THE RESULTS OF the workforce survey were disseminated at the college’s Conference for General Practice in Dunedin in July where Dr O’Hagan delivered an extraordinarily personal presentation, entitled “Outing Burnout”, in which she spoke eloquently about her own experience. At the end of her presentation, the packed audience gave her a standing ovation.
Dr O’Hagan talks about the “culture of medicine”, in which GPs shoulder increasingly heavy workloads and rarely take lunch breaks, as being partly responsible for piling on the pressure.
“It’s hard to look after yourself in the culture of medicine,” she tells New Zealand Doctor. “I think doctors take their jobs quite seriously, and that’s a good thing. They do invest a lot of themselves in it.
“But general practice is a really high-pressure job. It’s intense, there’s a sustained intensity to it, you are making quite big decisions. And the job has changed in my lifetime. A lot of easier tasks are being done by other people. The GP is dealing with very complex, difficult problems, without any respite.”
Sometimes, the patients themselves can be part of the problem.
Christchurch GP Jeremy Baker also spoke at the Dunedin conference, explaining the theory of “trauma in consult”, when doctors can be harmed by constant exposure to demanding patients who can drain the energy from GPs who immerse themselves too fully in their work.
“I’m putting my money on the fact that a lot of what we face is [from] dealing with those instances right in the 15-minute consultation,” Dr Baker says. “I think more than budgets, more than PHO negotiations… it’s the patient in front of us that may grind us down. They’re usually someone who consciously or unconsciously sucks the energy out of the room, and we’re like fish gasping on the floor.
“If you face too many of these in a week, you’re going to be drained and find yourself in a black hole.”
Dr Baker, who has worked extensively in mental health, says it’s important to pause and take stock in consultations, and to rise above some situations involving demanding or manipulative patients, who may be in a kind of psychological duel with the GP.
Dr O’Hagan vividly describes the constant, overwhelming demands posed by a full practice, where the GP doesn’t have time to go to the toilet, or eat lunch and gets “hangry at the nurses”.
She also echoes Dr Medlicott’s views on the stresses of running a business where funding is a constant source of pressure.
“The way that we are funded hasn’t changed, so we still have to do the same level of productivity, seeing people in 15 minutes to make the income,” she says. “People are driven by income to a certain extent. The whole way we are funded and use funding needs to change.”
BUT THERE ARE other, more subconscious, pressures weighing heavily on the shoulders of the stressed GP.
In her presentation Dr O’Hagan wrote: “Have you too got the professor of surgery in your head? A whakapapa of medical deans who scrutinise you, remind you, with their volume of cautionary tales, how you might get it wrong?”
She goes on: “They will keep you safe, but the cost of inviting them into your head will be your own self. And when you fall off the edge, the peers in your head will desert you, judge you, patronise you…”
Dr Scott-Jones recognises that self-imposed pressure and the weight of expectation from his own training in the UK. “Right from the beginning we were told we were the top 2 per cent of intellects in the country.” He says the process of constant assessment measuring a doctor’s worth “is really destructive for a lot of people”.
Dr O’Hagan says part of the motivation for giving her presentation was to aid her own recovery, “being able to stand up and talk about it without shame or failure”. She uses the word “shame” frequently, and it’s something she believes needs to be confronted.
“I believe in the power of testimony,” she says. “I think most doctors would recognise what I am talking about. The culture of medical education we went through – education by humiliation – if you don’t know the answer, that is shameful. I don’t think we can solve the burnout problem until we challenge the culture of medicine.
“The force of shame is very powerful in doctors. Doctors who burned out are talked about in whispered tones. They disappear for a while.”
She describes, after her burnout, having to tick the box in her online application to renew her GP practising certificate. In it there is a question about whether the doctor has been affected by a mental or physical condition that has the capacity to affect their ability to practise. A “Yes” sends it straight to the Medical Council’s health committee, she writes.
“I pressed ‘Yes’ and wept. ’Yes’ was shame. You see, the burnout was bad, but the shame was crippling. Shame is worse than failure.”
Writing in the RNZCGP’s self-care document, Medical Council chair Andrew Connolly acknowledges this anxiety, but says the outcomes can ultimately be positive.
“Despite their initial reactions to involvement with the committee, which are often of fear or anger,” Mr Connolly writes, “many doctors express gratitude for the help they have received when they reach the point of being no longer under its supervision. And some choose to stay under its supervision, albeit at arm’s length, as a form of safety net.”
But Dr Scott-Jones agrees with Dr O’Hagan about the taint of shame attached to burnout. “The idea of shame does resonate,” he says. “Talking about burnout among colleagues can be a really difficult thing to do. When I talk to colleagues about what I went through, some are great, but some of them get a bit cold. I bring into these conversations a sense of failure. There’s a sense of failure and shame around that.
“I’ve been asking people subsequently, and everybody has a burnout story. Some are not open to share it, but most of us have been there.”
Dr Medlicott says he is impressed by the two GPs’ willingness to share their personal stories with New Zealand Doctor and the wider sector, saying he hopes it will help people to be more open.
“At a less public level, certainly talking with colleagues, your doctor, or counsellor about your burnout is important.”
He says doctors hold themselves to high standards, – “You feel bad when you make mistakes. Sometimes there is a stigma about making mistakes.”
But he believes it’s becoming more acceptable for people to talk about issues such as mental health, and to seek help, and he urges struggling doctors to use the resources offered by various organisations. Free counselling is available for doctors who are Medical Protection Society or Medical Assurance Society members.