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?!!

I don't understand what being on call involves.

You have 1 child who is at school r majority of the day. Yes your job sounds stressful but you are putting in much less in term of hours than other working parents.

Thank you all, this is helping me to think and reflect.

OK, so:

1. I need to get a cleaner. DH wants to support me in anyway he can, so he will go along with this.

1. I need to get some support for my mental health.

I'm a member of doctors.net but purely use it for email, so I'll explore 'the couch' as I've never heard of it! I had some sessions with a psychiatrist about 5 years ago who specialises in doctors - this was after a series of family crises left me depressed, and then sertraline made me suicidal. He was very helpful, so I know this is irrational, but I'm really ashamed of having to go back to him and go 'Hi, me again!' after all the work we did last time. He's the GP Health service person for this area, so it'd almost certainly be him. He told me that I have a hard time accepting that I'm human (and therefore have limits), so I guess this fits with that analysis!

1. I realise that I'm very fortunate to have so much time to myself. This is why I feel so ashamed to be in this state. I feels as though I ought to be able to cope better, and the self care should be enough. I think part of the problem is that I feel so overwhelmed by stuff that needs doing that I then lose motivation to start, and don't do anything at all.

The introvert/ INFJ/ HSP thing I discovered as part of the work I did 5 years ago to understand myself better, and it has been a revelation and very helpful. Before that, I'd spent most of my life telling myself/ being told that I was just needed to think less, care less, and toughen up, and that's a hard thing to get rid of even when I know it's unhelpful. I'm very hard on myself, and wouldn't dream of talking to a friend or patient in the same way that I talk to myself. If I'd have known myself better/ trusted my instincts, I don't think I'd have gone into medicine at all. But I'm a good GP, and I am proud of that and don't want it to go to waste.

I either need to get the hell over myself and go back to the nice psychiatrist, or see someone else on a private basis.

I'm also that lovely gp who always runs late because of the time I spend with patients. I sometimes have similar reservations about continuing and worry about burnout.
I agree with others on this thread that a cleaner would be a help as it would free up more of your time.
I also wonder if you should look at moving practices. I think the grass could be greener in a practice with more permanent doctors to share the work load and provide you with more support. Have you considered a partnership? Although my workload is still horrendous I feel that at least as a partner I have some control of the decisions we make.
I have been where you are with stress and anxiety a few years back. If you still find being a gp rewarding you need to find the right environment to practice in. Do you have a mentoring scheme in your area? That might help with finding your path for the future. You sound like an amazing GP and the profession needs doctors like you but your health and happiness has to come first.

Don’t be ashamed. People hugely underestimate the emotional exhaustion with these type of jobs. You are on high alert for 2 days every week- that’s exhausting

If you want to see a different psych who specialises in Drs just inbox me

You sound very caring and conscientious @TiredofbeingaGP, probably a fantastic GP, wife and mother. Probably you are the type who likes to give 110% to all that you do and this is where you struggle.

If you perceive that your performance as a parent, keeping on top of the house or work isn't 'perfect ' you take that burden on yourself.

Reading your posts I don't think it's about the hours you do, I think it's about the emotional weight you are carrying from being good with your patients and your need to give 110%.

I don't think changing jobs would necessarily be any better for you, because as a sensitive conscientious person you will probably find you feel more stressed easily in any role.

I think the key may be in managing your thoughts and looking at Mindfulness and CBT would be a great starting point.

Your dh sounds fantastic and your son will become more mature and less demanding soon.

I wish you well and hope you find peace & balance soon. The NHS needs more Doctors like you

Please don't feel ashamed OP Some of us cope better with stressful jobs than others. I recently took a step 'backwards' in my career, as the extra responsibility was making me anxious and unable to switch off. I had to recognise that it wasn't worth sacrificing my own mental health for the sake of a job. Its just the way some of us are wired, and it means you care a great deal about what you do.
I wonder if there is a 'sideways' step you could take (I'm thinking teacher to TA type switch) - I have no idea if this is possible for you but if money isn't too much of an issue then maybe a related but less intense job might suit you better.

I have a good friend who is a GP. He feels very much like you about work, and he has a wife at home who doesn't work and they have a cleaner and gardener.
Actually they view paying for help as a positive thing, giving employment to someone local.
If you can't change anything at work then at least make life easier by throwing some money at the domestic side.

Sorry you feel this way about what should be a fullfilling job.

It seems the increasing 'austerity' policies of the last 10 years have made life more stressful for most workers - heavier workloads or not enough hours or too many hours, stressed out managers putting too much pressure on staff and bullying - Then sick leave and more pressure on whoever is left and all these people end up at the overworked gp with the physical or mental symptoms of this stress which needs more than 10 mins to deal with and the GPs get stressed and ill and can't treat people as they should be treated. It's a vicious circle and I can't see when things will improve. Everyone I know who works for the NHS seems to have increasingly crap working conditions.

I can only echo what some others have said. Use your money to take some pressure off. Maybe regular massages.

OK, so the workload and 'being on call'.

For our practice to be fully clinically staffed, we'd need two GPs there every day, plus a nurse practitioner (NP), and a practice nurse, and an HCA.
At present, there's me, a NP (who is fab) and sometimes an HCA.
We are contractually obliged to deal with anything that comes up between 8am and 6pm, except for 999 emergencies (although a fair few of those turn up on our doorstep rather than call an ambulance), and minor injuries (which go the the walk-in centre).
I have 'emergency appointments' x10 which the reception staff can book straight into. The NP has appointment for minor ailments, the practice nurse sees chronic disease reviews/ dressings etc (she's not in on my days) and the HCA does bloods/ ecgs/ urine tests etc.
Everything else - every clinical query, medication request, request for a report or letter, people wanting an appointment, all comes to me to triage and sort out. Because we are so short staffed there are no prebookable GP appointments for 3-4 weeks, so anything that needs/ wants to be seen sooner than that comes to the on call GP.
On top of that, I have a number of patients with complex medical problems or serious mental health problems who need the continuity of care, for whom seeing another GP (probably a locum) would potentially be harmful, so I 'squeeze in' appointments for them in the on call day. I see probably 30 people face to face, do approx 15-20 further phone calls, sign 150-200 repeat prescriptions and check anything from 20-120 (if the NP isn't there) blood results. I have to act on anything worrying. I also have a list of 'tasks' which are queries from other staff members/ locums who have seen patients and need advice or to ask me to act on something. That's anything between 25-40 a week, and often things that are not straightforward, or they would have been dealt with before they got to me.

I never know what is going to walk through the door/ happen in any given day. Last week, in one day, I had three emergency admissions (including two blue light ambulances, one of whom is now in ITU) and a police call out (suicidal patient with history of violence toward medical staff). Each of these took an hour to sort out.

I don't do overnight on call, that's dealt with by the out of hours service, but if a home visit comes in at 17:59, I've got to deal with it, so until the phones switch over at 6pm I still have no idea what time I'm going to get home.

In the past two years I've left work on time on three occasions. I'm efficient and have no difficulty making decisions under pressure, but that's an awful lot of clinical decisions to make in a day, a lot of which could lead to significant harm if they're wrong. And what keeps me awake at night is not the stuff I've done, it's the stuff I haven't noticed because I was too busy or too tired. The one time I didn't check the blood results (because it's not that often there's an urgent issue, and it was 9pm already), I missed a patient with acute renal failure.

So, yes, I can only do two days of this a week. And I do think there is a problem with the workload.

Just wondering if your practice has explored alternative workforce to take the pressure off at all? Locally we have practices employing mental health nurses for patients with MH issues, paramedics to do home visits and assess patients, physios to see MSK problems etc etc
Obviously GP input still needed at times but could help? Also do the responsibilities of duty doctor need reviewing? If locums cant do visits can they take on more of the path/docman etc??
P.S I could be you. Currently on Mat leave but I am definitely getting a cleaner when I go back. Have realised I just cannot do it all.

If you worked more days would there be more time to get through the investigation results as they turn up? Or are these things shared over the practice? If you’ve requested a fasting glucose on Mrs X and it’s high on Thursday, say, and the results are back when you’re not working will someone else contact her or will it wait for you to get back?

It seems to be as though you’re ending your days stressfully by going though results, calling patients etc when by rights that deserves its own time that isn’t “your time”. It means you’re also leaving with an unfinished, worried feeling.

Could you just see fewer patients and save some time at either end of the day to sort stuff?

I don’t understand the NHS system but it sounds untenable, both in and out of the hospital. Are there any options other than private where you could have more time per patient and incorporate some admin time?

It does not sound like a small workload at all. It sounds like you're taking on more stress and responsibility because no other permanent non locum staff.

I had a fantastic GP ten years ago who would go to any lengths for her patients and worked more hours than she was contracted for. I had an OT at the same time who contracted for two days due to illness would work five when asked.

The first, was well aware of her limitations and the impact doing extra work had on her and her children. She willingly took on patients other Drs would avoid, those like me who have multiple issues and could take a long time - though we found a long appointment to sort everything and only seeing her made things much much easier. She'd attend meetings about my care as well. She would do more than contracted as she always ran late but was strict about leaving work at work and took very good care of her work/life balance.

When she got pregnant the practice were extremely angry - and they actually complained to patients about it! She was allowed minimum time off and when she went back they demanded full time from her or shed be forced to leave. She told them to shove it as she was in demand and walked out the door. The most unprofessional way to treat someone. She's now a partner in a practice far away, I still see her, she still says hello, she's very well respected as a GP and separately as a person where she lives.

The OT ended up having a breakdown under the pressure of her work. She was a good friend (I worked with her before she was my OT) and she had no work/life balance. She suffered with depression and eating disorders and spent a lot of time in hospital and wasn't strong enough, really, to work in the NHS. She really should have got out instead of being part time. She'd get rung and told to go in most days. She died six years ago.

Both were meant to be working less hours than they were contracted for. One was able to manage that and work their home life around it (the GP had two other children), they employed help because they needed to for their own health but the second gradually buckled under the pressure and bullying culture which existed within that team and didnt get any help in as they were ashamed to admit they needed it - there's no shame needing a bit of support to keep yourself healthy.

I think you need to look at how you're managing your whole life, not only your work life. I worked full and part time in the NHS and found part time much harder than full, people had zero understanding of it.

I know not all patients say thankyou, even trying is a sodding nightmare as you must go through complaints who get all shifty about if you really mean it or not but patients do appreciate good GPs, even if all they seem to do is complain!

X-post.

Sorry, that was quite a rant!

I think there is a mentoring scheme - I'll see if I can find the email address. I think that could be helpful. All the partners I know are really stressed with the financial side of things, and I have no interest in managing people, but a more stable practice would be lovely!

We do have a paramedic for visits, and it's great when he's around, but he's been seconded to one of the other practices which is in even more dire straights than ours. I believe management are looking into who else we can hire in the absence of interested GPs, and I've suggested a physio and a mental health worker, so hopefully something will come of that.

Most of our locums won't do path. Some will do a visit and some won't. That one chap was being paid to do a visit but refused because it would take him too long (mental health issue in housebound patient). Most of them won't sign repeat scripts (which to be fair is a bit dodgy indemnity wise for locums).

Everyone is trying their best to help. It's just not a doable job at the moment. The sad thing is that it would be a really great practice if we just had a couple more GPs!

OP

I mean this in the kindest way possible and please refer down thread to the reference that I only ever suffered stress when I didn't have enough to do.

I think you have too much time on your hands. Stop worrying about yourself. You're great. You're doing a great job.

Seriously, this really sounds like a Couch post. If you go to the forum area, you'll find the couch on the list of areas. You can post anonymously, and you'll (usually) get sensible replies from a bunch of doctors. Okay, some of us may be slightly weird, but it's pretty supportive.

I am a PM and my immediate observation is that you need to talk to your PM about the oncall workload. THat is insane.

It sounds like our practices are of a similar size looking at your workforce but we don't have a ANP. My feeling is that your day has not been adjusted to take into account the fact that you are heading a team rather than just clearing your own workload. Practical things to discuss with the PM:

• Reduce your f-2-f appts on the oncall days. My oncall GP sees 14 patients in the morning and then has 10 urgent slots in the afternoon. Nothing else.
• Urgent slots are exactly that. We have done a ot of coaching with our frontline team to weed out or signpost non-urgent on-the-day calls elsewhere.
• Telephone triage as much as poss. Oncall GP gets no visits or only one. Your PM needs to get onto your locums - they need to take the visits that they are given.
• If you have to do all the blood results, that huge. You have to have more time in the day to tackle those.
• You don't mention letters. If your practice hasn't implemented document management, then they need to do so asap. We pass an average of 3-7 letters a day to the oncall GP, no more.

My lovely salaried GP does 2 days a week and is super-invested in her patients like you. She does one oncall day, one non and she has the practice laptop so she can leave t a reasonable time and tidy up the next day for an hour at home. Better that she sees her kids at bedtime and then works a little the next day than do a hideous long day.

Our oncall GPs don't tackle tasks or non-urgent things at all. Those go to the GPs who aren't working the oncall. If you are having to pick those up too, then your f-2-f load has to reduce even further - even to the extent of not seeing anyone at all on an oncall day other than the urgent slots.

Buy in all of the personal help that you can.

But yes - workload is unsustainable for all of us in general practice. I got home 40 minutes ago and will back in the practice at 7:30 tomorrow.

All we can do is protect ourselves and do what we can.

Your husband really doesn't sound very supportive. Could this be part of the problem?

Haven't RTFT as it’s a bit close to home for me at the moment as a senior nurse going through a depression episode mostly triggered by work. But just wanted to say that I am so so grateful for the support I’ve received from my GP who also looked ill and stressed herself the last time I saw her. You sound as wonderful as she is.

Where are the GPs going? Where I live in Australia there are loads of GPs, each practice seems to have at least 6!

People usually need to pay though, some things are free such as vaccinations etc and there are some clinics that entirely bulk bill under Medicare but for most people there is some kind of cost. Less if they are of low income or have high health needs and some don’t charge for children. What what I can gather the clinics seem well run and well staffed and whenever I call a GP about a worrying result for a shared patient he/she is often already aware of it and acted on it.

I also once had principles about private practice. However if it means you can spend more time with patients, be safer in terms of investigations and follow up and let you do the job you need to surely that’s better?

It doesn’t sound like the NHS values GPs if they are worked into the ground.

I’m laughing at the thought that you haven’t got enough to occupy you

You sound like a fantastic GP. Please please get a cleaner!!!

We definitely need more training for the reception staff regarding use of emergency appointments and on call list! That is being acted on, but it's slow going.
The results are a problem currently because there isn't really anyone else to look at them. If we were properly staffed I'd only be getting about 1/5th of these, if that. Ditto the tasks.
Part of the problem is that the company has taken on two more struggling practices in the past year, so our nursing/ AP staff are expected to support those practices (one of which is entirely locum staffed currently) in addition to their workload at our practice.

DH is loving and supportive, but has a busy working and home life himself. I'm also not very good at recognising when I need help/ asking for it (although better than I used to be!), and he's not a mind reader. This thread has helped me to realise that I need to have a long talk with him about where I'm at mentally/ emotionally, and what we need to do as a family about that.

Thank you everyone for your input. It's been really helpful to write it all down and hear your views. I'm going to bed now, but will read through again tomorrow.