Burnout drives out passionate GPs: No mystery behind crashing and burning in general practice

Is there really anything more to say about burnout? From a little-heard term to overused catchphrase in a matter of two or three years, the word’s impact has weakened as we all grapple with the demands of our day jobs.

We pivot, we manage, we mop up the extra work, all the while being brought slowly to the boil just like the proverbial frog.

The Commonwealth Fund in November last year noted that New Zealand’s younger (under 55 years) GPs reported the highest level of burnout following the COVID-19 pandemic among countries surveyed. Stressed Out and Burned Out: The Global Primary Care Crisis also says those younger Kiwi GPs disclosed the highest level of emotional distress – an eye-watering 74 per cent.

Reports such as this go largely unread and unheeded, and suggestions of how to support a stressed workforce are met with obfuscation and stonewalling by those with the power to facilitate change. If these health leaders heard from individuals who had fallen apart under the pressure of working in our dysfunctional health system, would they feel differently?

I spoke to four GPs who described themselves as having variously “crashed and burned”, “completely [fallen] apart”, become “very distressed” or gone into “freefall”.

The GPs spoke on condition of anonymity, in the hope that sharing their experiences would help others and prevent the entire profession going down in flames.

Two GPs were from Auckland, one was from Christchurch and one from a rural area in the North Island. They had spent between five and 15 years in general practice. All had walked away from their jobs; three have returned to general practice, but with specific caveats and non-negotiable boundaries to ensure they can manage workload and continue working in a job which they all profess to love.

Trauma is a significant feature, and all became distressed while detailing their experiences. The same themes emerged repeatedly. Relationships suffered (“I feel robbed of those years…I feel detached emotionally from my family”) and there was a huge amount of guilt at not being able to manage while everyone around them seemed to be keeping their heads above water.

A feeling they were “letting the side down” and leaving colleagues to shoulder the burden was a source of shame. In one case, the GP I spoke to said they were the first to call it, but others have gone since. “Of the four doctors [in the practice], every one has now left.”

None of these practitioners had felt able to share their increasingly difficult situation with colleagues. They described feeling at fault for not working hard enough, or smart enough, and not being able to share their situation because “everyone is in the same boat”. “If I tell them how I feel,” they wondered, “will it make me look incompetent or weak?”

Of the four doctors in the practice, every one has now left

What was it that had led to this situation where these committed clinicians felt their only option was to resign? They pointed to the broken 15-minute model of care and the fact this comes with no acknowledgement of the increasing complexity of patients with comorbidities.

The GPs spoke of the “sheer workload, the paperwork”. Repeatedly, each GP highlighted the unpaid invisible workload of the inbox, emails and paperwork, undertaken in their own time in the evenings and over weekends and holidays. This caused a negative spiral of exhaustion and anxiety, a fear of missing a significant result or diagnosis and eventually, in all four cases, severe effects on mental health.

The loneliness and lack of support, coupled with the high level of personal responsibility for large numbers of complex patients, were cited as additional stressors.

Pay was not a significant feature, other than not being paid at all for up to 50 per cent of their working week.

All these GPs had tried to minimise the effects of their ever-expanding role by cutting hours and dropping sessions, but had soon realised “it is impossible to do it properly – it takes everything out of you”.

They said no amount of time was enough under the current model of care. As one interviewee put it: “We get no supervision. We have to wait till we are broken. We hold so much in our job.”

Another report was released, albeit quietly. Towards the end of last year, on the Department of the Prime Minister and Cabinet website, was the then Transition Unit’s review of primary care funding. The findings confirm what those of us working in general practice are all too aware of. Primary care is woefully underfunded. The current funding model does not take account of patient complexity or levels of deprivation.

The average practice was running at a loss of $29 per person per year, the review found, and it suggested the current environment is unsustainable. Practices with a large number of high-needs patients would require increases in the range of 34 to 231 per cent from current funding levels.

The report noted that actual losses were likely being managed by approaches such as reducing incomes, minimising staff, relying on voluntary time and constraining access to care. The impacts were likely to be seen in phenomena such as long delays in appointments, or books being closed to new enrolments. Yes: all these, plus attrition of general practice’s most valuable asset, its staff. Without the unpaid voluntary work GPs provide, this significant section of the health system would fall over.

What I haven’t mentioned is the gender of the GPs I spoke to. All were female. My initial thought was to omit this detail as not being relevant. But then I realised that the gradual feminisation of medicine, and general practice in particular (60 per cent of current GP trainees are female, the Medical Council has reported), has meant that primary care has turned into yet another area where women bear the burden of unpaid work.

Three of the GPs I spoke to are now working again, after breaks from practice of up to a year. All have opted to locum initially, trying out general practice with their new boundaries of fixed hours and no unpaid paperwork.

All have found this focus on clinical medicine satisfying and report seeing more acute medicine, fewer complex patients and a greater variety of conditions. However, for the system as a whole this is unsustainable unless new models of care and funding are introduced – and unless women are not expected to work for free.

Orna McGinn is an Auckland-based specialist GP and chair of the New Zealand Women in Medicine Charitable Trust