Stress snapshot

How are GPs coping? Helen Signy finds out.

WINTER 2009: surgeries are flooded with patients thinking they have swine flu, the global financial crisis is making practice management more challenging, and the Government’s plans for primary care are leaving GPs feeling uncertain and undervalued.

If you’re feeling more stressed than ever, you’re not alone. The MO Stress Test, an exclusive Medical Observer survey of nearly 500 GPs conducted by Julie Dang & Associates, found more than 50% reported worrying stress levels, with 4% saying their stress was unmanageable.

And things are getting worse. Three in five respondents rep­orted higher stress levels now than two years ago, with most saying the increase had been significant.

Little wonder, says BEACH director Associate Professor Helena Britt. The number of GP consultations has been steadily climbing for five years, and in 2008-09 reached 109.5 million – up from 102.8 million two years ago.

“We are trying to diagnose disease earlier, offer preventive care and treat increasing levels of chronic disease, all under virtually the same structures we have always had,” she says.

“If we want to continue the trend that’s going on now, then we have to think of restructuring the system somehow.”

GPs’ increasing workload isn’t the only reason they are reporting more stress, the survey shows.

Twenty-four per cent of respondents laid the blame on bureaucracy and red tape, 20% on worry about legal issues such as litigation, and 18% on concerns about providing the best quality care within time constraints and a changing environment.

Across the board, GPs reported that stress was having a significant impact on their physical and emotional health. Seventy-three per cent said stress was affecting them physically, and 83% said they were suffering emotionally. Two-thirds knew a colleague at risk of burnout.

DOWNWARD SPIRAL

Meredith McVey, a social worker and executive secretary of the Medical Benevolent Association of NSW, has seen numerous cases of how stress can ultimately lead to a devastating downward spiral.

Physical symptoms, such as high blood pressure and diabetes, and emotional ones like depression, anxiety and substance abuse, can prevent GPs from working.

Once they take time off, they very quickly find their problems compounded by financial stress, which in turn impacts on the family and other areas of the doctor’s life.

“We are seeing individuals becoming really, really unwell,” Ms McVey says.

“They are not taking enough time to care for themselves, to get enough exercise, to keep an eye on their finances.”

The MO Stress Test confirms this: many GPs are not living a lifestyle that enables them to deal with the stresses of the job.

Only 27% of respondents said they were following RACGP guidelines to exercise five or more times a week, with 13% not getting any regular exercise. GPs said they slept on average just under seven hours a night, with 10% sleeping less than six.

Almost 20% had not taken a break from work for the last 12 months, and just under half did not have their own GP.

This is of concern as there is worldwide evidence that stressed and unhealthy doctors are less able to provide optimal patient care, says Dr Narelle Shadbolt, immediate past president of the NSW Doctors’ Health Advisory Service.

OLDER GPs MORE AT RISK

While stress is affecting GPs across the board, some are more at risk than others. Older and more experienced survey respondents were more likely than their younger peers to report high or unmanageable stress levels – but less likely to claim any effect on their physical or emotional health.

This group was more likely to have a greater roll in managing or running a practice, and reported their key stressors as bureaucracy, financial reward, workforce shortages, the stress of running a practice, and limited career options.

By comparison, younger GPs were more worried about pressure from patient demands, balancing work and family life, and a lack of respect and recognition.

Men and women reported similar levels of stress, but women were more likely to say they were stressed by the pressure they placed on themselves to give patients the best quality of care (21% of women compared to 16% of men).

They also were more concerned about balancing work and family life (10% of women compared to 5% of men), but were more likely than men to have a healthier lifestyle and better peer support (19% of women compared to 9% of men).

Rural GPs were more likely than urban GPs to be suffering physically and emotionally, and more likely to know a colleague at risk of burnout – 83% of regional GPs and 78% of rural GPs knew of someone in this situation, compared to 62% of their urban peers.

Their stress centred around overwork, difficulty in accessing specialist care,  and workforce shortages in rural and remote areas.

While older, male GPs saw the solution to their stress in structural reform to make practice management easier and more financially rewarding, younger and female GPs were more likely to focus on personal factors for stress relief, such as lifestyle and personal wellbeing.

CUMULATIVE IMPACT

One reason older GPs are more stressed may be the cumulative impact of burnout and vicarious trauma, Ms McVey says.

“In your 30s, study is a really good preventer of burnout and vicarious trauma. Doctors at this age haven’t experienced all the nasty, nasty things that someone in their 50s has.”

But work structure also emerged as one of the central indicators of GP stress.

Doctors who worked part time – many of whom were younger – reported lower stress levels, were more likely to say they were under less pressure than two years ago, and were less likely to be suffering physical or emotional consequences.

They were more positive in their outlook, less likely to feel trapped, and reported a more balanced lifestyle with better exercise, sleep, diet and holidays.

Flinders University’s Hugh Kearns, co-author of The Ultimate Time Management Guide for GPs, says the findings are borne out by his work with thousands of GPs over several years: that part-time general practice is less stressful.

Even introducing more variety into one’s working life, such as engaging in medical education or study, is less stressful than fronting patients for 10 hours a day followed by hours of paperwork, he says.

“The system might be under a lot of pressure, but that doesn’t mean you have to kill yourself.”

WORK NOT VALUED

However, reducing hours is not the only way to prevent stress. RACGP president Dr Chris Mitchell says one of the most significant issues for general practice is recognition and reward.

“When you’re proud of the work you’re doing, you’re much more resilient,” he says.

“A lot of GPs are not feeling their work is valued at the moment.”

The AMA also believes there needs to be more Federal Government support for primary care. AMA council of general practice chair Dr Rod Pearce says the management of swine flu has been a good example: GPs shouldered the burden without adequate Commonwealth help.

“The reality is medicine isn’t just about being a private industry, it’s about being a professional support for the community,” he says.

“The Government should support general practice to link in with other health providers rather than partitioning it.”

But, ultimately, reducing GPs’ stress levels may come from within. Lennox Head GP Dr Hilton Koppe, a medical educator for North Coast GP Training who developed the GP Wellbeing Project, says it’s all down to having a positive attitude.

“You don’t necessarily have to reduce your hours, it’s the attitude you bring to work,” he says.

“We have to learn optimism. In medicine, it’s very easy to focus on the negative things. The antidote is to notice the good things that are happening, to celebrate success, notice how patients like us and respect us and notice when people do get better.”

A PORTRAIT OF GP STRESS LEVELS

The statistics show GPs are clearly working under considerable stress with almost six in 10 reporting their level of stress as troubling or worse, and 4% claiming their current level of stress is unmanageable. Only 15% indicate their stress is acceptable. 

At the sub-group level, there is surprising consistency in stress levels reported. Splits for gender, location, years in practice and work status claim 50% or more of GPs experience stress at levels considered troubling or worse. Part-time GPs emerge as the least stressed of the sub-groups, with close to one in four describing their current stress level as manageable.

KEY REASONS FOR STRESS

• Medicare bureaucracy/red tape: 24%
• Legal issues: 20%
• Long hours/time pressures: 18%
• Keeping up-to-date to minimise mistakes: 18%
• Poor remuneration/financial recognition: 17%
• Pressure and demands from patients: 8%
• Poor work/life balance: 7%
• Concern for disappearing role of GPs: 5%
• Concern for shortage of GPs and ageing GP population: 5%
• Lack of respect and recognition for GP role: 4%
• Accessibility of specialist or other care: 4%
• Personal health issues: 3%

ISSUES AFFECTING HEALTH OF GPs

• Time pressure/long working hours: 53%
• Bureaucracy/red tape: 47%
• Legal issues: 30%
• Poor remuneration/financial recognition: 30%
• Stress issues: 25%
• Problems balancing work and life: 24%
• Health issues: 23%
• Patient demands/pressure: 22%
• Shortage of GPs/ageing GP population: 12%
• Lack of respect/support for GPs: 9%
• Keeping up-to-date/education issues: 1%
• Patients can’t afford care: 1%