General practice stress

Winds of change buffet general practitioners

MJA 1998; 169: 126-127  

The long-running television series GP,1 with its changing cast of "general practitioners" and patients, nicely portrayed the enormous range and diversity of human problems which Australians expect their general practitioners (GPs) to help them solve. The series showed GPs to be ordinary humans, affected like the rest of the community by changing social and political pressures. In recent years, Australian GPs have felt particularly buffeted by their changing roles and feelings of being undervalued in comparison with their specialist colleagues. A national survey of GPs carried out in 19952 showed that, while about two-thirds were satisfied with their current role, 35 per cent indicated that they would leave general practice if they had somewhere else to go, with urban practitioners significantly more likely than their rural colleagues to report this view. The most common sources of dissatisfaction or frustration were a belief that the contribution of GPs is not appreciated by government, apprehensiveness about the changes and reforms in general practice, a belief that government was interfering in the ability to make clinical decisions, pressure to bulk bill patients, and the introduction of "blended" payments (remuneration through a mixture of fee-for-service and non-fee-for-service payments). In this issue of the Journal, Schattner and Coman3 report on a national sample of metropolitan GPs and their perceptions of stress in their work lives. One hundred and fifty-seven of the 296 respondents (53%) had considered leaving general practice because of occupational stress, and 32 (10.8%) claimed that they had experienced severe occupational stress in the past 12 months. Major work stressors (in terms of both frequency and severity) were time pressure to see patients, paperwork in general practice, and too much work to do in a limited time -- factors the authors define as linked to the context (ie, organisation and environment) rather than the content (ie, clinical duties) of general practice. Other frequent stressors were intrusion of work on family life, earning enough money, the pressure to bulk bill, the cost of practice overheads, phone interruptions during consultations, home visits during office hours, and unrealistic community expectations of the medical profession. There were complex relationships between frequency and severity of stressors -- for example, threat of litigation was ranked lowest for frequency but highest for severity. A third of respondents recorded General Health Questionnaire scores of 4 or more, and 12.8% recorded scores of 8 or more, suggesting that significant numbers of GPs are under real psychological strain. How serious is all of this? Should we be alarmed that those who are the first port of call for sick and stressed people are themselves often feeling stressed and unhappy? Or are GPs simply reflecting the fact that we are all being pushed by the pace of change and pressure to be more efficient and effective? Either way, policymakers would be unwise to ignore these findings. We are an affluent society and can afford a system in which GPs and their patients can spend relatively unpressured time together. The clinical decisions made at the first point of contact should not be made in the context of rapid throughput and time constraint. If our system is stressing the doctors, it is almost certainly also stressing their patients. So what are the solutions? The 1998-99 federal Budget4 contains a number of new initiatives in general practice which grew out of two major strategy reviews, the reports of which have recently been released: General practice. Changing the future through partnerships,5 and General practice education: the way forward.6 The Budget papers claim that these reviews mark a "watershed for general practice, providing a vision which will guide and support the work of the profession in the coming years". They argue that the achievement of this vision will depend to a large extent on building strong partnerships based on mutual trust between general practice, the community and government. The Report of the General Practice Strategy Review Group5 contained 174 recommendations, including a number relating to indexation of the GP benefits schedule, additional funding for rural workforce initiatives, incentives to promote microeconomic reform and practice amalgamations, support for expanded use of information technology, a new Practice Incentive Program to replace the unpopular Better Practice Program, and new funds for research. Most of the Review recommendations have been taken up by the Government, as outlined in the ministerial response to the Report, released on 10 June 1998.7 A report should also be available this year on the Relative Value Study, currently being undertaken under the auspices of the Department of Health and Family Services. This study is assessing the relative value of work (beginning with patient attendances) across craft groups within the medical profession, including an assessment of the relative cost structures of those activities. There are also some signs that GP leaders are talking to each other and that there is some mutual give-and-take by them with government. That, itself, is a healthy sign. Whether stress, dissatisfaction, and psychological strain for GPs working in their consulting rooms will diminish as a result of these and the many other changes on the horizon remains to be seen. Robert M Douglas Director Beverly M Sibthorpe Fellow, National Centre for Epidemiology and Population Health The Australian National University, Canberra, ACT GP [television series]. ABC Sydney: screened 1989 and 1994. Bailie R, Sibthorpe B, Douglas B, et al. Mixed feelings: satisfaction and disillusionment among Australian general practitioners. National Centre for Epidemiology and Population Health discussion paper number 12. ANU, Canberra: NCEPH, 1997. Schattner PL, Coman GJ. The stress of metropolitan general practice. Med J Aust 1998; 169: 133-137. Budget 1998-99 fact sheets. No. 4. Canberra: Department of Health and Family Services, 1998. General practice. Changing the future through partnerships. Report of the general practice strategy review group. Canberra: Commonwealth Department of Health and Family Services, 1998. General practice education: the way forward. Report of the ministerial review of general practice training. Canberra: Commonwealth Department of Health and Family Services, 1998. The Government's response to the reviews of general practice: general practice -- foundations for the future. Canberra: Commonwealth Department of Health and Family Services, 1998.