Not sure how much longer I can keep working like this (NHS GP)

[TiredofbeingaGP]

I've name changed for this, as don't want it tied to my usual username.
Sorry this is long, I guess I just want to vent and consider my options, and I'd be interested to hear from anyone who's been in this situation and come out of the other side of it...

I'm a GP in a severely understaffed practice. It's a medium sized practice that's run by a non-profit group that has taken over the contracts for several practices in the area, as the partners have handed back the contracts to NHS England for various reasons (retirement, emigration, burnout).

I've been there for 2 years (qualified GP for 11 years), and there's never been much stability of clinical staff, but the management are supportive, if overstretched themselves. There's lots of good innovative thinking, but this translates into an exhausting rate of change. At the moment this is causing low morale in the admin team and some of the clinical team.

I'm an introvert and a HSP. I have a lovely, energetic and exhausting 8yr old DS, and a lovely but busy DH, who is a full time consultant in a hospital specialty, so works a lot of weekends and evenings.

I have always struggled with the emotional burden of general practice - I'm the sort of GP who listens, and is supportive and understanding, and therefore runs late all the time (my regular patients bring a book). I wouldn't/ couldn't practice any other way, and I do make a difference to my patients' lives, but it means I shoulder more than my fair share of complex chronic illness and mental health issues (especially when we need a lot of locum GPs to keep afloat).

I am increasingly struggling with stress and anxiety. This has been worse since Easter, when another GP left, and I've been on-call constantly since then. I only work clinically two days a week, but those are inevitably 12 hour days, busy and full of clinical risk, trying to sort out the same day urgent work and fit in my regular patients as well. I then do the vast majority of parenting and the mental load of the household, simply because DH isn't around much. When he is here, he mucks in and does his share of parenting and housework.

I gave up a stressful academic post last year, having had to take time off sick with stress the year before. Initially this helped a lot, but since then we've lost two more GPs.

I am doing all the self care stuff - talking to colleagues, exercising regularly, trying to eat well, meditating, CBT-ing myself constantly, taking time on my own when I can to recharge - but increasingly it isn't enough to keep my head above water. I'm not sleeping well, feeling tearful a lot of the time, binge eating carbs (which is a stress response), having difficulty letting go of work when I'm at home, being grumpy and impatient with DS and then feeling really guilty.

I'm aware the practice isn't really safe - I keep picking up on things the locums have missed, some because they aren't very good, and some because they just don't know the patients. Continuity of care saves lives. I'm also aware that my decision making after 11 hours of clinical work isn't the best, and I worry about what I'm missing.

The thing is, I don't think the grass is necessarily greener elsewhere (IE working for a different practice), and I don't know what else to do to keep going. I've tried academia/ medical teaching (massive workload, bullying management), tried working part-time, tried walk-in centre work (missed the continuity and the contact with other GPs).

I've talked to the managers and they know I'm struggling, but there's little else they can do unless we can recruit more GPs, and they're very thin on the ground! I don't really want to take medication for symptoms that are actually a fairly proportionate response to an impossible situation. I also had a severe adverse reaction to sertraline, so I'm wary of taking anything similar. I love being a GP, but not at the indefinite expense of my mental health and my family.

Any ideas how I can get out of this mess?!!

You're right, it's silly to be struggling this much and not have a cleaner when we can afford it. I will speak to DH about it again, He knows how much I'm struggling, so I think he'll be amenable.

We're so short staffed that attempting to split the working hours over more days would just result in a greater workload. I do 'hand back' stuff when it get's really busy, but the practice manager is also trying to run another practice that the company has recently taken over (rather than letting it close and having to cope with the redistributed patients), so she's often not there. Basically I reach a point where I tell the reception staff to redirect anyone else wanting an appointment of phone call to the walk-in centre, or they can wait until tomorrow. Unfortunately, if I'm busy dealing with something urgent and time consuming (admission/ mental health crisis), I often don't realise that the on call list has piled up until it's too late to redirect them. There isn't anyone else senior enough to make that decision on my behalf unless the practice manager happens to be there.

I work two days together, in the middle of the week. So excluding the school run, I theoretically have about 18 hours a week when DS is at school. Of those I spend 6 hours (2 x 3 hours)at the gym (including travel and shower time) which I find essential for my mental and physical health, 3-4 hours walking the dog (which is relaxing), 2 hours doing CPD (which I get paid for and have to do to revalidate) and the rest doing chores and jobs. I'm not especially house proud - we're talking basic hygiene measures, and I don't iron at all.

[Edited by MNHQ to protect identifying information]

Sorry Tired, no advice but thank you for what you do

You sound a brilliant GP and I couldn't do what you do. I'm certain your patients don't mind waiting a bit to see you because they know you will really listen to them.

What would they do if you refused to be on call every day? I’m assuming it all falls to you as the locums can’t do it so it falls to you? When you say on call constantly do you mean 7 days a week or the two days you work?

But if you leave they’ll have a practice fully staffed by locums and then none of them will be able to do it? Even if you mean you’re on call two days a week would saying you’ll only do one day a week or one day a fortnight help. Then the other days you can have longer appts?

Echo what people said. Thank you! I too work in a very stressful job (won't go in to details but think of biggest change happening in UK) and I job share which makes a HUGE difference. Can you suggest they try and recruit a job share partner?

If you’re this stressed working for only two days, I think you need to go back and see that psychiatrist. You sound utterly consumed by everything which isn’t normal as I’m sure you know. Perhaps you have deeper mental health difficulties than you think. Good luck.

Firstly as PPs have said to u sound like an amazing GP. And secondly this sounds as much about your home set-up as about your work.

Firstly get a cleaner. DH also didn’t like the idea of us having one. When I pointed out that he was therefore free to do as much cleaning as he liked himself because I’d had enough, he stopped whining about it. There is no moral virtue in doing your own housework, and you can remind your DH that by paying someone else to do it you are providing valuable employment to others, as well as keeping yourself sane. In terms of outsourcing we get a repeat, basic shop delivered every week, that does us all our basics and a few standard meals. If we fancy something different we either get it from the little local shop or edit the delivery, but if we forget or don’t have time stuff still turns up so there are things for dinner and we don’t run out of bread or milk or cat litter. We also have a calendar and stuff has to be on it or it won’t happen - I refuse to remember things for DH so after a few occasions of him missing social events, family birthdays and even on one occasion getting a pissy phone call from the nursery to say he’d forgotten to collect DC, he has been much better about using and checking the calendar. But I had to weather feeling really mean, and let stuff not be perfect for a while, which was very hard as there is more than a slight streak of perfectionism in my character (which has been compounded in recent years by postnatal anxiety). And sounds like it would be for you too.

I’m still in medical school, don’t know much about the realities of being a GP, but could you alter your sessions? Ten hour days are long, even before they’re extended. DH is a shift worker in the emergency services and seems to tip into exhaustion with the ten-hour+ shifts, but manages anything less than that fine. If you did say four mornings rather than two full days, even if you stayed late checking things presumably you’d still then get home mid-afternoon rather than late evening. You’d have fewer days at home but decent evenings to unwind. Or could you drop to one day, but do some sessions for one of the online private GP services - I know you said you’d miss your contact with others but if you were still getting that sometimes? Also, is there any possibility at all for your DH to reduce or restrict his hours even slightly? Realise it depends very much on the hospital and on the specialty but it sounds like you could just do with having him at home a bit more, even if short term?

I’m sure this is all stuff you’ve already thought about, so apologies if none of it is useful. At the end of the day your family and your own mental health matter more than anything else .

1. Get a cleaner. Ignore your DH. Get a cleaner.

1. Join www.doctors.net.uk and post on The Couch. There will be many wise heads on there who can advise, both emotionally and professionally. You can post anonymously and it is doctors only. The GP Forum there is also a fount of wisdom.

1. Do not get caught in sunk costs fallacy. If you left they would have to fix the problem.

1. Do you need help yourself from the GP Health Service? gphealth.nhs.uk/

My dad refused a cleaner for similar reasons. It was hard on my working mum and unnecessary.
When I got a cleaner, she was delighted. Tell your husband
: cleaning ( household care) is a proper job. Pay a decent rate to a good cleaner. Mine stayed 15 years.
: working parents need proper down time as a family. The only housework I did at weekends was cooking. Because I like it.
: I encouraged my friend, cash rich/time poor, working from home, to pay her cleaner to come in Mon-Fri 9-11. She says it's the best thing she ever did! Her cleaner rules them with a rod of iron, mind.

Firstly, get a cleaner. It is ridiculous to spend your free time cleaning when you are so stressed and unhappy. Fuck dh's sensibilities. You need your free time to look after your own well-being.

Secondly have you contacted GP Health run by the Practitioners Health Programme? They can offer free high quality CBT/ therapy. Please contact them, even if you don't want therapy. They are experienced at helping GPs in similar positions.

Thirdly I felt horribly stressed reading your description of your work days. You cannot continue to prop up NHS general practice. There are so many cuts, deficiencies, shortages, please don't sacrifice your happiness and your dc's well-being to try and achieve the impossible for patients. You need to put more boundaries in your work to protect yourself, or move to a less stressful role, to look after your own mental health. Yes patients will suffer, but what is the alternative, you exhaust yourself and end up burnt out, or making a serious error, or depressed on sick leave? Patients are suffering due to decisions taken by politicians and voters, not due to an individual GP's decision to stick to a safe sustainable workload, you are not to blame.

Yes working as a locum, or in a hub/ walk in centre/ private clinic is not your ideal, but as a short term change it will give you some breathing space and help you to continue your GP career with less stress, less responsibility, fewer hours. You can return to NHS GP later when things have improved.

Another option is the GP Retainer scheme.

Thank you for your suggestions.

Yes, the cleaner angst is a bit daft, and we have had this conversation on several occasions (including the point about having a responsibility to create jobs!). I am going to have another chat with DH about it.

DS has school dinners. DH does the bulk of the food planning/ complex cooking and he batch cooks, so there's usually healthy food in the house.

I hadn't thought of it, but reflecting on it, I do think the bullying and being made to feel weak in the academic job has had an impact on my self confidence. I feel like a wimp for admitting that DH does the cooking/ food shopping on top of his busy full time job and I STILL can't cope! That's entirely my perspective by the way, DH is very supportive, and says his job is nothing like as intense as mine.

Also, I have been calling this 'stress', but actually I do have symptoms of depression and anxiety, and I really need to acknowledge that!

We tried letting locums do the on call. One was making really weird clinical decisions and also upsetting the patients, another disappeared for a 3 hour lunch break (!!!), yet another refused to do a home visit because the patient was complicated and 'it would take too long'. Frankly they create more problems than they solve.
I'm only on call for the days that I'm there, and we do have some good longer term locums covering the on call on the other days at the moment, which is an improvement on a couple of months ago, but they're costing the practice a fortune and we won't be able to keep hiring them indefinitely.

I'm reading back my responses and realising how negative I'm sounding! I really do appreciate your suggestions and responses.

Oh I also meant to say - your feelings may be totally proportionate to the situation, but that doesn’t mean medication wouldn’t still give you a bit of headspace. I was vehemently against taking anything but when postnatal anxiety + doing badly at uni + ill DH + stressful family stuff all added up and I thought my head was going to explode (and I also remember saying that I wasn’t ill, just reacting normally to a lot of stress) giving in and taking SSRIs for a little while just seemed to quiet my brain down enough to see the wood for the trees, and I was able to sort things out and make some decisions, and actually come off them again fairly quickly in a much better place.

I'm a cleaner so I would say this wouldn't I, but find a good one, book a couple of full days to get the whole house up to scratch, then a regular weekly or twice weekly visit. Honestly it will make a huge difference not only saving you time but the boost of coming home to a clean house. Is your husband 90? Sounds a bit "old fashioned" re the not having a cleaner thing. Tell him it's ok I don't feel exploited thanks I like my job ;)

Thinks are tough in the nhs and unfortunately people do not critically appraise the ‘evidence’ produced by the media. They blindly see the salary. I’m knackered- to the point I feel there’s something physically wrong with me but reflecting on my day during which majority of people on my caseload cried I can see my tiredness may not actually be physical. Oh and the 6 day week I’ve done since April but the headlines say I had a 29% pay rise??!
Lots of factors at play in nhs in general. Chronic underpayment of staff, bullying, nepotism, staff working part time, agency staff that do the minimum required-one that nobody likes to talk about is immigration- if you increase a population by a third there should be a third increase in services. This equates to an extra 10 staff in my workplace. We had zero.

You’re an HSP, that’s the bit that leaps out to me. What advice would you give to an HSP who works with people and sorts out their problems?

There is a GP like you in most practices and, as you know, patients flock around to get the very best care. You sound like a brilliant GP. Please don't ignore your body and brain - they're telling you something vital. I sense your H is a difficult character. Do you have friends? Do you get out and laugh and have fun? You really can't be your own therapist or doctor. I really would recommend that you find a therapist to open up to.

I'm not a doctor, and my oncall work is constant, but not life-critical, but please, please, don't even think twice.

Get a cleaner. Get one that'll do the laundry too, maybe even the washing up.

The relief of coming home to a clean house, without mounds of laundry is immense - just try it for a month, you will feel the difference.

Joining the chorus of voices saying you sound like you're a fantastic GP and I wish I was on your list.

DH isn't keen on having a cleaner - we both have very working class roots, but he grew up with a lot of financial stress and he doesn't like hiring people to do jobs that we're perfectly capable of ourselves.

Funnily enough, you're exactly the type of person I use as a counter example to this sort of misplaced (in my view) attitude to paying for a cleaner. You've won life's genetic lottery - you're bright enough to qualify as a doctor and are being a damned good one. Not everyone can do that, and we as a society need doctors like you. If paying a cleaner is what it takes to lighten your load and enable you to continue doing what you're good at, provided you pay the cleaner a living wage (plus enough for sick pay and holiday pay, and NI contributions) I don't see the problem. ("From each according to his abilities; to each according to his needs..." )

BTW, I also second the idea that you shouldn't underestimate the long-term effects of the bullying issue/research post problems. I was made redundant from a research post (through no fault of my own - budget cut crap), and the process was long, drawn out, painful and extremely badly handled by management. For several years afterwards I would have moments where I had panic attacks, particularly in seminars and meetings - lots of people around me in an academic context (I was taking a course to retrain in a different discipline) made me just want to bolt out the room. These things leave their mark.

Just get the cleaner. I let my DH be the blocker to a cleaner for too long. It didn't sit right with him. But who's doing all the ducking cleaning?!

Get the cleaner to come on one of your days off, while you're at the gym. DH will probably just assume you did it!

Time is money. And money is time. Why spend so much time earning money that you cannot spend on things that buy you more time as a family? You're damaging your mental health with a work and home regime that is not sustainable.

Other PP's are right. You cannot CBT yourself. You sound resigned to not being able to change your workplace stresses. Which will only continue to damage you and your home life.

Quit your job. Join a local agency. Pick up 2 shifts a week without any of the bullshit. You may even end up back at your old practice! I know this is not the clinical practice you want to do, in terms of the way you believe a GP relationship with patients should be. See it as a short term measure, to concentrate on work life balance. Providing you pick up your 20 days per year and you have a supervisor in place for CPD/revalidation - you can take the time you need to give your family and yourself the priority it needs.

And the GP crisis will continue to get worse - either suffer with it or chose a different path.

Just wanted to say you sound like a great GP and you are so not alone in the NHS feeling like this. I could have written much of your post a year ago. I'm a PAM and have been for 25 years but the rate of change, the constant "efficiency savings " (cuts), the unsafe service and the apologising for things outside my control became overwhelming. After my second lot of time off due to severe insomnia induced by stress, I knew something had to change for my sake and my children's. I now work privately and am SO much happier.
It was a really hard decision as I fully support the ethos of the NHS but my work was no longer sustainable. Private work may or may not be an answer for you but I wanted to let you know you are not alone.

I felt similar as a paramedic and switched to working part time on the bank (days only) and whilst the reduction in hours and no nights was my aim, the added bonus was feeling in control of my own life for the first time in years. Which is strange considering I left behind the "security" of an NHS contract.

Could you go ooh or pick up some a&e shifts if you have the right background, shift finishes when you go home, no practice politics for you to be involved in. You pick when and how much you work.

I think you already know you need make some drastic changes, do it now whilst you are in control, not when it is forced upon you by ill health, or a mistake.

I’m in Scotland and the on call is done by locums (I presume as it isn’t the local gps) who also have a driver service to ferry them about as it’s a big countryside area. This came in when the gps contracts changed years ago. As long as you keep covering nothing will change in your practice but as you see it is done differently in some places and we patients are quite happy with it. Imv not many have no vehicle access to get them to A/e in an emergency so not much on call is required. Being the senior doctor taking on the most serious patients plus doing the on call is crazy. If you were a family member I would be furious with you for so overstretching yourself - you can’t prop up the NHS single handed. Find a less stressful post for your sons sake if not for yourself.

Also, 're your new user name, you may not be tired of being a GP. It may be your current job that is making you tired of it. Try a new pattern / place of work and you may we have a new lease of life. I certainly do now that I am out of the NHS and I had thought my professional days were over!

I can only echo everyone else's thanks, and also gently suggest that there is some anxiety/depression running underneath your work stress. I don't mean this unkindly, but I would love to have as much time as you do in the gym and walking the dog, it would be a real luxury for most people including myself to have this much 'me' time. I only point this out because I don't think there's an awful lot more you can do to help yourself without seeking professional help regarding medication and/or therapy such as CBT.

OK so going back on your responses:

Recognising it's not stress, it's more than that is a great first step. As others have recommended, please don't faff about with seeing your GP, going in the waiting list for counselling etc etc - there is a whole health service designed especially to support GPs so use it. Refer yourself to GP Health.

On the cleaner front you say he doesn't like hiring people to do jobs that we're perfectly capable of ourselves - however how does this really work? At work it would be a waste of a well-paid doctor for you to do the photo-copying, do the ECGs, take all the bloods etc. But these are all jobs the doctor used to do - but they stopped doing as someone else could do them and the doctor's time was better spent doing something else.

At home, you could do the cleaning, you are both perfectly capable but is it the best use of your time? From what you are saying, the answer is a big fat no.

Personally, I decided to have a cleaner right from when I was a registrar even though I couldn't afford it then as I wasn't buying cleaning, I was buying my time back. Even if I spend that time doing nothing at all, it's vital to me.

I'm not sure this post is about being a GP

if i read the post correctly (and please correct me if I am wrong) you are contracted for a 20 hour week but because you are conscientious and caring this translates into a 24 hour week

This is not an insurmountable load. Whatever is going on here, this is definitely not about workload. This is a light workload.

I think there are two potential courses of action open to you

1. Give up work entirely, raise chickens and make sure you're on top of the house
2. Work full time which in your occupation means full time plus. My job working full time is around 60 hours a week which is what I suspect would be the same for you

I can't work out whether you are stressed because you don't have enough to do or not. The only time I suffered from stress was when I didn't have enough to do if that makes sense. Whatever is going on here, it's not about workload.