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?

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”