Unhappy doctors: what are the causes and what can be done?

Edwards et al correctly point out that in order to reduce unhappiness among doctors training and preparation needs to equip doctors better for the reality of the roles that they will face.

While the authors suggested this should happen earlier in doctors careers it is my contention that it should happen even earlier still - at medical school.

The reality is that students are still trained in a way that doesn't represent practice. There is a perhaps subconcious emphasis on "medicalisation", a problem addressed recently by Richard Smith and others1. Students who are trained primarily as diagnosticians can potentially find the reality of medicine a huge culture chock. Valiant efforts are being made to address these problems centrally, but clinical students often face teachers who still expect and teach older philosophies. The numbers involved make policing the educational experience of individual students techinically difficult.

Until a new generation of trainers arrive, fully supporting the development of the "new compact"2 it may be difficult to ensure that new philosphies are instilled into ever increasing numbers of students.

One potential approach is a move towards graduate entry. This theoretically will attract people who have considered more carefully the implications and realities of a career in medicine. This approach has disadvantages too of course.

I agree with the authors that more discussion and research is required, but if students and their trainers are excluded, we will not be dealing with the problem as effectively as we could - that is, surely, at it's beginning.

Jason O'Neale Roach Former editor StudentBMJ Final Year Medical Student Guy's King's and St.Thomas' Hospitals Medical School

1. Smith R. Too much medicine. BMJ 2002;324:859-60 2. Edwards et al. Unhappy doctors: what are the causes and what can be done? BMJ 2002;324:835-8

Totally agreed,

The old world was - doctor orders treatment - patient accepts.

The new world is- doctor offers advise - patient explores -accepts or rejects or chooses alternative

Responsibility in the first instance lies with the doctor.

In the second instance clearly with the patient.

I am sure that the majority of doctors are happy with the second situation, provided there are no comebacks.

Unfortunately, medical practice today in the UK means that the patient has all the rights to make the decision, but if anything goes wrong (as it inevitably will in the imperfect science that is medicine), the doctor is held responsible,

Is anything fair any longer????

Shouldn't the decision maker accept responsibility for thier actions?

Nigel Edwards and his colleagues' article takes an interesting but rather depressing view of the issue of doctor unhappiness. I felt distinctly less happy after reading this than I did before it!

The conclusions reached seem to be that the issue could be satisfactorily addressed by asking doctors to work within guidelines, be accountable for management-set objectives, contribute towards the setting of these guidelines and objectives, work within resource constraints and work in teams rather than alone. To support this great plan doctors should be given time off dealing with patients ("the hamster wheel") to engage in, and train in, these management activities.

I don't think you make slaves in the galley any happier by giving them the opportunities to manufacture their own oars and chains to national standards by following oar and chain manufacture guidelines!

The essay by Antonia Felix in this week's BMA News gives other clues to the problem and potential solutions. She makes it very clear why she became a doctor - "I want to help people" and she gives a couple of examples where she felt personally rewarded by being able to do this. The examples themselves are interesting. They are not about producing "cures", or delivering objectives or guidelines - they are examples of care.

The Guardian has also been asking for comments about the NHS this week - see www.guardian.co.uk/publicvoices. Read some of the comments from the doctors who have contributed. They are unhappy because they lack the time they know is necessary to spend with their patients, because they are faced with so-called solutions to the problems of the NHS which are based on "managerialism" and because their training and job structures fail to enable them to be effective in relieving the suffering of chronic disease.

Here are the clues. The answers are unlikely to lie in different management, in guidelines and greater accountability. The answers might lie in creating the structures and training to let doctors do what they became doctors to do - care for people.

Ask any of your doctor colleagues when they feel happiest in their jobs and they are likely to tell you that it is when a patient improves after their treatment - when a patient recovers from their acute event, or comes back to outpatients saying they feel much better and more able to cope with their lives - these are the experiences which bring doctors happiness.

The clues are in the Edwards article but seem to get lost - "At present the problem is that there is often not the time to have the conversation about expectations or to develop the relationship to use time in consultations most productively". Better guidelines, targets, objectives, training in management and being freed up from seeing patients to work in administration is not likely to deliver and answer to that problem.

Yes, public attitudes have changed too, but the problem is not that they now lack a deferential attitude, the problem is that they are no longer prepared to take a merely passive role in decisions and actions about their care and their lives. This is a very healthy development but doctors will need to be given the time and resources to develop these healthy partnerships if the NHS is to address this cultural change.

Sir,

I read this article with interest, and particularly noted the idea of a "compact" between doctors, patients and the state. To set up a compact it is necessary to have some role specifications and at present these are at best vague in primary care.

About 30 years ago general practice was exclusively concerned with reacting to symptoms and making a diagnosis from these. Indeed at present patients still tend to get very worried about URTI, gastro-enteritis, rashes, ear ache, febrile children and abdo pain. Usually these symptoms are due to minor self limiting diseases and indeed doctors are doing more work treating distress about the symptoms than they are in treating the illnesses themselves!

Indeed doctors often complain that their surgeries are of this kind of "trivial" illness. The danger in filling our surgeries with this stuff is that we miss the seriously ill patients as we are distracted by too many patients worrying needlessly. One current political demand is for 48 hour access but I suspect this will simply fill our surgeries with more of this kind of minor illness.

Alongside this traditional reactive work there has been a developing drive towards proactive care of specific diseases. Politically this is represented by NSFs. Historically it develops on from the idea of "upstream intervention" in the river of disease model. Basically this model sees acute problems as needless complications of undertreated risk factors. If someone is overweight, hypertensive and smoking why wait for the myocardial infarction before you do anything about it?

The difficulty in this kind of approach is getting patients interested in it. What worries patients is not really what they should be worried about. Few are very bothered about their obesity, their excess alcohol or other harmful behaviours. Even fewer of those who are bothered can be bothered enough to do anything about it.

In the new compact we need to decide if general practice is to continue on a reactive model responding to excess worry about minor illnesses or whether it is to throw its efforts into energetic and effective treatment of the current real threats to health of people in this country.

Until this conflict is resolved it is difficult for general practitioners to know what they should be aiming to achieve in their consultations. If we do not know what to aim for we can have no idea what we have achieved, if anything. If we cannot appreciate our achievements we will become demoralised and unhappy.

NSFs or 48 hour access: Whose choice is it?