Depersonalised doctors: a cross-sectional study of 564 doctors, 760 consultations and 1876 patient reports in UK general practice

Burnout among diabetes specialist registrars across the United Kingdom in the post-pandemic era

Introduction

Burnout syndrome is a condition resulting from chronic work-related stress exposure and can be identified by the presence of one or more of the three classic dimensions of burnout, i.e., emotional exhaustion, depersonalization, and lack of personal accomplishment, which negatively impact physician health and productivity.

Objective

This study aimed to identify burnout among Diabetes and Endocrinology Specialty Training Registrars (DStRs) across the United Kingdom.

Design/setting

It was a Cross-sectional observational study after ethical approval ERSC_2022_1166, utilizing the gold standard Maslach Burnout Inventory to measure burnout syndrome, and to determine self-reported stressors and compare them with the results of our previous survey in 2018.

Participants

Over 430 DStRs across the United Kingdom were invited electronically through their deanery representatives and specialty training bodies.

Results

Using Google Forms™ to gather data, we were able to collect 104 completed surveys. Results revealed that 62.5% (n = 65) of participants have burnout (5% increase from the previous survey in 2018), 38.6% (n = 40) have high emotional exhaustion, and 44.2% (n = 46) feel a lack of personal accomplishment. "General Internal Medicine specific workload" was the most common self-reported stressor reported by 87.5% (n = 91) of participants, whereas bullying/harassment and discrimination at work were reported by 35.6% (n = 37) and 30.77% (n = 32) of participants, respectively. Using multivariable logistic regression model, personal stress (OR, 4.00; 95% CI, 1.48-10.86; p = 0.006) had significant, while Bullying/harassment (OR, 3.75; 95% CI, 0.93-15.12; p = 0.063) had marginal impact on the presence of burnout.

Conclusion

Diabetes and Endocrinology Specialty Training Registrars frequently experience burnout syndrome, which has increased over the last 4 years. However, organizational changes can help identify, prevent, and treat physician burnout.

Trial registration

NCT05481021 available at https://ichgcp.net/clinical-trials-registry/NCT05481021.

Reducing health inequalities through general practice: a realist review and action framework

Background

Socio-economic inequalities in health have been in the public agenda for decades. General practice has an influential role to play in mitigating the impact of inequalities especially regarding chronic conditions. At the moment, general practice is dealing with serious challenges in relation to workforce shortages, increasing workload and the impact of the COVID-19 pandemic. It is important to identify effective ways so that general practice can play its role in reducing health inequalities.

Objectives

We explored what types of interventions and aspects of routine care in general practice decrease or increase inequalities in health and care-related outcomes. We focused on cardiovascular disease, cancer, diabetes and/or chronic obstructive pulmonary disease. We explored for whom these interventions and aspects of care work best, why, and in what circumstances. Our main objective was to synthesise this evidence into specific guidance for healthcare professionals and decision-makers about how best to achieve equitable general practice.

Design

Realist review.

Main outcome measures

Clinical or care-related outcomes by socio-economic group, or other PROGRESS-Plus criteria.

Review methods

Realist review based on Pawson's five steps: (1) locating existing theories, (2) searching for evidence, (3) selecting articles, (4) extracting and organising data and (5) synthesising the evidence.

Results

Three hundred and twenty-five studies met the inclusion criteria and 159 of them were selected for the evidence synthesis. Evidence about the impact of general practice interventions on health inequalities is limited. To reduce health inequalities, general practice needs to be: • connected so that interventions are linked and coordinated across the sector; • intersectional to account for the fact that people's experience is affected by many of their characteristics; • flexible to meet patients' different needs and preferences; • inclusive so that it does not exclude people because of who they are; • community-centred so that people who receive care engage with its design and delivery. These qualities should inform action across four domains: structures like funding and workforce distribution, organisational culture, everyday regulated procedures involved in care delivery, interpersonal and community relationships.

Limitations

The reviewed evidence offers limited detail about the ways and the extent to which specific interventions increase or decrease inequalities in general practice. Therefore, we focused on the underpinning principles that were common across interventions to produce higher-level, transferrable conclusions about ways to achieve equitable care.

Conclusions

Inequalities in general practice result from complex processes across four different domains that include structures, ideas, regulated everyday procedures, and relationships among individuals and communities. To achieve equity, general practice needs to be connected, intersectional, flexible, inclusive and community-centred.

Future work

Future work should focus on how these five essential qualities can be better used to shape the organisational development of future general practice.

Study registration

This trial is registered as PROSPERO CRD42020217871.

Funding

This award was funded by the National Institute for Health and Care Research (NIHR) Health and Social Care Delivery Research programme (NIHR award ref: NIHR130694) and is published in full in Health and Social Care Delivery Research; Vol. 12, No. 7. See the NIHR Funding and Awards website for further award information.

Explaining and addressing the limitations in usefulness of available estimated prevalence figures relating to burnout in family doctors: Evidence from a systematic scoping literature review

Burnout in family doctors (FDs) affects their well-being, patient care, and healthcare organizations, and is considered common worldwide. However, its measurement has been so inconsistent that whether the widely divergent prevalence figures can be meaningfully interpreted has been questioned. Our aim was to go further than previous systematic reviews to explore the meaning contribution and usefulness of FD-burnout prevalence estimates. Worldwide literature was systematically reviewed using Levac's scoping framework, with 249 papers undergoing full-text review. Of 176 studies measuring burnout, 78% used the Maslach Burnout Inventory (MBI), which measures burnout as now defined by the World Health Organization. We, therefore, concentrated on the MBI. Its burnout measurement was markedly inconsistent, with prevalence estimates ranging from 2.8% to 85.7%. Researchers made prevalence claims relating to burnout severity and implied diagnoses based on participants' MBI scores, even though the MBI has not been validated as a clinical or diagnostic tool. Except when comparisons were possible between certain studies, prevalence figures provided limited meaning and added little to the understanding of burnout in FDs. Our review revealed a lack of research-supported meaningful information about the prevalence of FD burnout and that care is required to avoid drawing unsubstantiated conclusions from prevalence results. This paper's overall purpose is to propose how obtaining meaningful prevalence estimates can begin, which are recognized as key to developing improved prevention policies and interventions. Researchers must adopt a consistent means to measure burnout, use the MBI as its authors intended, and explore making progress through quantitative and qualitative collaboration.

A national study of burnout and spiritual health in UK general practitioners during the COVID-19 pandemic

OBJECTIVES

To quantify the burnout and spiritual health of general practitioners (GPs) in the United Kingdom (UK) who worked during the Covid-19 Pandemic.

DESIGN

Online survey, April/May 2021, distributed via emails to general practices, Clinical Commissioning Groups (CCGs), Health boards, Clinical Research Networks, professional groups, social media GP groups and networks.

SETTING

United Kingdom.

PARTICIPANTS

1318 GPs who had worked in the National Health Service (NHS) during the COVID-19 pandemic (March 2020 -May 2021).

MAIN OUTCOME MEASURES

Burnout scores, measured by the Maslach Burnout Inventory (MBI) for Medical Personnel; spiritual health, measured using the Functional Assessment of Chronic Illness Therapy-Spiritual Well-Being, Non-Illness (FACIT-SP-NI).

RESULTS

19% of surveyed GPs were at the highest risk for burnout, using accepted MBI 'cut off' levels. There was no evidence of a difference in burnout by gender, ethnicity, or length of service. GP burnout was associated with GP spiritual health, regardless of identification with a religion. GPs with low spiritual health were five times more likely to be in the highest risk group for burnout.

CONCLUSIONS

Burnout is at crisis levels amongst GPs in the UK NHS. A comprehensive response is required, identifying protective and precipitating factors for burnout. The potentially protective impact of spiritual health merits further investigation.

The global prevalence of burnout among general practitioners: a systematic review and meta-analysis

BACKGROUND

Burnout among general practitioners (GPs) has attracted the attention of more and more researchers. An adequate understanding the prevalence and related factors of burnout to prevent and reduce burnout is necessary. This study systematically measured the global prevalence of burnout among GPs.

METHODS

Eligible original studies were identified from the PubMed, Ovid Embase, Ovid Medline (R), and Web of science databases. We searched the full-time period available for each database, up to 30 September 2021. The adjusted prevalence rate was estimated using a random-effects meta-analysis. The heterogeneity was evaluated using I2 statistic. Differences by study-level characteristics were estimated via subgroup analyses and meta-regression.

RESULTS

A total of 16 cross-sectional studies with 7,595 participants were included. The pooled burnout rate showed 37%, 28%, and 26% of general GPs suffer from high emotional exhaustion (EE), high depersonalization (DP), and low personal exhaustion (PA), respectively. Groups comparisons found that high EE, high DP, and low PA rate data obtained from 2001 to 2009, high DP rate data obtained from Europe, low PA rate data obtained from high-quality studies had much higher rates.

CONCLUSIONS

This study demonstrated the prevalence of burnout in the GPs and alert health managers to tailor their strategies to retain this community. Targeted initiatives are needed to provide adequate GPs' well-being and maintain primary health care.

Burned-out with burnout? Insights from historical analysis

Fierce debates surround the conceptualization and measurement of job-related distress in occupational health science. The use of burnout as an index of job-related distress, though commonplace, has increasingly been called into question. In this paper, we first highlight foundational problems that undermine the burnout construct and its legacy measure, the Maslach Burnout Inventory (MBI). Next, we report on advances in research on job-related distress that depart from the use of the burnout construct. Tracing the genesis of the burnout construct, we observe that (a) burnout's definition was preestablished rather than derived from a rigorous research process and (b) the MBI has little in the way of a theoretical or empirical foundation. Historical analysis suggests that the burnout construct was cobbled together from unchallenged personal impressions and anecdotal evidence before getting reified by the MBI. This state of affairs may account for many of the disconcerting problems encountered in burnout research. We close our paper by presenting the Occupational Depression Inventory (ODI), a recently developed instrument reflective of a renewed approach to job-related distress. The ODI has demonstrated robust psychometric and structural properties across countries, sexes, age groups, occupations, and languages. The instrument addresses job-related distress both dimensionally and categorically. A dimensional approach can be useful, for instance, in examining the dynamics of etiological processes and symptom development. A categorical approach can serve screening and diagnostic purposes and help clinicians and public health professionals in their decision-making. It is concluded that the ODI offers occupational health specialists a promising way forward.

Burnout in diabetes and endocrinology specialist registrars across England, Scotland and Wales in the pre-COVID era

BACKGROUND

Presence of either emotional exhaustion, depersonalization or lack of personal accomplishment define Burnout Syndrome which may lead to decreased workforce productivity, increased absenteeism, depression and medical errors as well as decreased patient satisfaction.

OBJECTIVE

The aim of this study was to assess the frequency of burnout syndrome among Diabetes Specialist Registrars across England, Scotland and Wales and to identify any self-reported factors which may be contributory to burnout.

METHODS

Over 430 Diabetes Specialist Registrars were invited to anonymously participate in an electronic survey which used Maslach Burnout Inventory and selfreporting questionnaire to identify burnout and contributory factors.

RESULTS

In this pre-pandemic times study, Burnout was identified in 61 (57.5%; n = 106) respondents using Maslach burnout cut-off scores. 45.2% (48/106) participants had scored high in Emotional Exhaustion, while lack of personal accomplishment and depersonalization was seen in 24.5% (26/106) and 21.6% (23/106) of the respondents respectively. The commonest self-reported stressors by participants were "General Internal Medicine workload" 60.4% (64/106) followed by "Lack of specialty training" 36.8% (39/106) and "Lack of audit/research/Continuing Professional Development time" 10.8% (11/106) CONCLUSION: Burnout syndrome is frequent among the participating Diabetes Specialist Registrars and urgent steps may be required address this problem nationally to ensure that these physicians remain physically and mentally healthy, especially after the pandemic.

General practitioner wellbeing during the COVID-19 pandemic. A systematic review

Background: Doctors’ organisations in the UK have reported worrying levels of work-related stress and burnout in the general practitioner (GP) workforce for some time, and the COVID-19 pandemic has presented clear new challenges. Aims: To synthesise international evidence exploring the impact of COVID-19 on primary care doctors’ mental health and wellbeing and identify risk factors associated with their psychological wellbeing during this time. Design and setting: Mixed-methods systematic review. Method: We searched six bibliographic databases, Google Scholar and MedRxiv and conducted reference checking to identify studies of GP psychological wellbeing during the pandemic. Two reviewers selected studies, extracted data and assessed the quality of studies using standardised tools. Heterogeneity in outcomes, setting and design prohibited statistical pooling; we combined the studies using a convergent integrated thematic synthesis. Results: Thirty-one studies were included. Multiple sources of stress were identified, including changed working practices, risk, exposure and inadequate PPE, information overload, pandemic preparedness and cohesion across sectors. Studies demonstrated an impact on psychological wellbeing, with some GPs experiencing stress, burnout, anxiety, depression, fear of COVID, lower job satisfaction and physical symptoms. Studies described gender and age differences: women report poorer psychological outcomes across all domains and older GPs reported greater stress and burnout. Use of outcome measures and reporting practice varied greatly. Conclusion: Our review of international evidence demonstrates that the COVID-19 pandemic has adversely affected GPs’ wellbeing around the world. Further research could explore gender and age differences, identifying interventions targeted to these groups.

Investigating the links between diagnostic uncertainty, emotional exhaustion, and turnover intention in General Practitioners working in the United Kingdom

BACKGROUND

General Practitioners (GPs) report high levels of burnout, job dissatisfaction, and turnover intention. The complexity of presenting problems to general practice makes diagnostic uncertainty a common occurrence that has been linked to burnout. The interrelationship between diagnostic uncertainty with other factors such as burnout, job satisfaction and turnover intention have not been previously examined.

OBJECTIVES

To examine associations between diagnostic uncertainty, emotional exhaustion (EE), depersonalization (DP), job satisfaction, and turnover intention in GPs.

METHODS

Seventy general practices in England were randomly selected through the Oxford-Royal College of General Practitioners Research and Surveillance Centre (RCGP-RSC). A total of 348 GPs within 67 these practices completed a 10-item online questionnaire which included questions on GP characteristics, work-life balance, job satisfaction, sickness presenteeism, diagnostic uncertainty, turnover intention as well as EE and DP. Associations between diagnostic uncertainty and each of EE, DP, job satisfaction, and turnover intention were evaluated in multivariate mixed-effect ordinal logistic regressions whilst adjusting for covariates, to account for the correlation in the three outcomes of interest.

RESULTS

Almost one-third of GPs (n = 101; 29%) reported experiencing >10% of diagnostic uncertainty in their day-to-day practice over the past year. GPs reporting greater diagnostic uncertainty had higher levels of EE [OR = 3.90; 95% CI = (2.54, 5.99)], job dissatisfaction [OR = 2.01; 95% CI = (1.30, 3.13)] and turnover intention [OR = 4.51; 95% CI = (2.86, 7.11)]. GPs with no sickness presenteeism had lower levels of EE [OR = 0.53; 95% CI = (0.35, 0.82)], job dissatisfaction [OR = 0.56; 95% CI = (0.35, 0.88)], and turnover intention [OR = 0.61; 95% CI = (0.41, 0.91)].

CONCLUSION

Diagnostic uncertainty may not only negatively impact on the wellbeing of GPs, but could also have adverse implications on workforce retention in primary care.

Prevalence of Burnout among General Practitioners: A Systematic Review and Meta-Analysis

Background Burnout is a work-related syndrome documented to have negative consequences for general practitioners (GPs) and their patients. Our objective was to conduct a systematic review and meta-analysis of the literature to provide an estimate of how widespread this phenomenon is.

AIM

To review the existing literature concerning studies published up to December, 2020, on the prevalence of burnout amongst GPs in general practice, to determine GP burnout estimates worldwide.

DESIGN AND SETTING

Systematic literature search and meta-analysis.

METHOD

Searches of CINAHL Plus, Embase, MEDLINE, PsycINFO, and Scopus were conducted to identify published peer-reviewed quantitative empirical studies in English up to December, 2020, that have used the Maslach Burnout Inventory-Human Services Survey to establish the prevalence of burnout in practising GPs (i.e., excluding GPs in training). A random-effects model was employed.

RESULTS

Wide-ranging prevalence estimates (6% to 32%) for 22,177 GPs across 29 countries were reported for 60 studies included in this review. Mean burnout estimates were as follows: 16.43 (EE); 6.74 (DEP); and 29.28 (PA). Subgroup and meta-analyses documented that country-specific factors may be important determinants of the variation in GP burnout estimates. Moderate overall burnout cut-offs were found to be determinants of the variation in moderate overall burnout estimates.

CONCLUSION

Moderate to high GP burnout exist worldwide. However, substantial variations in how burnout is characterised and operationalised resulted in considerable heterogeneity in GP burnout prevalence estimates. This highlights the challenge of developing a uniform approach, and the importance of considering the GP's work context, to better characterise burnout.

Examining GP online consultation in a primary care setting in east midlands, UK

Background

Increasing pressure threatens to overwhelm primary care services, affecting the quality of care and their role as gatekeepers to specialised care services. This study investigated healthcare users’ acceptability of – and the effectiveness of – an e-consultation system in primary care services.

Methods

Seven GP practices in East-Midlands, all of whom use online consultation system participated in the study, with a retrospective review being undertaken of 189 electronic patients’ records (age range of 18–76 years) over 5 months. The focus was on the electronic records of patients who accessed the service for five different conditions identified as presenting common conditions seen by the GPs practices. Statistical analysis was done using SPSS to perform an exploratory data analysis and descriptive statistics.

Results

The results showed a positive reception of the online consultation platform, with an average satisfaction score of 4.15 (most likely to recommend score = 5). Given the nature of the conditions, 47.6% of patients had experienced a previous episode of the health condition they were seeking consultation for, and a total of 72% had existing comorbidities. Follow-up activity occurred for 87.3% of patients, 66.1% of which included at least one follow-up visit for the same condition as the initial online consultation.

Conclusion

The results suggest that online consultation is convenient for patients, and it also has the potential to relieve pressure placed on primary care services. Although a number of challenges were identified, such as patient verification, this study gives insight into – and enhances our understanding of – the use of online GP consultations.

Working conditions in primary care: a qualitative interview study with physicians in Sweden informed by the Effort-Reward-Imbalance model

BACKGROUND

Many problems with primary care physicians' psychosocial working conditions have been documented. Many studies on working condition have used the Effort-Reward-Imbalance (ERI) model, which posits that poor health and well-being may result from imbalances between the level of effort employees perceive that they put into their work and the rewards they receive. The model has not been used in qualitative research or applied to investigate primary care physicians' working conditions. The aim of this study was to apply the ERI model to explore the perceived efforts and rewards by primary care physicians in Sweden and approaches they take to cope with potential imbalances between these efforts and rewards.

METHODS

The study has a qualitative design, using semi-structured interviews. A purposeful sampling strategy was used to achieve a heterogeneous sample of primary care physicians who represented a broad spectrum of experiences and perceptions. We recruited 21 physicians; 15 were employed in public health care and 6 by private health care companies.

RESULTS

The analysis of the interviews yielded 11 sub-categories: 6 were mapped to the efforts category, 3 were attributed to the rewards category and 2 were approaches to coping with effort/reward imbalances. Many of the statements concerned efforts in the form of high workload, restricted autonomy and administrative work burden. They also perceived resource restrictions, unpredictability of work and high expectations in their role as physicians as efforts. Three types of rewards emerged; the physicians found their job to be stimulating and meaningful, and the work climate to be supportive. The physicians coped with imbalances by means of job enrichment and using decisional latitude.

CONCLUSIONS

Primary care physicians perceive numerous types of efforts in their job, which is consistent with research concerning work stress and associated consequences, such as poor subjective health and well-being. There are also rewards according to primary care physicians, but the findings suggest a lack of reciprocity in terms of efforts and rewards although firm conclusions cannot be drawn since the study did not investigate the magnitude of the various efforts and rewards or the effectiveness of the approaches the physicians use to cope with imbalances. The ERI model was found to be useful to explore physicians' primary care work and working conditions but its applicability likely depends on the type of work or professions being studied.

How to strengthen basic competencies in self-care - a pre-post interventional study with postgraduate trainees in family medicine in Germany

Introduction: Self-care includes taking care of our psychosocial health. Many experts agree that self-care should be included in training for Family Medicine (FM) residents, though it is unclear to what extent and by what means. Objective: The aim of this study was to evaluate competencies of FM residents in self-care and changes in knowledge, skills and attitudes after an educational compact intervention.Methods: The authors performed a pre-post comparison on residents who were registered in the FM residency program KWBW VerbundweiterbildungPLUS© (n = 401). FM residents were offered participation in a self-care training (270 minutes featuring a broad spectrum of input and practical experience). The intervention group (IG) completed a questionnaire directly before the seminar (T1) and 10 weeks afterwards (T2). Non-attendees (=control group; CG) were asked to fill out a basic questionnaire once. Basic questionnaires for IG and CG covered previous experiences and skills while the follow-up questionnaire at T2 also focused on change of competencies and attitudes. All questionnaires contained free-text questions to capture qualitative impressions.Results: 287 FM residents (IG: n = 212; CG: n = 75) participated in the study. Generally, 86.4% of FM residents had worried that their profession might endanger their personal health (T1: n = 180, CG: n = 68). At T2, 59.5% of IG (n = 66/111) declared that they would not worry about their personal health anymore (T1:T2, p < .01). IG learned to facilitate time for recreation (T1:T2, p = .04) and to use relaxation techniques (T1:T2, p = .01). Gain in competence was described in awareness of stress, self-reward, activation of personal resources, and time management. A total of 85.6% of IG reflected their attitudes towards psychosocial health of physicians in general (n = 95/111) and 22.5% of IG changed the views on their own health (n = 25/111) in terms of improved risk-awareness, increased intention for self-care and change of behavior.Conclusion: A compact intervention in self-care strengthens competencies, increases awareness, and helps FM residents identify their psychosocial health risks. Further research is necessary to specify the effectiveness of similar compact interventions in self-care and their long-term results.

Is Burnout Primarily Linked to Work-Situated Factors? A Relative Weight Analytic Study

It has often been asserted that burnout is primarily linked to occupational-context factors, and only secondarily to individual-level (e.g., personality) and non-work (or general) factors. We evaluated the validity of this view by examining the links between burnout and an array of 22 work-situated (effort-reward imbalance, unreasonable work tasks, unnecessary work tasks, weekly working hours, job autonomy, skill development, performance feedback, and support in work life), work-unrelated (sentimental accomplishment, familial accomplishment, number of child[ren], leisure activities, residential satisfaction, environmental quality, security in daily life, and support in personal life), dispositional (neuroticism, sex, age, and physical condition), and intersecting (work–non-work conflict and non-work–work conflict) variables. The study involved schoolteachers from three different countries: France (N = 4,395), Spain (N = 611), and Switzerland (N = 514). Burnout was assessed with the Maslach Burnout Inventory for Educators. Most of our predictors were assessed based on widely used measures (e.g., neuroticism was assessed with the NEO-Five Factor Inventory). In order to assess sentimental accomplishment and familial accomplishment, we created two self-reported measures, namely, the Sentimental Accomplishment Inventory (SAI; 9 items) and the Familial Accomplishment Inventory (FAI; 9 items). The SAI and the FAI both showed strong reliability and high factorial validity. Exploratory structural equation modeling bifactor analysis and Mokken scaling suggested that both instruments could be considered essentially unidimensional. The study results showed that neuroticism, job strain, skill development, security in daily life, and work–non-work conflict were consistently associated with burnout across the three samples. Sample-specific predictors of burnout included sex, age, unreasonable work tasks, weekly working hours, job autonomy, support in work life, sentimental accomplishment, leisure activities, support in personal life, and non-work–work conflict. Relative weight analysis indicated that neuroticism was the best predictor of burnout in each sample. Our findings suggest that burnout’s nomological network may not be primarily job-related. We conclude that the tendency to de-emphasize individual-level and non-work factors in burnout research is unwise. This tendency may constitute a roadblock in the development of effective interventional strategies. The implications of our findings for burnout’s conceptual status are discussed. The neuroticism-burnout link should be further examined in longitudinal studies.

Group practice impacts on patients, physicians and healthcare systems: a scoping review

OBJECTIVE

To identify the advantages and disadvantages that group practices have on patients, physicians and healthcare systems.

STUDY DESIGN

A scoping review was performed based on the methodology proposed by Arksey and O'Malley, and refined by Levac et al. Titles and abstracts were screened by two reviewers. A quantitative analysis was performed to assess the type, year and region of publication, as well as the population studied. A qualitative descriptive analysis was performed to identify common themes.

STUDY SETTING

MEDLINE, EMBASE and Cochrane databases were searched from database inception to October 2018 for papers which assessed outcomes relevant to the research question.

RESULTS

Our search strategy returned 2408 papers and 98 were included in the final analysis. Most papers were from the USA, were surveys and assessed physician outcomes. Advantages of group practices for patients included improved satisfaction and quality of care. Studies of physicians reported improved quality of life and income, while disadvantages included increased stress due to poor interpersonal relationships. Studies of healthcare systems reported improved efficiency and better utilisation of resources.

CONCLUSIONS

Group practices have many benefits for patients and physicians. However, further work needs to be done assessing patient outcomes and establishing the elements that make a group practice successful.

Limited evidence of benefits of patient operated intelligent primary care triage tools: findings of a literature review

Introduction

There is consistent evidence that the workload in general practices is substantially increasing. The digitalisation of healthcare including the use of artificial intelligence has been suggested as a solution to this problem. We wanted to explore the features of intelligent online triage tools in primary care by conducting a literature review.

Method

A systematic literature search strategy was formulated and conducted in the PubMed database and the Cochrane Library. Articles were selected according to inclusion/exclusion criteria. Results and data were systematically extracted and thematically analysed. 17 articles of that reported large multimethod studies or smaller diagnostic accuracy tests on clinical vignettes were included. Reviews and expert opinions were also considered.

Results

There was limited evidence on the actual effects and performance of triage tools in primary care. Several aspects can guide further development: concepts of system design, system implementation and diagnostic performance. The most important findings were: a need to formulate evaluation guidelines and regulations; their assumed potential has not yet been met; a risk of increased or redistribution of workloads and the available symptom checker systems seem overly risk averse and should be tested in real-life settings.

Conclusion

This review identified several features associated with the design and implementation of intelligent online triage tools in a primary care context, although most of the investigated systems seemed underdeveloped and offered limited benefits. Current online triage systems should not be used by individuals who have reasonable access to traditional healthcare. Systems used should be strictly evaluated and regulated like other medical products.

Digital consultations in Swedish primary health care: a qualitative study of physicians' job control, demand and support

Background

Digital consultation with primary care physicians via mobile telephone apps has been spreading rapidly in Sweden since 2014. Digital consultation allows remote working because physicians can work from home, outside their traditional primary care environment. Despite the spread of digital consultation in primary care, there is a lack of knowledge concerning how the new service affects physicians’ psychosocial work environment. Previous research has focused primarily on the patients’ point of view and the cost-effectiveness of digital consultation. Hence, there is a paucity of studies from the perspective of physicians, focusing on their psychosocial work environment. The aim of this study was to investigate primary care physicians’ perceived work demands, control over working processes, and social support when providing digital consultation to primary care patients.

Methods

The study has a qualitative design, using semi-structured interviews conducted in Sweden in 2019. We used a purposeful sampling strategy to achieve a heterogeneous sample of physicians who represented a broad spectrum of experiences and perceptions. The interviews were conducted by video meeting, telephone, or a personal meeting, depending on what suited the participant best. The interview questions were informed by the Job Demand-Control-Support (JDCS) model, which was also used as the framework to analyze the data by categorizing the physicians’ perceptions and experiences into the three categories of the model (Demand, Control, Support), in the deductive analysis of the data.

Results

Analysis of the data yielded 9 subcategories, which were mapped onto the 3 categories of the JDCS model. Overall, the participants saw numerous benefits with digital consultations, not only with regard to their own job situation but also for patients and the health care system in general even though they identified some shortcomings and risks with digital care.

Conclusions

This study has demonstrated that physicians perceive working with digital consultation as flexible with a high grade of autonomy and reasonable to low demands. According to the participants, digital consultation is not something you can work with full time if medical skills and abilities are to be maintained and developed.

Operational failures and how they influence the work of GPs: a qualitative study in primary care

Background

Operational failures, defined as inadequacies or errors in the information, supplies, or equipment needed for patient care, are known to be highly consequential in hospital environments. Despite their likely relevance for GPs’ experiences of work, they remain under-explored in primary care.

Aim

To identify operational failures in the primary care work environment and to examine how they influence GPs’ work.

Design and setting

Qualitative interview study in the East of England.

Method

Semi-structured interviews were conducted with GPs (n = 21). Data analysis was based on the constant comparison method.

Results

GPs reported a large burden of operational failures, many of them related to information transfer with external healthcare providers, practice technology, and organisation of work within practices. Faced with operational failures, GPs undertook ‘compensatory labour’ to fulfil their duties of coordinating and safeguarding patients’ care. Dealing with operational failures imposed significant additional strain in the context of already stretched daily schedules, but this work remained largely invisible. In part, this was because GPs acted to fix problems in the here-and-now rather than referring them to source, and they characteristically did not report operational failures at system level. They also identified challenges in making process improvements at practice level, including medicolegal uncertainties about delegation.

Conclusion

Operational failures in primary care matter for GPs and their experience of work. Compensatory labour is burdensome with an unintended consequence of rendering these failures largely invisible. Recognition of the significance of operational failures should stimulate efforts to make the primary care work environment more attractive.

Mental health of postgraduate trainees in primary care: a cross-sectional study

Background

General Practitioners (GPs) are increasingly affected by stress-related complaints and burnout. Although many studies have addressed this issue, little is known about the stress burden and burnout rates of postgraduate trainees specialising in General Practice (GP). This cross-sectional study was performed to explore the prevalence and risk of depression, stress and burnout in a large cohort of GP trainees.

Methods

All GP trainees enrolled in the postgraduate training programme KWBW Verbundweiterbildung^plus© in southwest Germany were invited to participate. A paper-based survey for the purpose of psychosocial screening was used: Prevalence of depression, perceived stress and burnout were measured with the depression module of the Patient Health Questionnaire (PHQ-9), Perceived Stress Questionnaire (PSQ-20) and Maslach Burnout Inventory (MBI). Additionally, linear regression models were used to analyse the association between sociodemographic characteristics and mental health scales.

Results

N = 211 GP trainees participated in this study (response rate 95%). 75.3% (n = 159) of the participants were female and median age was 34 (IQR 32; 39). GP trainees had a mean PHQ-9 sum score of 5.4 (SD 3.4). Almost 11% (n = 23) reported symptoms of a moderate or moderately severe depression. PSQ-20 revealed moderate level of distress, whereas 20.8% (n = 42) showed a high level of perceived stress with a sum-score higher than .59. GP trainees showed moderate rates of burnout and only 2.5% (n = 5) scored high in all three dimensions of the MBI score. GP trainees showed increased levels of depression, perceived stress and burnout when compared with age-matched general population. Being a woman led to a higher PHQ-9 sum score (p < .05). Higher age was associated with less depersonalisation in the MBI (p < .05).

Conclusions

The results of our study suggest that GP trainees considerably suffer from stress. Some GP trainees were even affected by depression or burnout. To detect and support colleagues at risk, trainees should be supported by early preventive measures such as anti-stress or resilience trainings and mentoring during their training. Prospective longitudinal studies are needed to understand the character and the course of the stress burden among GP trainees.

A real-time measurement of general practice workload in the Republic of Ireland: a prospective study

Background

Demand for GP services in the Republic of Ireland (RoI) is increasing, and the resultant escalation in workload demands is an issue of growing concern. Accordingly, the accurate measurement and description of GP workload is essential to inform future healthcare planning.

Aim

To provide a real-time measurement of GP workload with respect to hours worked and of proportional time expenditure on typical workload activities.

Design and setting

A prospective study among GPs in the RoI that took place from January 2019 to March 2019.

Method

Participants were invited to enrol in the study by direct email invitation and via notifications posted within GP-specific monthly journals; online forums; and a social media platform. Participants used a time-management software program to self-record workload activity in real time over 6 weeks.

Results

In total, 123 GPs were included for final analyses with a total of 8930 hours of activity recorded. The mean duration of a two-session day (excluding break-time) was 9.9 hours (95% confidence interval [CI] = 9.7 to 10.0; interquartile range [IQR] 7.9 to 13.9). Of this time, 64% was spent on clinical consultations. In total, 25.4% of activity was recorded outside the hours of 9.00 am and 5.00 pm. An average of 12.4 face-to-face consultations were completed per session of activity. The mean duration of a 10-session week was greatest for the partner (50.8 hours; 95% CI = 49.8 to 51.9) and >55-year-old (50.8 hours; 95% CI = 49.3 to 52.2) demographics, relative to their respective colleagues.

Conclusion

To the authors’ knowledge, this is the first study to provide an objective, accurate, and granular real-time measurement of GP workload in the RoI, demonstrating the significant volume and variety of work undertaken by GPs in the RoI.

Mobile consulting (mConsulting) and its potential for providing access to quality healthcare for populations living in low-resource settings of low- and middle-income countries

Objective

The poorest populations of the world lack access to quality healthcare. We defined the key components of consulting via mobile technology (mConsulting), explored whether mConsulting can fill gaps in access to quality healthcare for poor and spatially marginalised populations (specifically rural and slum populations) of low- and middle-income countries, and considered the implications of its take-up.

Methods

We utilised realist methodology. First, we undertook a scoping review of mobile health literature and searched for examples of mConsulting. Second, we formed our programme theories and identified potential benefits and hazards for deployment of mConsulting for poor and spatially marginalised populations. Finally, we tested our programme theories against existing frameworks and identified published evidence on how and why these benefits/hazards are likely to accrue.

Results

We identified the components of mConsulting, including their characteristics and range. We discuss the implications of mConsulting for poor and spatially marginalised populations in terms of competent care, user experience, cost, workforce, technology, and the wider health system.

Conclusions

For the many dimensions of mConsulting, how it is structured and deployed will make a difference to the benefits and hazards of its use. There is a lack of evidence of the impact of mConsulting in populations that are poor and spatially marginalised, as most research on mConsulting has been undertaken where quality healthcare exists. We suggest that mConsulting could improve access to quality healthcare for these populations and, with attention to how it is deployed, potential hazards for the populations and wider health system could be mitigated.

Promoting general practice as a career to medical students; a qualitative study of the approaches of undergraduate GP tutors

BACKGROUND

Undergraduate (UG) General Practice (GP) tutors have been identified in the literature and in key UK workforce planning documents as one of the main influences on medical students' decisions about pursuing a career in GP.

AIM

To explore the attitudes and educational approaches of UG GP tutors in promoting GP as a career.

DESIGN AND SETTING

A pragmatic constructivist qualitative study, interviewing 8 UG GP tutors supervising undergraduate final year medical students on placement.

METHOD

Interviews were transcribed, coded and grouped into themes using NVIVO11. Analysis was descriptive and interpretive using principles of thematic analysis.

RESULTS

Tutors saw their role as promoting GP, supporting informed career decisions, correcting misconceptions and giving honest views. They used tutorials, critical reflection, exposure to authentic GP and role-modelling to promote GP, challenge misconceptions, and showcase managing complexities..

DISCUSSION

By guiding students to identify, discuss and reflect on their beliefs and by using clinical encounters and role modelling with further reflection, tutors enabled students to get a true picture of GP to identify if they could handle the challenges and complexities of the job. Kolb's experiential learning cycle could form a framework to guide tutors in clinical settings supporting students making informed career decisions.

A Cross-Sectional Study on Prevalence and Predictors of Burnout among a Sample of Pharmacists Employed in Pharmacies in Central Italy

Burnout is defined as an occupational phenomenon linked to chronic workplace stress that has not been successfully managed and included among the factors influencing health status or contact with health services. Although several studies were performed for assessing this phenomenon, there is a lack of data on the prevalence of burnout and associated predictors, due to different definitions of the syndrome and heterogeneity of assessment methods. One of the well-known evidences on burnout is related to the highest risk professions, which include policemen, firemen, teachers, psychologists, medical students, nurses, physicians, and other health professionals, such as pharmacists. Objective. The aims of the present study were to (1) assess the occurrence of burnout syndrome among a sample of pharmacists employed in public and private pharmacies located in Rome province (Latium Region; central Italy); (2) evaluate the role of some potential predictors for the development of the syndrome. Materials and Methods. A questionnaire elaborated ad hoc was administered online to 2,000 members of the Association of Professional Pharmacists of Rome and its province and employed in public or private pharmacies. The questionnaire included the 14-item Shirom-Melamed Burnout Measure (SMBM) tool and questions on demographic characteristics and working conditions. Results. Physical exhaustion was the burnout dimension with the highest score; besides, approximately 11% of the studied pharmacists were categorized as having clinically relevant burnout levels (≥4.40). Several of the investigated variables significantly influenced the single burnout dimensions at the univariate analyses; multivariate analyses demonstrated that alcohol consumption and workplace location have a significant independent role on the overall SMBM index, while working time significantly influences clinically relevant burnout level. Conclusions. The results revealed that pharmacists are at risk of burnout, and thus, it is necessary to perform specific preventive intervention for managing this occupational threat.

Prevalence of burnout and associated factors among general practitioners in Hubei, China: a cross-sectional study

Background

High occupational burnout among general practitioners (GPs) is an important challenge to China’s efforts to strengthen its primary healthcare delivery; however, data to help understand this issue are unavailable. This study aimed to investigate the prevalence of burnout and associated factors among GPs.

Methods

A cross-sectional design was used to collect data from December 12, 2014, to March 10, 2015, with a self-administered structured questionnaire from 1015 GPs (response rate, 85.6%) in Hubei Province, Central China. Burnout was measured using a 22-item Maslach Burnout Inventory-Human Services Survey (MBI-HSS). MBI-HSS scores and frequency were analyzed by the three dimensions of emotional exhaustion (EE), depersonalization (DP), and personal accomplishment (PA). Factors associated with burnout among GPs were estimated using a multiple linear regression model.

Results

Of the respondents, 2.46% had a high level of burnout in all three dimensions, 24.83% reported high levels of EE, 6.21% scored high on DP, and 33.99% were at high risk of PA. GPs who were unmarried, had lower levels of job satisfaction, and had been exposed to workplace violence experienced higher levels of burnout. Intriguingly, no statistically significant associations were found between burnout and the duration of GP practice, age, sex, income, practice setting, and professional level.

Conclusion

This is the first study of occupational burnout in Chinese general practice. Burnout is prevalent among GPs in Hubei, China. Interventions aimed at increasing job satisfaction, improving doctor-patient relationships and providing safer workplace environments may be promising strategies to reduce burnout among GPs in Hubei, China.

Mental well-being and job satisfaction in general practitioners in Denmark and their patients' change of general practitioner: a cohort study combining survey data and register data

OBJECTIVES

Low job satisfaction and poor well-being (eg, stress and burnout) among physicians may have negative consequences for patient experienced healthcare quality. In primary care, this could manifest in patients choosing another general practitioner (GP). The objective of this study was to examine change of GP (COGP) (unrelated to change of address) among patients in relation to their GPs' job satisfaction, well-being and self-assessed work-ability.

DESIGN AND SETTING

Data from a nationwide questionnaire survey among Danish GPs in May 2016 was combined with register data on their listed patients. Associations between patients' COGP in the 6-month study period (from May 2016) and the job satisfaction/well-being of their GP were estimated as risk ratios (RRs) at the individual patient level using binomial regression analysis. Potential confounders were included for adjustment.

PARTICIPANTS

The study cohort included 569 776 patients aged ≥18 years listed with 409 GPs in single-handed practices.

RESULTS

COGP was significantly associated with occupational distress (burnout and low job satisfaction) in the GP. This association was seen in a dose-response like pattern. For burnout, associations were found for depersonalisation and reduced sense of personal accomplishment (but not for emotional exhaustion). The adjusted RR was 1.40 (1.10-1.72) for patients listed with a GP with the lowest level of job satisfaction and 1.24 (1.01-1.52) and 1.40 (1.14-1.72) for patients listed with a GP in the most unfavourable categories of depersonalisation and sense of personal accomplishment (the most favourable categories used as reference). COGP was not associated with self-assessed work-ability or domains of well-being related to life in general.

CONCLUSIONS

Patients' likelihood of changing GP increased with GP burnout and decreasing job satisfaction. These findings indicate that patients' evaluation of care as measured by COGP may be influenced by their GPs' work conditions and occupational well-being.

Work strain and burnout risk in postgraduate trainees in general practice: an overview

Primary care physicians (general practitioners (GPs)) are burdened for various reasons and are particularly affected by stress-related complaints and an increasing prevalence of burnout. Thus, the prevention of physician burnout has become a major interest for health care services. Although many studies have addressed this issue in recent years, little seems to be known about the work strain and burnout rates in GP trainees. Therefore the objective of this article is to review the psychosocial burden and relevant prevention strategies for GPs with a special emphasis on GP trainees. Regardless of the specialty, burnout is more prevalent among medical trainees and so-called 'early career' physicians than among the age-matched population. Accordingly, burnout seems to be frequent among GP trainees, although there is some evidence that there are fewer doctors working in general medicine who were already heavily burdened at the time of choosing their career. The sudden assumption of responsibility in patient care as well as the fear of showing imperfection in front of their supervisors, or lack of recognition from senior doctors, the medical team, or patients might be stressors typical to this career stage. GP trainees might also feel burdened by the new level of personal involvement and thus have to develop or increase their individual level of professionality to deal with the patients' medical and personal problems. In conclusion, interventions to promote physical and mental health of GP trainees are a necessity to ensure passionate GPs in the future and should therefore be integrated into any postgraduate training curriculum in general practice.

Mental well-being, job satisfaction and self-rated workability in general practitioners and hospitalisations for ambulatory care sensitive conditions among listed patients: a cohort study combining survey data on GPs and register data on patients

BACKGROUND

Physicians' work conditions and mental well-being may affect healthcare quality and efficacy. Yet the effects on objective measures of healthcare performance remain understudied. This study examined mental well-being, job satisfaction and self-rated workability in general practitioners (GPs) in relation to hospitalisations for ambulatory care sensitive conditions (ACSC-Hs), a register-based quality indicator affected by referral threshold and prevention efforts in primary care.

METHODS

This is an observational study combining data from national registers and a nationwide questionnaire survey among Danish GPs. To ensure precise linkage of each patient with a specific GP, partnership practices were not included. Study cases were 461 376 adult patients listed with 392 GPs. Associations between hospitalisations in the 6-month study period and selected well-being indicators were estimated at the individual patient level and adjusted for GP gender and seniority, list size, and patient factors (comorbidity, sociodemographic characteristics).

RESULTS

The median number of ACSC-Hs per 1000 listed patients was 10.2 (interquartile interval: 7.0-13.7). All well-being indicators were inversely associated with ACSC-Hs, except for perceived stress (not associated). The adjusted incidence rate ratio was 1.26 (95% CI 1.13 to 1.42) for patients listed with GPs in the least favourable category of self-rated workability, and 1.19 (95% CI 1.05 to 1.35), 1.15 (95% CI 1.04 to 1.27) and 1.14 (95% CI 1.03 to 1.27) for patients listed with GPs in the least favourable categories of burn-out, job satisfaction and general well-being (the most favourable categories used as reference). Hospitalisations for conditions not classified as ambulatory care sensitive were not equally associated.

CONCLUSIONS

ACSC-H frequency increased with decreasing levels of GP mental well-being, job satisfaction and self-rated workability. These findings imply that GPs' work conditions and mental well-being may have important implications for individual patients and for healthcare expenditures.

Association of GP wellbeing and burnout with patient safety in UK primary care: a cross-sectional survey

BACKGROUND

GPs have particularly high levels of burnout and poor wellbeing. Although both are associated with poorer safety outcomes within secondary care, there have been no quantitative studies investigating this within primary care. Furthermore, little is known about how occupational demands, burnout and wellbeing, and patient safety are all associated.

AIM

To investigate whether occupational variables (demands and support) are associated with patient safety outcomes in general practice through their influence on GP burnout and wellbeing.

DESIGN AND SETTING

Cross-sectional survey in the UK between March 2016 and August 2017.

METHOD

A total of 232 practising GPs completed an online or paper survey measuring burnout, wellbeing, occupational demands and support, and patient safety.

RESULTS

In all, 93.8% of GPs were classed as likely to be suffering from a minor psychiatric disorder, 94.7% as suffering from mild (22.0%) or severe (72.7%) exhaustion, and 86.8% as having mild (37.9%) or severe (48.9%) disengagement. Structural equation modelling (SEM) analyses showed that spending a higher number of hours on administrative tasks and on call, and feeling less supported in their practice, was associated with lower wellbeing, which in turn was associated with a higher likelihood of having reported a near miss in the previous 3 months. A higher number of hours spent on administrative tasks, a higher number of patients seen per day, and feeling less supported were associated with higher burnout levels, which in turn was associated with worse perceptions of safety.

CONCLUSION

To improve patient safety within general practice changes could be made at both practice and individual levels to promote a healthier work environment for staff and patients.

Policies and strategies to retain and support the return of experienced GPs in direct patient care: the ReGROUP mixed-methods study

Background

UK general practice faces a workforce crisis, with general practitioner (GP) shortages, organisational change, substantial pressures across the whole health-care system and an ageing population with increasingly complex health needs. GPs require lengthy training, so retaining the existing workforce is urgent and important.

Objectives

(1) To identify the key policies and strategies that might (i) facilitate the retention of experienced GPs in direct patient care or (ii) support the return of GPs following a career break. (2) To consider the feasibility of potentially implementing those policies and strategies.

Design

This was a comprehensive, mixed-methods study.

Setting

This study took place in primary care in England.

Participants

General practitioners registered in south-west England were surveyed. Interviews were with purposively selected GPs and primary care stakeholders. A RAND/UCLA Appropriateness Method (RAM) panel comprised GP partners and GPs working in national stakeholder organisations. Stakeholder consultations included representatives from regional and national groups.

Main outcome measures

Systematic review – factors affecting GPs’ decisions to quit and to take career breaks. Survey – proportion of GPs likely to quit, to take career breaks or to reduce hours spent in patient care within 5 years of being surveyed. Interviews – themes relating to GPs’ decision-making. RAM – a set of policies and strategies to support retention, assessed as ‘appropriate’ and ‘feasible’. Predictive risk modelling – predictive model to identify practices in south-west England at risk of workforce undersupply within 5 years. Stakeholder consultation – comments and key actions regarding implementing emergent policies and strategies from the research.

Results

Past research identified four job-related ‘push’ factors associated with leaving general practice: (1) workload, (2) job dissatisfaction, (3) work-related stress and (4) work–life balance. The survey, returned by 2248 out of 3370 GPs (67%) in the south-west of England, identified a high likelihood of quitting (37%), taking a career break (36%) or reducing hours (57%) within 5 years. Interviews highlighted three drivers of leaving general practice: (1) professional identity and value of the GP role, (2) fear and risk associated with service delivery and (3) career choices. The RAM panel deemed 24 out of 54 retention policies and strategies to be ‘appropriate’, with most also considered ‘feasible’, including identification of and targeted support for practices ‘at risk’ of workforce undersupply and the provision of formal career options for GPs wishing to undertake portfolio roles. Practices at highest risk of workforce undersupply within 5 years are those that have larger patient list sizes, employ more nurses, serve more deprived and younger populations, or have poor patient experience ratings. Actions for national organisations with an interest in workforce planning were identified. These included collection of data on the current scope of GPs’ portfolio roles, and the need for formal career pathways for key primary care professionals, such as practice managers.

Limitations

The survey, qualitative research and modelling were conducted in one UK region. The research took place within a rapidly changing policy environment, providing a challenge in informing emergent policy and practice.

Conclusions

This research identifies the basis for current concerns regarding UK GP workforce capacity, drawing on experiences in south-west England. Policies and strategies identified by expert stakeholders after considering these findings are likely to be of relevance in addressing GP retention in the UK. Collaborative, multidisciplinary research partnerships should investigate the effects of rolling out some of the policies and strategies described in this report.

Study registration

This study is registered as PROSPERO CRD42016033876 and UKCRN ID number 20700.

Funding

The National Institute for Health Research Health Services and Delivery Research programme.

Prevalence of burnout among German general practitioners: Comparison of physicians working in solo and group practices

Background

Studies from general practitioner (GP) populations from various European countries show a high prevalence of burnout, yet data from Germany are scarce and there are no data comparing GPs from solo versus group practices.

Methods

This cross-sectional survey addressed all GPs from a German network of family medicine practices comprising 185 practices. Participants were asked to fill in a self-administered questionnaire addressing socio-demographic and job-related characteristics. The German version of the Maslach Burnout Inventory was used to measure the dimensions emotional exhaustion (EE), depersonalization (DP), and personal accomplishment (PA). Each participant was categorized as having high EE, high DP and low PA following pre-defined cut-offs.

Results

A total of 214 GPs from 129 practices participated: 65.9% male, 24.8% solo practice. Of all GPs, 34.1% (n = 73) scored high for EE, 29.0% (n = 62) high for DP, 21.5% (n = 46) low for PA and 7.5% (n = 16) for all three dimensions. A higher risk for EE was found among female physicians, those unsatisfied with their job, those using few stress-regulating measures regularly and those reporting bad work-life balance. Burnout prevalence was higher in GPs in group than in solo practices (37.9% vs. 28.8% had high EE, 33.1% vs. 18.9% had high DP and 22.8% vs. 18.9% had low PA). A significantly higher prevalence of burnout symptoms was found in group practice employees compared to group practice owners.

Conclusion

Burnout prevalence was higher among physicians in group practices compared to solo practices. In group practices, employed, young, female and part-time working physicians showed a higher burnout risk.

Supporting trainees in challenging learning environments - is there a way?

The working and learning environment within the NHS is challenging. 46% of GPs report emotional exhaustion, and trainees experience burn-out with higher prevalence than expected. Attending Balint groups (BGs) has been suggested to prevent burnout and compassion fatigue, helping GPs to thrive in their jobs. For this pilot service evaluation of BGs for GP trainees we used qualitative research methodology including surveys, participant observation, and semi-structured interviews. Fonagy's concept of resilience was used as the theoretical frame of reference. The data-led analysis identified trainees having burn-out sensations: un-met expectations for their training; their need for more support and the value of attending the BGs. Trainees experienced BG as a safe place, allowing open discussions and honest accounts of anxieties, facilitating clinical learning and learning skills of reflection as an important supplement to normal training. The theory-led analysis showed that BG sessions taught trainees new approaches to improve elements that are assessed as key in the selection process for GP training and as Fonagy described as characteristic for people with resilience. As a result of this project, a number of trainees expressed interest in continuing Balint group work. Trainees were recruited to an ongoing monthly BG, within the GP training scheme. However, due to budget restraints, difficulties with new interest and failing to find a non-training GP facilitator in the local area, the group has floundered.

Potential correlates of burnout among general practitioners and residents in Hungary: the significant role of gender, age, dependant care and experience

BACKGROUND

Burnout is increasingly prevalent among general practitioners (GPs) in Hungary, which may lead to functional impairment and, subsequently, to poor quality of patient care. However, little is known about potential predictors of burnout among GPs. The aim of this study was to explore psychosocial correlates of burnout among GPs and residents in Hungary.

METHODS

We collected socio-demographic and work-related data with self-administered questionnaires in a cross-sectional study among GPs (N = 196) and residents (N = 154). We assessed burnout with the Maslach Burnout Inventory Human Services Survey (MBI-HSS) and calculated the mean level of burnout and the proportion of physicians suffering from low, intermediate and high degree of burnout. To identify potential socio-demographic and work-related correlates of burnout among physicians, we determined Spearman's and Mann-Whitney U correlation coefficients and conducted stepwise linear regression analyses. We deployed Mann-Whitney U test to explore gender disparity in the level of burnout between female and male physicians and between general practitioners and residents.

RESULTS

The prevalence of moderate to high level emotional exhaustion, depersonalisation, and impaired personal accomplishment was 34.7, 33.5 and 67.8% as well as 41.0, 43.1, and 71.1% among GPs and residents, respectively. Residents reported significantly lower level of personal accomplishment vs GPs. We identified a significantly higher level of depersonalization among male physicians compared to female physicians. Age correlated negatively with emotional exhaustion and depersonalization and positively with personal accomplishment among GPs. Dependant care was positively associated with burnout among female GPs. Female residents were more likely to report depersonalization. High workload was positively correlated with depersonalization among female GPs. Younger age emerged as the strongest predictor of emotional exhaustion. Male gender and fewer years of experience predicted depersonalization best, and male gender showed a significant predictive relationship with low personal accomplishment.

CONCLUSION

We identified specific socio-demographic and work-related correlates of burnout, which may guide the development of specific and effective organizational decisions to attenuate occupational stress and subsequent burnout as well as functional impairment among GPs, and thus, may improve the quality of patient care.

The Implications of Psychological Symptoms for Length of Sick Leave

BACKGROUND

In this cross-sectional study, we aimed to determine the relation between sick leave duration, burnout symptoms, depression, anxiety, and somatization in a primary care setting.

METHODS

Patients receiving a sickness certificate in one of 14 participating primary care practices were consecutively asked by their primary care physician to fill in a questionnaire comprising the Maslach Burnout Inventory-General Survey (MBI-GS) and the Patient Health Questionnaire (PHQ) containing the depression (PHQ-9), somatization (PHQ-15), and anxiety (GAD-7) scales. The main diagnosis on the sickness certificate was documented by the issuing physician. A quasi-Poisson regression analysis was performed to estimate the influence of burnout symptoms, depression, and anxiety on length of sick leave.

RESULTS

225 patients participated, 122 (54.2%) were female; the mean age was 39.5 years. Length of sick leave correlated with emotional exhaustion (p = 0.005), depersonalization (p = 0.013), depression (p = 0.006), anxiety (p = 0.023), and somatization (p = 0.001). However, regression analysis revealed that the only predictors for length of sick leave were anxiety (exp[0.081] = 1.084; p = 0.013), age (exp[0.017] = 1.017; p = 0.041) and education (exp[- 0.508] = 0.602; p = 0:029). The pseudo R2 of the model was 0.25.

CONCLUSION

The impact of anxiety on burnout symptoms and sick leave days might have been underestimated so far. A holistic approach in patient centered communication should comprise the evaluation of psychosomatic comorbidity under consideration of the established concepts of depression and anxiety disorder to ensure adequate diagnostic and therapeutic management.

Prevalence of Burnout Among Physicians: A Systematic Review

Importance

Burnout is a self-reported job-related syndrome increasingly recognized as a critical factor affecting physicians and their patients. An accurate estimate of burnout prevalence among physicians would have important health policy implications, but the overall prevalence is unknown.

Objective

To characterize the methods used to assess burnout and provide an estimate of the prevalence of physician burnout.

Data Sources and Study Selection

Systematic search of EMBASE, ERIC, MEDLINE/PubMed, psycARTICLES, and psycINFO for studies on the prevalence of burnout in practicing physicians (ie, excluding physicians in training) published before June 1, 2018.

Data Extraction and Synthesis

Burnout prevalence and study characteristics were extracted independently by 3 investigators. Although meta-analytic pooling was planned, variation in study designs and burnout ascertainment methods, as well as statistical heterogeneity, made quantitative pooling inappropriate. Therefore, studies were summarized descriptively and assessed qualitatively.

Main Outcomes and Measures

Point or period prevalence of burnout assessed by questionnaire.

Results

Burnout prevalence data were extracted from 182 studies involving 109 628 individuals in 45 countries published between 1991 and 2018. In all, 85.7% (156/182) of studies used a version of the Maslach Burnout Inventory (MBI) to assess burnout. Studies variably reported prevalence estimates of overall burnout or burnout subcomponents: 67.0% (122/182) on overall burnout, 72.0% (131/182) on emotional exhaustion, 68.1% (124/182) on depersonalization, and 63.2% (115/182) on low personal accomplishment. Studies used at least 142 unique definitions for meeting overall burnout or burnout subscale criteria, indicating substantial disagreement in the literature on what constituted burnout. Studies variably defined burnout based on predefined cutoff scores or sample quantiles and used markedly different cutoff definitions. Among studies using instruments based on the MBI, there were at least 47 distinct definitions of overall burnout prevalence and 29, 26, and 26 definitions of emotional exhaustion, depersonalization, and low personal accomplishment prevalence, respectively. Overall burnout prevalence ranged from 0% to 80.5%. Emotional exhaustion, depersonalization, and low personal accomplishment prevalence ranged from 0% to 86.2%, 0% to 89.9%, and 0% to 87.1%, respectively. Because of inconsistencies in definitions of and assessment methods for burnout across studies, associations between burnout and sex, age, geography, time, specialty, and depressive symptoms could not be reliably determined.

Conclusions and Relevance

In this systematic review, there was substantial variability in prevalence estimates of burnout among practicing physicians and marked variation in burnout definitions, assessment methods, and study quality. These findings preclude definitive conclusions about the prevalence of burnout and highlight the importance of developing a consensus definition of burnout and of standardizing measurement tools to assess the effects of chronic occupational stress on physicians.

Mental well-being and job satisfaction among general practitioners: a nationwide cross-sectional survey in Denmark

Background

Poor mental well-being and low job satisfaction among physicians can have significant negative implications for the physicians and their patients and may also reduce the cost efficiency in health care. Mental distress is increasingly common in physicians, including general practitioners (GPs). This study aimed to examine mental well-being and job satisfaction among Danish GPs and potential associations with age, gender and practice organisation.

Methods

Data was collected in a nationwide questionnaire survey among Danish GPs in 2016. Register data on GPs and their patient populations was used to explore differences between respondents and non-respondents. Associations were estimated using multivariate logistic regression analysis.

Results

Of 3350 eligible GPs, 1697 (50.7%) responded. Lower response rate was associated with increasing numbers of comorbid, aging or deprived patients. About half of participating GPs presented with at least one burnout symptom; 30.6% had high emotional exhaustion, 21.0% high depersonalisation and 36.6% low personal accomplishment. About a quarter (26.2%) experienced more than one of these symptoms, and 10.4% experienced all of them. Poor work-life balance was reported by 16.2%, low job satisfaction by 22.1%, high perceived stress by 20.6% and poor general well-being by 18.6%. Constructs were overlapping; 8.4% had poor overall mental health, which was characterized by poor general well-being, high stress and ≥ 2 burnout symptoms. In contrast, 24.6% had no burnout symptoms and reported high levels of general well-being and job satisfaction. Male GPs more often than female GPs reported low job satisfaction, depersonalisation, complete burnout and poor overall mental health. Middle-aged (46–59 years) GPs had higher risk of low job satisfaction, burnout and suboptimal self-rated health than GPs in other age groups. GPs in solo practices more often assessed the work-life balance as poor than GPs in group practices.

Conclusion

The prevalence of poor mental well-being and low job satisfaction was generally high, particularly among mid-career GPs and male GPs. Approximately 8% was substantially distressed, and approximately 25% reported positive mental well-being and job satisfaction, which shows huge variation in the mental well-being among Danish GPs. The results call for targeted interventions to improve mental well-being and job satisfaction among GPs.

Electronic supplementary material

The online version of this article (10.1186/s12875-018-0809-3) contains supplementary material, which is available to authorized users.

'Treading water but drowning slowly': what are GPs' experiences of living and working with mental illness and distress in England? A qualitative study

OBJECTIVES

This paper provides an in-depth account of general practitioners' (GPs) experiences of living and working with mental illness and distress, as part of a wider study reporting the barriers and facilitators to help-seeking for mental illness and burn-out, and sources of stress/distress for GP participants.

DESIGN

Qualitative study using in-depth interviews with 47 GP participants. The interviews were audio recorded, transcribed, anonymised and imported into NVivo V.11 to facilitate data management. Data were analysed using a thematic analysis employing the constant comparative method.

SETTING

England.

PARTICIPANTS

A purposive sample of GP participants who self-identified as: (1) currently living with mental distress, (2) returning to work following treatment, (3) off sick or retired early as a result of mental distress or (4) without experience of mental distress. Interviews were conducted face to face or over the telephone.

RESULTS

The findings report GP participants' in-depth experiences of distress and mental illness with many recollecting their distressing experiences and significant psychological and physical symptoms relating to chronic stress, anxiety, depression and/or burn-out, and a quarter articulating thoughts of suicide. Many talked about their shame, humiliation and embarrassment at their perceived inability to cope with the stresses of their job and/or their symptoms of mental illness.

CONCLUSIONS

These findings paint a concerning picture of the situation affecting primary care doctors, with participants' accounts suggesting there is a considerable degree of mental ill health and reduced well-being among GPs. The solutions are complex and lie in prevention and provision. There needs to be greater recognition of the components and cumulative effect of occupational stressors for doctors, such as the increasing workload and the clinical and emotional demands of the job, as well as the need for a culture shift within medicine to more supportive and compassionate work environments.

Does a modified mindfulness-based cognitive therapy (MBCT) course have the potential to reduce stress and burnout in NHS GPs? Feasibility study

AimTo explore, for the first time, whether a modified mindfulness-based cognitive therapy (MBCT) course has the potential to reduce stress and burnout among National Health Service (NHS) General Practitioners. BACKGROUND: There is a crisis of low morale among NHS GPs, with most describing their workload as 'unmanageable'. MBCT has been demonstrated to improve stress and burnout in other populations, but has not yet been evaluated in a cohort of NHS GPs. METHODS: NHS GPs in South East England (n=22) attended a modified version of the MBCT course approved by National Institute for Health and Care Excellence for prevention of depressive relapse. This comprised eight weekly 2-h sessions with homework (mindfulness practice) between sessions. Participants completed the Maslach Burnout Inventory (MBI) and Perceived Stress Scale (PSS) before (baseline) and then again one month (T2) and three months (T3) after attending the course. We also obtained qualitative data on participants' experiences of the course.FindingsCompliance with the intervention was very high. All GPs attended at least six sessions and all completed baseline questionnaires. At T2, data were obtained from 21 participants (95%); PSS scores were significantly lower than at baseline (P&lt;0.001), as were MBI emotional exhaustion (P&lt;0.001) and depersonalization scores (P=0.0421). At T3 we obtained data for 13 participants (59%); PSS scores and MBI emotional exhaustion scores were significantly lower (P&lt;0.001; P=0.0024, respectively) and personal accomplishment scores were significantly higher (P&lt;0.001) than at baseline. Participants reported that the course helped them to manage work pressures, feel more relaxed, enjoy their work and experience greater empathy and compassion (for self, colleagues and patients). Findings of this preliminary evaluation are promising. Further research is needed to evaluate this approach within a larger randomized-controlled trial.

Empathy, burn-out and the use of gut feeling: a cross-sectional survey of Danish general practitioners

OBJECTIVE

Research has suggested that physicians' gut feelings are associated with parents' concerns for the well-being of their children. Gut feeling is particularly important in diagnosis of serious low-incidence diseases in primary care. Therefore, the aim of this study was to examine whether empathy, that is, the ability to understand what another person is experiencing, relates to general practitioners' (GPs) use of gut feelings. Since empathy is associated with burn-out, we also examined whether the hypothesised influence of empathy on gut feeling use is dependent on level of burn-out.

DESIGN

Cross-sectional questionnaire survey. Participants completed the Jefferson Scale of Physician Empathy and The Maslach Burnout Inventory.

SETTING

Primary care.

PARTICIPANTS

588 active GPs in Central Denmark Region (response rate=70%).

PRIMARY OUTCOME MEASURES

Self-reported use of gut feelings in clinical practice.

RESULTS

GPs who scored in the highest quartile of the empathy scale had fourfold the odds of increased use of gut feelings compared with GPs in the lowest empathy quartile (OR 3.99, 95% CI 2.51 to 6.34) when adjusting for the influence of possible confounders. Burn-out was not statistically significantly associated with use of gut feelings (OR 1.29, 95% CI 0.90 to 1.83), and no significant interaction effects between empathy and burn-out were revealed.

CONCLUSIONS

Physician empathy, but not burn-out, was strongly associated with use of gut feelings in primary care. As preliminary results suggest that gut feelings have diagnostic value, these findings highlight the importance of incorporating empathy and interpersonal skills into medical training to increase sensitivity to patient concern and thereby increase the use and reliability of gut feeling.

Compassion fatigue and compassion satisfaction among family physicians in the Republic of Srpska, Bosnia and Herzegovina

Aims. The aim of this study was to examine self-perceived compassion fatigue and compassion satisfaction among family physicians in Bosnia and Herzegovina and describe potential contributing factors. Methods. The cross-sectional study enrolled 120 family physicians. Professional quality of life compassion satisfaction and fatigue version 5 (ProQOL5) was used to assess compassion satisfaction and two components of compassion fatigue, secondary traumatic stress and burnout. The symptoms of chronic fatigue were evaluated using the Chalder fatigue scale. Results. The majority of family physicians had moderate levels of compassion satisfaction (70%), burnout (75%) and secondary traumatic stress (55.8%). Family physicians with higher levels of secondary traumatic stress reported chronic fatigue (p = 0.001), longer length of service (p = 0.024) and residency training (p = 0.041). Chronic fatigue (p = 0.001), living in a rural environment (p = 0.033), larger size of practice (p = 0.006) and high number of patients with chronic disease (p = 0.001) were associated with a higher risk of burnout. Conclusion. Family physicians with large practices, long years of experience, a high number of chronically ill patients and experiencing chronic fatigue are at risk of developing compassion fatigue. A systematic exploration of compassion fatigue in relation to working conditions might provide an appropriate starting point for the development of preventive interventions.

What are the sources of stress and distress for general practitioners working in England? A qualitative study

OBJECTIVES

This paper reports the sources of stress and distress experienced by general practitioners (GP) as part of a wider study exploring the barriers and facilitators to help-seeking for mental illness and burnout among this medical population.

DESIGN

Qualitative study using in-depth interviews with 47 GP participants. The interviews were audio-recorded, transcribed, anonymised and imported into NVivo V.11 to facilitate data management. Data were analysed using a thematic analysis employing the constant comparative method.

SETTING

England.

PARTICIPANTS

A purposive sample of GP participants who self-identified as: (1) currently living with mental distress, (2) returning to work following treatment, (3) off sick or retired early as a result of mental distress or (4) without experience of mental distress. Interviews were conducted face-to-face or over the telephone.

RESULTS

The key sources of stress/distress related to: (1) emotion work-the work invested and required in managing and responding to the psychosocial component of GPs' work, and dealing with abusive or confrontational patients; (2) practice culture-practice dynamics and collegial conflict, bullying, isolation and lack of support; (3) work role and demands-fear of making mistakes, complaints and inquests, revalidation, appraisal, inspections and financial worries.

CONCLUSION

In addition to addressing escalating workloads through the provision of increased resources, addressing unhealthy practice cultures is paramount. Collegial support, a willingness to talk about vulnerability and illness, and having open channels of communication enable GPs to feel less isolated and better able to cope with the emotional and clinical demands of their work. Doctors, including GPs, are not invulnerable to the clinical and emotional demands of their work nor the effects of divisive work cultures-culture change and access to informal and formal support is therefore crucial in enabling GPs to do their job effectively and to stay well.

Why do GPs leave direct patient care and what might help to retain them? A qualitative study of GPs in South West England

OBJECTIVE

To identify factors influencing general practitioners' (GPs') decisions about whether or not to remain in direct patient care in general practice and what might help to retain them in that role.

DESIGN

Qualitative, in-depth, individual interviews exploring factors related to GPs leaving, remaining in and returning to direct patient care.

SETTING

South West England, UK.

PARTICIPANTS

41 GPs: 7 retired; 8 intending to take early retirement; 11 who were on or intending to take a career break; 9 aged under 50 years who had left or were intending to leave direct patient care and 6 who were not intending to leave or to take a career break. Plus 19 stakeholders from a range of primary care-related professional organisations and roles.

RESULTS

Reasons for leaving direct patient care were complex and based on a range of job-related and individual factors. Three key themes underpinned the interviewed GPs' thinking and rationale: issues relating to their personal and professional identity and the perceived value of general practice-based care within the healthcare system; concerns regarding fear and risk, for example, in respect of medical litigation and managing administrative challenges within the context of increasingly complex care pathways and environments; and issues around choice and volition in respect of personal social, financial, domestic and professional considerations. These themes provide increased understanding of the lived experiences of working in today's National Health Service for this group of GPs.

CONCLUSION

Future policies and strategies aimed at retaining GPs in direct patient care should clarify the role and expectations of general practice and align with GPs' perception of their own roles and identity; demonstrate to GPs that they are valued and listened to in planning delivery of the UK healthcare; target GPs' concerns regarding fear and risk, seeking to reduce these to manageable levels and give GPs viable options to support them to remain in direct patient care.

Use of an electronic consultation system in primary care: a qualitative interview study

BACKGROUND

The level of demand on primary care continues to increase. Electronic or e-consultations enable patients to consult their GP online and have been promoted as having potential to improve access and efficiency.

AIM

To evaluate whether an e-consultation system improves the ability of practice staff to manage workload and access.

DESIGN AND SETTING

A qualitative interview study in general practices in the West of England that piloted an e-consultation system for 15 months during 2015 and 2016.

METHOD

Practices were purposefully sampled by location and level of e-consultation use. Clinical, administrative, and management staff were recruited at each practice. Interviews were transcribed and analysed thematically.

RESULTS

Twenty-three interviews were carried out across six general practices. Routine e-consultations offered benefits for the practice because they could be completed without direct contact between GP and patient. However, most e-consultations resulted in GPs needing to follow up with a telephone or face-to-face appointment because the e-consultation did not contain sufficient information to inform clinical decision making. This was perceived as adding to the workload and providing some patients with an alternative route into the appointment system. Although this was seen as offering some patient benefit, there appeared to be fewer benefits for the practices.

CONCLUSION

The experiences of the practices in this study demonstrate that the technology, in its current form, fell short of providing an effective platform for clinicians to consult with patients and did not justify their financial investment in the system. The study also highlights the challenges of remote consultations, which lack the facility for real time interactions.

Shame and the vulnerable self in medical contexts: the compassionate solution

Shame is a powerful experience that plays a vital role in a whole range of aspects of the clinical encounter. Shame experiences can have an impact on our psychological and physiological state and on how we experience ourselves, others and our relationships. The medical encounter is an obvious arena for shame because we are presenting (aspects of) our bodies and minds that can be seen as unattractive and undesirable, diseased, decayed and injured with the various excretions that typically might invite disgust. In contrast, experiences of compassion of acceptance, validation and kindness and can increase approach, openness and preparedness to engage with painful difficult scenarios. While shame is an experience that separates, segregates, marginalises and disengages people, caring and compassion facilitate integration, (re)connection and support. Given the potential opposite impacts of these different types of social experience, this paper will outline their evolutionary origins and compare and contrast them with particular reference to the medical context.

Use of a primary care online consultation system, by whom, when and why: evaluation of a pilot observational study in 36 general practices in South West England

OBJECTIVES

Evaluation of a pilot study of an online consultation system in primary care. We describe who used the system, when and why, and the National Health Service costs associated with its use.

DESIGN

15-month observational study.

SETTING

Primary care practices in South West England.

RESULTS

36 General practices covering 396 828 patients took part in the pilot. The online consultation website was viewed 35 981 times over the pilot period (mean 9.11 visits per 1000 patients per month). 7472 patients went on to complete an 'e-consultation' (mean 2.00 online consultations per 1000 patients per month). E-consultations were mainly performed on weekdays and during normal working hours. Patient records (n=485) were abstracted for eight practices and showed that women were more likely to use e-consultations than men (64.7% vs 35.3%) and users had a median age of 39 years (IQR 30-50). The most common reason for an e-consultation was an administrative request (eg, test results, letters and repeat prescriptions (22.5%)) followed by infections/immunological issues (14.4%). The majority of patients (65.2%) received a response within 2 days. The most common outcome was a face-to-face (38%) or telephone consultation (32%). The former were more often needed for patients consulting about new conditions (OR 1.56, 95% CI 1.05 to 2.27, p=0.049). The average cost of a practice's response to an e-consultation was £36.28, primarily triage time and resulting face-to-face/telephone consultations needed.

CONCLUSIONS

Use of e-consultations is very low, particularly at weekends. Unless this can be improved, any impact on staff workload and patient waiting times is likely to be negligible. It is possible that use of e-consultations increases primary care workload and costs. Online consultation systems could be developed to improve efficiency both for staff and patients. These findings have implications for software developers as well as primary care services and policy-makers who are considering investing in online consultation systems.

Barriers, facilitators, and survival strategies for GPs seeking treatment for distress: a qualitative study

BACKGROUND

GPs are under increasing pressure due to a lack of resources, a diminishing workforce, and rising patient demand. As a result, they may feel stressed, burnt out, anxious, or depressed.

AIM

To establish what might help or hinder GPs experiencing mental distress as they consider seeking help for their symptoms, and to explore potential survival strategies.

DESIGN AND SETTING

The authors recruited 47 GP participants via e-mails to doctors attending a specialist service, adverts to local medical committees (LMCs) nationally and in GP publications, social media, and snowballing. Participants self-identified as either currently living with mental distress, returning to work following treatment, off sick or retired early as a result of mental distress, or without experience of mental distress. Interviews were conducted face to face or over the telephone.

METHOD

Transcripts were uploaded to NVivo 11 and analysed using thematic analysis.

RESULTS

Barriers and facilitators were related to work, stigma, and symptoms. Specifically, GPs discussed feeling a need to attend work, the stigma surrounding mental ill health, and issues around time, confidentiality, and privacy. Participants also reported difficulties accessing good-quality treatment. GPs also talked about cutting down or varying work content, or asserting boundaries to protect themselves.

CONCLUSION

Systemic changes, such as further information about specialist services designed to help GPs, are needed to support individual GPs and protect the profession from further damage.

Burnout and psychiatric morbidity among doctors in the UK: a systematic literature review of prevalence and associated factors

Aims and method To systematically review the prevalence and associated factors of burnout and stress-related psychiatric disorders among UK doctors. An extensive search was conducted of PubMed, EBSCOhost and British medical journals for studies published over a 20-year span measuring the prevalence of psychiatric morbidity (using the General Health Questionnaire) and burnout (using the Maslach Burnout Inventory). Results Prevalence of psychiatric morbidity ranged from 17 to 52%. Burnout scores for emotional exhaustion ranged from 31 to 54.3%, depersonalisation 17.4 to 44.5% and low personal accomplishment 6 to 39.6%. General practitioners and consultants had the highest scores. Factors significantly associated with increase in the prevalence of burnout and psychiatric morbidity include low job satisfaction, overload, increased hours worked and neuroticism. Clinical implications The results indicate a worryingly high rate of burnout and psychiatric morbidity among UK doctors, which could have a huge negative impact on healthcare provision in general. Factors at personal and organisational levels contribute to burnout and psychiatric morbidity, and so efforts made to counter these problems should target both levels.

Telephone triage systems in UK general practice: analysis of consultation duration during the index day in a pragmatic randomised controlled trial

BACKGROUND

Telephone triage is an increasingly common means of handling requests for same-day appointments in general practice.

AIM

To determine whether telephone triage (GP-led or nurse-led) reduces clinician-patient contact time on the day of the request (the index day), compared with usual care.

DESIGN AND SETTING

A total of 42 practices in England recruited to the ESTEEM trial.

METHOD

Duration of initial contact (following the appointment request) was measured for all ESTEEM trial patients consenting to case notes review, and that of a sample of subsequent face-to-face consultations, to produce composite estimates of overall clinician time during the index day.

RESULTS

Data were available from 16,711 initial clinician-patient contacts, plus 1290 GP, and 176 nurse face-to-face consultations. The mean (standard deviation) duration of initial contacts in each arm was: GP triage 4.0 (2.8) minutes; nurse triage 6.6 (3.8) minutes; and usual care 9.5 (5.0) minutes. Estimated overall contact duration (including subsequent contacts on the same day) was 10.3 minutes for GP triage, 14.8 minutes for nurse triage, and 9.6 minutes for usual care. In nurse triage, more than half the duration of clinician contact (7.7 minutes) was with a GP. This was less than the 9.0 minutes of GP time used in GP triage.

CONCLUSION

Telephone triage is not associated with a reduction in overall clinician contact time during the index day. Nurse-led triage is associated with a reduction in GP contact time but with an overall increase in clinician contact time. Individual practices may wish to interpret the findings in the context of the available skill mix of clinicians.

Human rights in childbirth, narratives and restorative justice: a review

This review describes the emerging global debate on the role of human rights childbirth. It is also tailored to a UK perspective in view of the Montgomery v. Lanarkshire [2015] legal ruling and it implications to practice. We can never underestimate the power of humane care on health. The compassion and evidence based medicine agenda in healthcare is interconnected with human rights in healthcare, feeding into the principles of decision making and patient centred care. When this has not happened and there is been healthcare conflict, the power of storytelling serves to connect disparate parties to their common humanity. Narratives are an important aspect of restorative justice processes and we suggest that this could be beneficial in the field of human rights in childbirth.