GP Wellbeing

Combatting Burnout in General Practice

Adam Staten, Euan Lawson

• Publisher: CRC Press
• Year: 2017
• Print ISBN: 9781138066342
• eBook ISBN: 9781351658898
• Edition: 1
• Topic: Medicina
• Subtopic: Medicina interna y diagnóstico

This is the first book to explore the impact of 'burnout' on the current NHS GP workforce and how this can be addressed, from an insider GP perspective. Adam Staten, recently qualified GP, and Euan Lawson, Fellow of the RCGP with over 20 years experience, discuss in engaging, accessible chapters how burnout manifests psychologically, the complex reasons why GPs burn out and the individual and broader impact this can have.

Most importantly, the book offers practical advice on how to avoid burning out and combatthe negative effects of an increasingly high-pressure role, exploring how GPs can develop resilience and work in a way that builds a healthier work-life balance. A section is dedicated to the array of GP job options, with testimonies from practitioners working in diverse areas from education and academia to military and humanitarian settings.

This book explores the challenges of working in general practice today, but it also demonstrates the potential for every GP to experience a personally and professionally satisfying career. Providing practical, workable advice and links to resources for help and support, the book enables readers to find opportunity within the perceived 'crisis'. By reading this book, you will find the means to improve not just your own working life but also to enhance the way you deliver care to your patients.

1

What is burnout?

DR. ADAM STATEN

The Red House Surgery, Bletchley, UK

Burnout is more than feeling stressed. Burnout is a pervasive and debilitating state that results from an unsustainable period of overwhelming stress. It is not a new phenomenon. The term was coined by the psychologist Herbert Freudenberger in 1974 who recognised the condition in himself and colleagues whilst working in drug addiction clinics in New York.¹ Nor is burnout limited to those working in health care.² It is a familiar concept in many areas of life from the financial services sector to professional sports.

Increasingly, burnout is recognised as a widespread issue in modern life, and this pervasiveness is reflected by the deluge of new research that is being conducted on burnout, not to mention the abundance of self-help literature that is published every year to assist people in coping with stress and burnout, whatever the cause. Burnout seems to be especially common amongst those in caring professions such as health care, social work and teaching, with a prevalence of up to 25% in these professions suggested by some research.³

In particular, burnout amongst general practitioners (GPs) working within the National Health Service (NHS) seems to be on the rise, and this is causing problems not just for the individuals concerned, but for a health care system that is reliant on having a healthy, happy and functional primary care workforce. Thus, it is essential that we as individuals, and the system as a whole, understand what burnout is, what impact it has and how it can be stopped.

KEY FEATURES OF BURNOUT

Burnout is classically defined as an experience of physical, emotional and mental exhaustion caused by long-term involvement with situations that are emotionally demanding.³ It comprises three major components: emotional exhaustion, depersonalisation and an absent sense of personal accomplishment.⁴ These three major components were incorporated into a scoring system, the Maslach Burnout Inventory, which has been used to evaluate and study burnout in a variety of settings, and in a variety of guises, since its creation in 1981.⁵

Maslach and colleagues defined each of these three components. Emotional exhaustion is described as the feeling of being emotionally overextended and exhausted by one’s work. Exhaustion is seen by many as the key component of the burnout syndrome, and some researchers have developed alternative scoring systems to reflect this.^{6, 7} Exhaustion has a pervasive effect on the ability of a doctor to carry out his or her work safely and effectively. In addition, a sense of exhaustion carries over into the personal life of a burnout sufferer, affecting relationships and the ability to have a happy and fulfilling life outside of work.

The second major component, depersonalisation, is described as an unfeeling, un-empathetic and impersonal response to the interaction with patients. In effect the burnout sufferer dehumanises the person with whom they are interacting, and this leads to cold, callous behaviour and cynicism. The result is unsatisfying patient–doctor interactions, both for the doctor and the patient, which contribute to a diminished sense of personal accomplishment for the doctor, carry the potential for further stress in the form of complaints against the doctor, and result in poor health care provision for the patient.

Personal accomplishment relates to a sense of competence or achievement in one’s work which results in job satisfaction or, if absent, dissatisfaction. This absence is the third major component of burnout. A poor sense of personal accomplishment has been found to be the leading feature of burnout amongst some groups of medical professionals such as physicians working in pain management in the United States.⁸

The Maslach Burnout Inventory uses a questionnaire from which a score can be given to each of these three features to identify those who are suffering from burnout and those who are at risk of burnout. This sterile, statistical way of considering a human problem is particularly useful for research, but the real-life interaction between these three components varies considerably, resulting in different degrees of distress and debilitation for sufferers.

Whilst the scope of this book is to consider the causes of burnout amongst medical professionals and specifically amongst the general practice population of the NHS, there are a number of general factors that contribute to occupational burnout in all workplaces.

In general, people are at high risk of occupational burnout when they do not feel in control of their work. It is not necessarily workload or the need to make decisions that causes stress, rather it is the lack of authority to make those decisions, otherwise known as a lack of decision latitude, which results in an inability to deal effectively with the workload, leading to unsustainable workplace stress and burnout.⁹ Related to this lack of control is dysfunctional workplace dynamics, which may include workplace bullying and an unclear or ill-defined job role.

Burnout can be the product of work that is monotonous or work that is chaotic, or work that combines elements of these two apparently conflicting features.⁴ Work within health care is often capable of combing these two elements, with mundane routine work frequently interspersed with complex, important and emotionally demanding tasks; perhaps this is why those working within health care find themselves at such high risk of burnout.

Low income can be a factor in the burnout, as demonstrated in a study of burnout among paediatric nurses.¹⁰ A poor work–life balance is another contributing factor to burnout, a common imbalance that is not limited to health care professionals.²

Certain personality traits, such as perfectionism, competitiveness and the need to feel in control, along with habitual high achievement, put people at higher risk of burnout. These traits are common amongst medical professionals, and in fact are often selected for in those applying to medical school.

These general factors, and a host of other factors that are specific to the role of an NHS GP, can combine to create burnout which may manifest itself in a multitude of ways.

IMPACT ON THE INDIVIDUAL

As with other mental health problems, burnout can cause a wide range of psychological and physical effects. Many of these problems are also features of anxiety and depression, conditions with which burnout has an enormous degree of overlap.

Burnout has often been described as occurring in three stages, each of which may have both psychological and physical symptoms.¹¹ The first of these stages is known as stress arousal. This first stage is typified by difficulty concentrating, memory lapses, irritability and anxiety. Physical symptoms, like those associated with anxiety disorders, include teeth grinding, palpitations, headaches, poor sleep and loss of libido.

The second stage is the period of energy conservation during which time someone beginning to suffer with burnout will attempt to compensate for the stress they are experiencing. It is at this point that an individual’s usual mechanisms for coping with stress may become overwhelmed, and so they begin to compensate in maladaptive ways. This results in avoidance behaviours including lateness, procrastination, social withdrawal and increased time off work. Avoidance behaviours can also manifest as difficulties in making decisions and problem solving which bring with them a predictable deterioration in occupational functioning. It is during this period that exhaustion can set in and psychological problems increase which may lead to self-medication and substance misuse.

The final stage is exhaustion. At this point, chronic mental health problems with anxiety and depression, including suicidality, may develop. Those experiencing this degree of burnout may increasingly rely on substance misuse as a coping strategy, so addiction may be a concomitant problem. Feelings of apathy are common and decision-making is poor, leading to poor patient care and, possibly, unethical behaviour.¹² Somatic symptoms which may also be present include non-cardiac chest pain, dizziness and chronic headaches.

It is important to recognise the features that may be present in each stage of this progression, both in ourselves and in our colleagues, but it is also important to recognise that there need not be an inexorable decline through the stages. Progression of stress and burnout can be halted and reversed if the problem is recognised and tackled (Figure 1.1).

Figure 1.1 Cycle of stress and burnout.

Unfortunately, if the problem is not recognised and is left untended, there can be long-term physical and mental health consequences. Beyond chronic depressive and anxiety states, occupational stress has been linked with an increased rate of myocardial infarction, and a poor prognosis following an ischaemic event, the metabolic syndrome, and even a postulated link with the formation of stones in the urinary tract.^13–15 Burnout is very bad for your health.

Substance misuse and addiction are also strongly associated with occupational burnout. Between 10% and 15% of US physicians ar...

Table of contents

• Title Page
• Copyright Page
• Table of Contents
• Preface
• Introduction
• 1 What is burnout?
• 2 External pressures
• 3 Pressures of the job
• 4 Changing the system
• 5 Changing the way we work
• 6 Finding the right career
• 7 Resilience
• 8 Interventions for burnout
• 9 Final thoughts
• Index