The first time managing expectations set by you and those around you

General practice can be considered like the relationship between Dame Elizabeth Taylor and her eight husbands (including Richard Burton who she married twice) – less of a triumph of hope over experience, and more persistence in the face of addictive adversity.

It’s hard, but we keep trying because when it’s good, it’s fantastic.

How do we cope with the expectations of our patients, our colleagues, the system and our perfectionist high-achieving selves, especially in a time of change?

Therapist and executive coach Megan Bruneau, writing in Forbes magazine, encourages seven personal behaviours that help build resilience (tinyurl.com/Forbes7Qualities):

• find meaning
• be prepared to ask for help
• practise self-compassion
• recognise what is in your control (and what is not)
• maintain a sense of humour
• be calm and measured
• cultivate perspective and gratitude.

So, be driven by your values and recognise the link between the work you do and what you consider “a life well lived”.

Seek support from others when it is needed – friends, family, colleagues and the support organisations that surround you, such as the Medical Protection Society (MPS), RNZCGP, PHOs, unions and advocacy groups, can all help. Remember, you are not alone.

Recognise and change negative self-talk and the tyranny of perfectionism. Get into your head that being good enough is fine – you don’t have to be “the best”.

Don’t waste time howling at the moon, but change for the better the things you do have control over.

Look for the funny side without reverting to sarcasm and irony, which bring negative energy. Stay calm in your personal interactions.

Approach problems from the perspective of “unconditional positive regard”. Consciously adopt the stance that everyone involved deserves respect and is trying their best to do the right thing.

This doesn’t mean you have to put up with being treated badly or have to bend to everyone’s expectations, but by taking a positive approach and minimising resentment, you will maintain your energy and build resilience.

This takes practice. Regular mindfulness, formal supervision, coaching and peer support can all help.

Being aware of the multiple standards we have to meet as GPs can feel overwhelming.

There are Medical Council of New Zealand standards (mcnz.org.nz/our-standards), ethical standards (World Medical Association International Code of Medical Ethics; tinyurl.com/WMA-ethics), college standards (RNZCGP Foundation programme; tinyurl.com/RNZCGP-Foundation), health system standards (Standards New Zealand; tinyurl.com/StandardsNZ), and patient and consumer rights (Code of Health and Disability Services Consumers’ Rights; tinyurl.com/CodeOfRights).

Then there are the warnings, guidance and story after story of problems arising for colleagues who have fallen into traps that we ourselves have often missed simply through good luck (MPS; tinyurl.com/MPSpublications).

There is no getting round these requirements upon us. They represent the way society expects us to behave and do our jobs. Just reading them all takes days, and if we were to focus on diligently implementing each and every standard against which we are held, we would have no time left to see our patients.

However, they can be summarised as:

• don’t try to do things you can’t
• don’t tell lies
• communicate
• always put patient welfare first.

If you stick to these basics, you’ll meet most of the expectations society places upon you.

We are not here to do just what people want; we are here to provide what people need

Change the things you can. Here, I provide two common examples using this approach:

“GP to chase” – these messages from colleagues in other parts of the system are a common pressure and come in various forms.

Quite literally, when an urgent-care service arranges a test but will not be following up the results, some will say “GP to chase results”. In other guises, this will be a request from one specialist for the GP to refer on to another service, or to ensure that a further test, which might be due in six months to five years, does indeed happen.

Taking an unconditional positive regard approach, you can quickly understand that the reason these requests happen is not because general practice is undervalued, but because the services aren’t yet set up to do these things themselves.

It is often safest for the patient if follow-up is managed by general practices, which are geared up to provide “cradle-to-grave” care with robust recall systems and an ongoing personal relationship with the patient.

Putting patient welfare first, it isn’t appropriate to simply refuse to deal with such requests. However, it is possible to change the system through direct communication, through the local support network of your PHO and Te Whatu Ora – Health New Zealand district clinical leaders.

A recent paper developed by combined PHOs emphasises principles about this “transfer of care” that have been implemented in several districts (search for “Guidance for doctors transferring patients targets much-maligned ‘GP to chase’ note” on nzdoctor.co.nz).

Write back to the urgent-care centre or specialist and say, “Yes, I will do this for this patient this time, but the impact of this on our service is XXX, and we would like to work with you to ensure patient care is maintained safely and effectively into the future.”

Copy in your Te Whatu Ora GP liaison team and PHO clinical leaders, and ask them to support conversations that improve the system. Hold them to account.

Patient demands – we are in a service industry. “The customer is always right” is a great marketing ploy for retailers and hoteliers, and is a much better approach than “caveat emptor” (buyer beware).

However, we don’t just provide a service. We are not here to do just what people want; we are here to provide what people need, and we have statutory responsibilities that sometimes require us to actively refuse to provide what people want.

Taking unconditional positive regard of the patient who is demanding an urgent medical certificate or an inappropriate medication will allow us to see the world through their eyes and appreciate their perceived need.

Applying the requirements to not try to do things you can’t and to put the patient’s welfare first, may mean having to say no to their demands.

Explaining why will hopefully maintain the doctor–patient relationship, but it is important not to keep pretending you have a therapeutic relationship when you do not. This is when complaints arise, signs are missed and mistakes happen.

When you cannot meet the patient’s expectations and they cannot accept that there are limitations, the relationship has broken down, and it is time to “divorce” (see “Medicolegal“, New Zealand Doctor, 18 August 2021).

Write to the patient explaining the situation as you see it and asking them to uplift their notes and find another general practice. After a reasonable period of time, you can make the patient “casual” in your books, and while you cannot refuse to provide care if they present to you with acute chest pain or bleeding from a head wound, you can stop providing medical certificates and prescriptions.

Finally, the key expectation we have to manage is that which we apply to ourselves.

We are selected into this profession because we are high achievers. We come with high expectations of ourselves and the service we work in. We all want to provide the best care, we strive for excellence, we hold great power, and with that comes great responsibility. This may feel like it is good for the patient, but it is not improving our resilience and will tempt us to try to do things we can’t and tell lies about what we’ve achieved.

Fight the temptation to strive for excellence, and accept that being good enough is okay.

Jo Scott-Jones is medical director for Pinnacle Midlands Health Network, has a general practice in Ōpōtiki and works as a specialist GP across the Midlands region