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GP Health

Australian general practitioners: desperately seeking satisfaction

Is the satisfied GP an oxymoron?

MJA 2001; 175: 85-86

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General practice can be soul-destroying. Over half the general practitioners in a 1996 Australian survey considered abandoning general practice because of occupational stress, and 13% had symptoms of severe psychiatric disturbance.1 In an article by McGlone and Chenoweth in this issue of the Journal, nearly one in four Victorian GPs reported dissatisfaction with their work, while a similar proportion reported a neutral position.2 On the international scene, GPs are no happier. Those in the United Kingdom shut their surgeries in May this year to protest against working conditions imposed by the government.3 In the same month, GPs in the Netherlands went on strike for three days over insufficient government funding of general practice.4 A British survey showed that more than one in four GPs had borderline or likely depression and were more likely than hospital consultants to exhibit suicidal thinking.5

Why should this be? Contrary to popular belief, it is not so much the clinical aspects of general practice that appear to be the main stressors (although some cases can exact their toll), but rather the interplay of organisational issues such as time pressures, phone interruptions, paperwork, fear of litigation, financial pressures, and low job control.1,2,6 Many doctors also appear to have personality traits (such as being highly self-critical) which predispose them to stress symptoms.7

Solutions

 Large-scale reform is clearly needed. Such reform should include greater consultation with GPs on issues impinging on their professional autonomy, from healthcare policy to workforce and training to remuneration. As the various general practice advocates play out their responses to the Relative Value Study8 or call for alternatives to fee-for-service, it is clear that greater financial remuneration is a major issue.

Practical strategies to improve the plight of GPs also have to be implemented as early as possible in the GP lifecycle, from the stage of medical student, to vocational trainee, and to practising GP ( Box).

Despite the policies and activities outlined in the Box, there is a dearth of research evaluating which strategies work to reduce GP stress. A search of the database listing projects funded by the General Practice Evaluation Program showed that only four out of 248 projects listed from 1990 to 2001 dealt with GPs' health, mainly concentrating on assessment of job stress and health needs (V Sellick, Information and Website Manager, National Information Service, Department of General Practice, Flinders University, personal communication).


How can individual GPs improve job satisfaction?

By professional upskilling and practice management: Much has been written on how to address the most frequent job stressors, and evidence exists to support some strategies. For instance, as dissatisfied GPs identify having more "heartsink" patients, acquiring the skills to deal with "difficult" patients can be useful.13 Practising patient-centred care (which includes recognising when patients' psychosocial problems are relevant and dealing with them) is more satisfying, but also more stressful unless strategies such as longer patient booking intervals are employed.14 Hospital outpatient staff who participated in decision-making through more frequent staff meetings reported higher job satisfaction.15 Practice staff meetings may well benefit GPs, particularly in ironing out organisational problems and providing support.

By upsizing: Many have looked to share the administrative, financial and clinical load by joining group practices or by corporatising.

By downsizing: GPs working at least six sessions per week have been to shown to be more highly stressed,1 so part-time practice and job sharing may well be the solution for some. The anecdotal evidence is that this works particularly well for women, who are more likely to be juggling professional and personal roles.

By sidestepping: Again, anecdotes abound on the success of combining clinical practice with other professional activities such as teaching, writing, and even medical editing (as one of us [M C] has done!).

By self-nurturing: Self-care is vital given the inverse relationship between job satisfaction and job stressors,6 and the fact that problems with work and with close relationships are associated with poorer physical, psychological and social functioning.16 This includes healthy eating, exercise, adequate rest, spending time with family and friends, and pursuing non-medical interests. It includes acquiring a regular source of care (such as having a regular GP), and peer support (such as a support group). It may also include active stress management, and data from a systematic review suggest that relaxation and cognitive-behavioural techniques are the most effective at alleviating job stress.17 All GPs should also be aware of services such as the Doctors' Health Advisory Service.

Yes, general practice can be soul-destroying. But there is also great privilege and satisfaction to be had in our partnerships with our patients. Changing the culture for GPs to progress beyond dissatisfaction or mere survival to greater job satisfaction is vital. There are signs that these changes are evolving in the policies and practices of professional institutions. However, strategies for change have to encompass grappling with our professional and personal lives. And remembering the ultimate words on keeping perspective in practice — no one ever died wishing they'd spent more time at the office.

Mabel Chew
 Deputy Editor

Alison Williams
 Kincaid-Smith Editorial Fellow
The Medical Journal of Australia

  1. Schattner PL, Coman GJ. The stress of metropolitan general practice. Med J Aust 1998; 169: 133-137.
  2. McGlone SJ, Chenoweth IG. Job demands and control as predictors of job satisfaction in general practice. Med J Aust 2001; 175: 88-91.
  3. Kmietowicz Z. GPs shut surgeries in protest at government targets. BMJ 2001; 322: 1082.
  4. bmj.com news roundup. Dutch GPs take three day strike action. BMJ 2001; 322: 1142.
  5. Caplan RP. Stress, anxiety, and depression in hospital consultants, general practitioners, and senior health service managers. BMJ 1994; 309: 1261-1263.
  6. Cooper CL, Rout U, Faragher B. Mental health, job satisfaction, and job stress among general practitioners. BMJ 1989; 298: 366-370.
  7. Firth-Cozens J. Predicting stress in general practitioners: 10 year follow up postal survey. BMJ 1997; 315: 34-35.
  8. Australian Department of Health and Aged Care, and the Australian Medical Association. Relative value study. <http://www.health.gov.au/rvs> (accessed 28 June 2001).
  9. AMA Position Statement. Health of medical practitioners. <http://domino.ama.com.au/AMAWeb/Position.nsf/> (accessed 28 June 2001).
  10. NSW Doctors' Mental Health Program. Doctors' Mental Health Policy. <http://www.dmh.org.au/dmh/policy.html> (accessed June 2001).
  11. Doctors' Health Advisory Service website <http://www.dmh.org.au/dhas/inter-state%20addresses.htm> (accessed 27 June 2001).
  12. RACGP. Content for teaching and learning. <http://www.racgp.org.au/training/curriculum/content.pdf> (accessed 28 June 2001).
  13. Mathers N, Jones N, Hannay D. Heartsink patients: a study of their general practitioners. Br J Gen Pract 1995; 45: 293-296.
  14. Howie JG, Hopton JL, et al. Attitudes to medical care, the organization of work, and stress among general practitioners. Br J Gen Pract 1992; 42: 181-185.
  15. Jackson SE. Participating in decision making as a strategy for reducing job-related strain. J Appl Psychol 1983; 68: 3-19.
  16. Stansfeld SA, Bosma H, Hemingway H, Marmot MG. Psychosocial work characteristics and social support as predictors of SF-36 health functioning: the Whitehouse II study. Psychosom Med 1998; 60: 247-55.
  17. Sims J. The evaluation of stress management strategies in general practice: an evidence-led approach. Br J Gen Pract 1997; 47: 577-582.

©MJA 2001
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→  John P Paterson. Australian Health Care Agreements 2003–2008: a new dawn? Med J Aust 2002; 177 (6): 313-315. [For Debate] <http://www.mja.com.au/public/issues/177_06_160902/pat10463_fm.html>

→  Peter R Mudge. Australian academic general practice: looking back, looking forward Med J Aust 2003; 179 (1): 8-9. [General Practice: Past] <http://www.mja.com.au/public/issues/179_01_070703/mud10262_fm.html>

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→  Kathryn S Panaretto and Mark Wenitong. The general practitioner Med J Aust 2006; 184 (10): 527-528. [Training and Workforce] <http://www.mja.com.au/public/issues/184_10_150506/pan10333_fm.html>

→  Catherine M Joyce and John J McNeil. Fewer medical graduates are choosing general practice: a comparison of four cohorts, 1980–1995 Med J Aust 2006; 185 (2): 102-104. [Workforce] <http://www.mja.com.au/public/issues/185_02_170706/joy10152_fm.html>

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Current policies and practices supporting self-care for general practitioners

  • Professional bodies such as the Australian Medical Association9 and the Doctors' Mental Health Working Group in New South Wales10 have outlined position statements and strategies which emphasise the need for educational, training and clinical institutions to promote mental health and self-care as essential to students and doctors; to promote early recognition of mental health problems, early intervention, and confidential treatment and rehabilitation where needed; and to provide working conditions more conducive to wellbeing, such as reasonable working hours, adequate leave, flexible career pathways and mentor programs.

  • The Doctors' Health Advisory Service in each State and Territory (offering independent, confidential medical help to doctors and medical students during personal crises) is advertised in the medical media, and contact details are available on the Internet.11

  • University medical curricula include core objectives throughout the course which deal with the stresses of clinical practice and self-care as students and doctors; these themes are also the focus of specific teaching and learning activities.

  • The Royal Australian College of General Practitioners (RACGP) Training Program — until recently, the body responsible for vocational training in general practice — has a curriculum which has a self-care component12 and, in NSW, conducts interactive sessions on self-care in two compulsory workshops for registrars (Dr Hilton Koppe, Medical Educator, RACGP Training Program, personal communication).

  • The RACGP Quality Assurance and Clinical Education (QA & CE) Program for GPs records 40 activities (out of a total 6 948) related to GP self-care for the 1999 to 2001 triennium (Maree Morgan, Activities Coordinator, QA & CE Program, RACGP, personal communication).

  • The National Information Service Activities of Divisions Database (for which 66 out of 123 Divisions of General Practice submitted plans from July 2000 to June 2001) shows that 42 Divisions reported having activities or programs which specifically addressed GP wellbeing (V Sellick, Information and Website Manager, National Information Service, Department of General Practice, Flinders University, personal communication).
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