that in a society whose decks are awash with
wealth, we can easily afford an NHS to be proud of. We already have the
beginnings of this alliance in the ordinary processes of continuing
anticipatory clinical medicine: all we need is to recognise our friends.
References
(1)Jowell R, Curtice J, Park A, Brook L, Thomson K, Bryson C (eds).
British Social Attitudes: the 14th Report: the end of Conservative values?
Aldershot: Ashgate Publishing/SCPR, 1997.
(2)Smith R. Global competition in health care. British Medical Journal
1996;313:764-5.
(3)Price D, Pollock AM, Shaoul J. How the World Trade Organisation is
shaping domestic policies in health care. Lancet 1999;354:1889-92.
(4)Guardian supplements 20/21.3.01.
(5)Bosanquet N, Pollard S. Ready for Treatment: popular expectations and
the future of health care. London: Social Market Foundation, 1997, pp.98-
103.
(6)Hart JT. Two paths for medical practice. Lancet 1992;340:772-5.
(7)Bunker J. Commentary: The role of medical care in contributing to
health improvements within societies. International Journal of
Epidemiology in press 2001.
Competing interests: No competing interests
Coming from a family chock-full of medicalists,I found myself graduating from medical school without ever having really given much thought to whether I really wanted to be a doctor.
What I enjoyed was the intellectual challenge of diagnosis and investigation,eliciting clinical signs and winning prizes;getting my Royal College Membership was always my goal to prove myself and be accepted as an equal by the rest of the family.
I now find myself a Registrar in a London teaching hospital and I am increasingly unhappy.
I have too few weekends to spend with my loved ones and feel like work rules all my waking hours.Even though I enjoy actual clinical work,I detest wholeheartedly the non-clinical and management meetings I have to attend and having to do other people's work(social workers in particular)because the system only moves when one makes an almighty fuss.
My partner has already noticed a change in me and I fear my relationship is suffering and I am on the verge of a clinical depression.I see no way out but to leave medicine but have no idea what I would like to retrain as.
Competing interests: No competing interests
My intermittent unhappiness is grounded in my inability to come to
terms with the fact that I make mistakes, a condition unfortunately shared
by my patients, my administrators, and my family.
Competing interests: No competing interests
Things really must get better:
Six years down the track, hoping to scrape over the final(s) hurdles
without toppling them, shouldn't I be full of enthusiasm and optimism for
the imminent opportunity to practise what I've learned? Though I do relish
the prospect of meaningful clinical work and a little responsibility, my
ardour is tempered by a distinct pessimism for a future in Britain.
Having previously been idealistic, private practice was no option.
However, more and more of my colleagues are considering this aspect in
future career aspirations and choice of speciality. Lack of flexibility in
the modern NHS training schemes invites early concern over such matters.
The few alternate routes to and intense competition for Calman training
numbers imposes mental restrictions on thoughts of work abroad or even
time out. What remains? Do I 'keep my head down', gain the relevant
membership and exit exams only to end up a cynical middle aged man, tired
of paperwork but having engaged in sufficient private work to allow kids
to escape the hit and miss state education and fund their mobile phone and
designer clothing habits)? Without these dubious perks, many seem unable
to bear the torment and frustration of underfunded, beaurocratic NHS work.
The only viable alternative, then, is to leave this green and
pleasant land. There are necessary fall backs, though. One would be
foolish not to register first - there may be a civil war in the chosen
destination (that would, at least, be exciting). Even in possession of a
GMC number, there is a certain pressure to gain some postgraduate
qualification, just in case one feels it necessary to re-enter the career
ladder at a later date. Little by little, we are coaxed (forced?) to stay
and fulfill our obligation to the tax-payer for fear of permanent exile.
Will the imminent election bring forth rays of hope (as many felt in
1997)? Probably not. Will more people feel compelled to leave the NHS - or
medicine altogether? Probably. Fortune favours the brave, but are any of
we twenty-somethings brave enough to risk 40 years in the NHS?
Mr. Blair, our obligation to the nation that funded our training can
only stretch so far. How many more obligations must be broken before
things do get better?
Robert Adam
Final Year Medical Student
Royal Free & University College Medical School
Competing interests: No competing interests
It's sad to read some of the judgemental responses above-- righteous and lacking in compassion--by some physicians towards fellow physicians, who are unhappy, e.g. If you're unhappy, you must be a lousy doctor, a whiner, bored... get out! Etc.
The lack of compassion so many physicans show towards one another, the competitiveness and paranoia many docs feel towards one another, is part of the reason many doctors are unhappy. I've facilitated weekly or bi-weekly physician support groups in New Hampshire for 18 years and worked with 8 such groups over that time. One physician participant commented that when he came into medicine, he expected no support from fellow physicians, as he saw them as being aloof and cynical-- consequently he wasn't proud to be a physician and kept his distance. Since his support group experience, he had come to appreciate fellow physicians as being compassionate and sensitive, now felt more pride and security in his role, and enjoyed most of his colleagues.
I've had 3 articles published on these groups--their structure, the challenges and opportunities, results, positive and negative. I'd be happy to e-mail the most recently published article to anyone interested. The article could be used as an interest generator for fellow physicians in begining a physician support group, as well as a motivator for an experienced group facilitator to work with such a group.
Though the title given to these groups is "support group", that's a superficial title, since it could imply that it is for impaired physicians needing support. In fact it is for the normally stressed physician, coping with normal family issues, issues with difficult colleagues and difficult patients, and trying to cope with a sick and impersonal medical system. The groups provide profound emotional/spiritual support, but additionally could be called consciousness raising groups, an interpersonal skills group, a physician empowerment group, etc. It isn't group therapy, but a successful group is very therapeutic.
Competing interests: No competing interests
Dear Sir
Dr Smith in his editorial claims that doctors are unhappy. He does
not offer any significant evidence to support this. He then tries to work
out why they are unhappy? It would seem unlikely that such an endeavour
could prove fruitful given the lack of time spent on defining the research
question or hypotheses.
Is there any evidence that doctors are more unhappy than they were?
If so, when did this slide start? If there is evidence that they are more
unhappy, are they are more unhappy than other public sector workers? Is
the level of unhappiness global or is it different for different
specialities, different age groups and different sexes? Is there any
evidence that the levels of unhappiness are associated with policy
changes, pay changes, media events or more global societal changes? Are
todays doctors really grappling with different sets of challenges than
their predecessors or has society, medical science and medical teaching
always been in a state of flux that pushes doctors to the limits? Is
there realy any significant difference in the challenge or is the
difference in the expectations of doctors?
Surely these are the types of questions we need to ask and answer
with research before we start hypothesising about causal links and what
needs to be done about it all?
A quantitative paradigm is implied from the above but qualitative
methodology may be initially more appropriate.
Of course, there are lots of ways of doing it, but the central point
remains. We forget basic scientific principles at our peril. Politicians
used to take a few soundings and call it a policy. They were rightly
criticised for this. The scientific method aims to improve on this. An
opinion piece is what I expect to read in the News Review, or perhaps in
Education and Debate but not really what I expect to read as an editorial
in a scientific journal. Am I the only one?
Competing interests: No competing interests
I cannot, with hand on heart, claim that I am over-worked and under-
paid. Of course I would welcome the opportunity to treat less patients
better and to earn the sort of salaries lawyers/company directors etc.
attract. My unhappiness stems from the declining influence I have over my
own practice and what goes on in my workplace and in my speciality.
Successive governments from the Thatcher era onwards have perversely
concluded that under-mining consultants and reducing their influence will
lead to a better NHS. They are overtly anti-doctor. However, they have
never had the courage to similarly control the legal profession and have
allowed it to profit handsomely by generating and sustaining the view that
incompetence in the NHS is rife. They have a vested interest in doing so
and have bled dry the legal aid budget along the way.
I still enjoy contact with the patients but I spend a lot of time
thinking about early retirement. I constantly re-calculate my pension
expectations seeking to determine that time when my pension might sustain
my future modest needs so that I can then get out of the NHS. I am just 54
years of age and had hoped to practise for a good few years yet. But,
whenever it might be, I know that in retirement I cannot escape for,
sooner or later, I will become a 'client/customer' (rather than a patient)
of this over-managed, bureaucratic NHS when - God help me - I might be
treated by doctors who are as demoralised as I am.
Competing interests: No competing interests
Richard Smith's editorial is extremely welcome as it highlights some
of the reasons why doctors are unhappy [1] and propells it to public
attention. While I agree with his comments I feel that he has not probed
deeply enough into some of these reasons and has also missed some key
issues, i.e. stress and violence in the workplace.
The average number of violent incidents per month per NHS trust is 13
and considering that there is underreporting of these incidents, this
number is likely to significantly underestimate the problem [2]. As a
result of such incidents the NHS zero tolerance has been launched [3].
This potential threat of violence in the work place together with issues
raised by Mr Smith result in substantial levels of sickness absence and
stress [4]. 57% of those questioned in one survey stated that they had
been victims of violent incidents [5] and a large proportion of health
care professionals who are assaulted subsequently suffer from post
traumatic stress [6].
Consequently to help tackle the reasons why doctors are unhappy, an
excellent starting point would be to provide safe working environments and
outlets to help staff cope with and reduce stress.
[1] Smith R. Why are doctors so unhappy? BMJ 2001;322:1073-4.
[2] Working together, Securing a Quality Workforce for the NHS: Managing
Violence, Accidents ans Sickness Absence in the NHS. HSC 1999/229.
[3] NHS zero tolerance zone. www.nhs.uk/zerotolerance
[4] Stress in Accident and Emergency Medicine 1999. British Association
for Accident and Emergency Medicine, BSC Print Ltd, London 1999.
[5] Fernandes C, Bouthillette F, Raboud J, et al. Violence in the
emergency department; a survey of health care workers. Can Med Assoc J
1999;161(10):1245-8.
[6] Rippon T. Aggression and violence in health care professions
[Experience Before And Throughout The Nursing Career]. J Adv Nurs
2000;31(2):452-60.
Competing interests: No competing interests
'Seething Discontent'
Sir,
I retired from clinical practice a few weeks ago at 65. It depresses
me that there is so much unhappiness in a professional body famed for
being caring and hardworking. I believe this to have been brought about by
politicisation of medicine. We should remember catastrophic damage done to
the teaching profession similarly from which it has never fully
recovered.
I recall strangely applicable words from a member of parliament to a
former minister of education:
'You stand accused of reducing a noble profession to a state of seething
discontent'
Those words have a familiar ring.
Andrew Gunn, FRCSE.
Competing interests: No competing interests