The unhappiness of doctors policy implications Richard Smith

The unhappiness of doctors: policy implications Richard Smith, BMJ

What I want to talk about • What is the evidence that doctors are unhappy? • Why might they be unhappy? • What does it mean for health policy?

League of unhappiness

Why might doctors be unhappy?

Why might doctors be unhappy? • Overwork – Perhaps nothing new – Doctors feel like hamsters in cages, but they actually have more time with patients--but there is more to do in that time – Who isn’t overworked?

Why might doctors be unhappy? • Underpaid – Doctors have lagged behind some comparable professionals--for example, barristers – But still much better paid than most other public sector professionals--like teachers – Many doctors have greatly supplemented incomes from private earnings – -Doctors have much less variability in earnings than other groups--for example, solicitors

Why might doctors be unhappy? • Inadequately supported – Most work in teams – Some doctors seem to think that nurses have “lost their way” – Singlehanded doctors are increasingly unusual, and even they have support staff – Relationships with managers are sometimes fraught – Many doctors feel unsupported by politicians

Why might doctors be unhappy? • Their status is falling – Still much more valued than, say, social workers – In Britain doctors are still the most trusted professionals (politicians and journalists are at the bottom)

Why might doctors be unhappy? • They are exhausted by too much change – Doctors are not alone in this – There will probably be more change in the next 10 years than in the past 10

Why might doctors be unhappy? • They have declining control over their work – Doctors, particularly GPs, have more control than many other groups – Nevertheless, they have less “freedom” than before--revalidation, audit, CHI, NICE, guidelines

Why might doctors be unhappy? • They are increasingly accountable – They are, but they were probably insufficiently accountable before

Why might doctors be unhappy? • Their job is not what they were trained for – Most doctors practising now were not trained in management, leadership, improvement, communication, ethics, etc – Some doctors may be “phobic” about education.

Why might doctors be unhappy? • They have to pick up the pieces in a society unable to cope – The NHS is almost the last of the “socialist” institutions – Doctors do find themselves trying to help the marginal (poor, unemployed, homeless, addicts, prisoners, asylum seekers, etc) but with very limited ability to do much

Why might doctors be unhappy? • Close contact with patients are disrupted – Little support for this explanation

Why might doctors be unhappy? • The health service is falling apart – Many doctors in Britain seem to feel this – The BMA begins to look at alternatives to the NHS

Why might doctors be unhappy? • Patients are too demanding • Politicians are stoking patients’ expectations • Modern medicine promises more than it delivers

The bogus contract: the patient's view • Modern medicine can do remarkable things: it can solve many of my problems • You, the doctor, can see inside me and know what's wrong • You know everything it's necessary to know • You can solve my problems, even my social problems • So we give you high status and a good salary

The bogus contract: the doctor's view • Modern medicine has limited powers • Worse, it's dangerous • We can't begin to solve all problems, especially social ones • I don't know everything, but I do know how difficult many things are • The balance between doing good and harm is very fine • I'd better keep quiet about all this so as not to disappoint my patients and lose my status

The new contract: both patients and doctors know • Death, sickness, and pain are part of life • Medicine has limited powers, particularly to solve social problems, and is risky • Doctors don't know everything: they need decision making and psychological support

The new contract: both patients and doctors know • We're in this together • Patients can't leave problems to doctors • Doctors should be open about their limitations • Politicians should refrain from extravagant promises and concentrate on reality

Possible implications for policy • Any reform in a health service may be difficult with a disenchanted workforce • Doctors may desert medicine • Medicine may be seen less as a vocation and more as a job (it is already) • Doctors may want flexible, portfolio careers (they do)

Possible implications for policy • Doctors need more career advice and support than has been usual • Some doctors might move into “chambers” • There is probably a need for more “clinical leaders” • Doctors’ organisations might become less reactive (usually saying no) and more constructive

Possible implications for policy • Politicians should avoid stoking patient expectation • Politicians can help encourage a “new contract”