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BJGP Long Read: A valedictory note on my retirement

Claire Stillman is a recently retired GP who spent 30 years in Scottish general practice, the last 20 of which were in Glasgow.

About eight months ago I wrote an emotional, angry rant about why I was leaving general practice. It was in response to a questionnaire from the LMC asking me for reasons why I was going. I never sent it to them; it seemed enough to write everything down and it exhausted my anger. I kept meaning to go back to it but I never did, probably because it was too upsetting when I was in work and then it became irrelevant when I left. My emotion had been expended. Also, I felt that I had said nothing new. There were no blinding insights, other people had said the same things over and over and nothing had changed. It is hard to see how anything can change given the current structure and funding of the NHS. I should say that I took early retirement at the age of 59 following 30 years in General Practice and I might have taken a handful of days of sick leave in that time. I never took any time off for stress.

Here are the reasons I left, or perhaps some of them:

Appointments

The appointment system is not fit for purpose. A GP has to be all things to all people in 10 minutes only and this is untenable. In this time we have to deal with the polypharmacised multiply morbid patient who has several problems to discuss. We have to manage an increasing amount of clinical work transferred from secondary to primary care. We have to deal with the manipulative, the dangerous and the deluded. We have to deal with those with shopping lists of demands, the worried well, those sent by third parties for proof of just about anything. We have to deal with the longwinded, the demented, the unhappy, the angry. We have to deal with the worried parent and the sick child. We have to deal with the medical emergency or those who think it is an emergency. The list goes on. We are accessible to everyone, every single being has the right to walk in to discuss anything; there is no filter, no prior discussion to see whether a trip to a GP is appropriate or suitable.

We pay an emotional price for constant availability for everything the world throws at us.

GPs can be bullied and manipulated by a public who increasingly demand certainty and rights and a bureaucracy that seeks to medicalise social problems. In all this we have no support. We were trained to help others’ suffering, not manage our own. We pay an emotional price for constant availability for everything the world throws at us (and I mean everything), and a professionalism that is never acknowledged or meaningfully supported. We face the relentless expectations of the ten minute appointment, the constantly full waiting rooms, the unacceptable waiting times to be seen and feel constantly punished because we cannot meet them. I can honestly say that in all my time as a GP principle, I can count on one hand the times I did not have a fully booked surgery. Government policy, patient expectation, pressure on our staff mean that we are constantly in the wrong, on the back foot, for not delivering a service that, quite frankly, is impossible to provide. We are supposed to be made of teflon, have no feelings, cope with the relentless daily, monthly, yearly pressure of not delivering the impossibly perfect service that this society believes is their right.

Patient expectations

Expectations by patients have changed over my thirty years in practice. Society has changed; the consumer approach, the belief that everything should have an answer, the inability to accept the uncertainty of life and health; the belief that if something goes wrong someone must be to blame have all increased over time. Expectations increasingly fuelled by the unrealistic claims made on the internet. Also the idea that everyone should have instant access, instant answers, has grown. These expectations are not really compatible with what GPs do, namely manage uncertainty. Because of this GPs have been harried into increasing amounts of patient tests, often with no clear goal in mind and no evidence that it would be useful. On the contrary, tests breed insecurity and more tests, because doctors feel the need to cover themselves, to insure themselves against patients demanding ever more certainty. It is ironic that in an age when the population has never been more healthy or long lived, health uncertainty and anxiety increases. Adding to patient expectations is the medicalisation of human sadness. The belief that a doctor can make grief, sadness, the ordinary difficulties of life better with a pill or therapy seems to have increased steadily over the years.

Lack of resources

Mental health services were reason enough to leave general practice.

GPs are damned if they do and damned if they don’t. We are placed in impossible double binds by chronic NHS underfunding and then blamed for the outcomes. Classic examples are the exploitation of our gate keeping roles by saying we must refer less into secondary care and then blaming us for not diagnosing enough cancers. We are held responsible for not diagnosing the rarest of cancers, which have no characteristic sets of symptoms, and yet demonised or refused by secondary care if we refer patients like these in.

Mental health services were reason enough to leave general practice. The NHS in my area refused to fund or possibly organise an even half functioning service and given society’s propensity for medicalising any adverse human experience we were imprisoned in the ultimate double bind and for us it was a life sentence. Throughout my entire career I was supposed to deal with the mentally distressed in ten minute appointments with no credible back up. The media slammed us for handing out too many antidepressants giving the impression that we had any alternatives. Trust me, we did not. The stark choices for GPs dealing with mental distress ranging from overt psychosis to a little sadness were a prescription for a pill then and there and a bit more than ten minutes (thereby pressurising everyone else in the waiting room), or a referral for a mental health treatment, be it talking therapy or more assessment which might occur within the next 3 to 6 months. The icing on the cake was that despite a GP referral, the mental health service might decide, several weeks later, not to offer any treatment at all. Truly GPs backs are up against the wall when dealing with mental health problems, which on a conservative estimate, take up to 20% of their work. Indeed, there is a psychological component to all disease. Dealing with mental health services throughout my career was the most excruciating and depressing aspect of my job.

Another problem caused by underfunding, which inexorably worsened throughout my time in practice, was waiting times. This has caused the NHS to become cruel in its dealing with suffering patients. I have seen people with severe, debilitating, painful conditions having to wait up to a year to be seen in secondary care. And then they get sent for tests, have to wait months for their results, and then they have to wait further months for follow up in clinics to get the results of said tests. Hospital doctors never make decisions without panels of tests that seem to grow larger by the year. Meanwhile the GP is the only doctor a patient can directly access while waiting for all these events, the walls are very high around secondary care, and we are expected to manage their pain, anxiety and frustration with no power to change anything. As usual, there is no support for the GP managing the patient in this vacuum and the more compassionate the GP, the more likely they are to be broken by this powerlessness in the face of suffering.

Complexity

Patients are becoming increasingly complex. They live longer, are on more medication and often have two, three or even more co-existing conditions. We are expected to deal with their needs in ten minutes, or consider their problems in the little time we have between fire-fighting paperwork and results and managing the practice. Meanwhile secondary care is becoming more specialised with increasing numbers of silos. A patient goes to a hospital clinic where a specialist has the luxury of dealing with one condition only, with all the back up of a hospital department. And it can happen that the decision a specialist makes about the one condition that is their remit will have a knock on effect for the other conditions a patient might have. It is left to the GP to sort it out. A record achieved by one of my patients was that he visited seven different specialties on a regular basis, all of which dealt with one aspect of his care and none of which could come up with an overarching explanation for his symptoms. Needless to say I had ten minutes to deal with all of them. The use of protocols, guidelines and non-doctor vetting of secondary care referrals also lead to GP stress, not to say cruelty to the patient. The silos are getting narrower, secondary care clinicians are more and more empowered to say what they will not deal with . Meanwhile GPs have to deal with their rejections with no support for their suffering patients.

Polypharmacy

This is a real problem in the ten minute appointment. All evidence based medicine derives from studies on single conditions and all medication guidelines come from them. The problem is that very few patients have only one condition. The GP has to juggle co-prescribed medications with their multiplicity of interactions and side effects in each individual, very difficult in a busy surgery with a waiting room full of patients expecting to be seen on time. Ironically when the community pharmacists started to be involved in the Scottish NHS new contract, they stated they would need thirty minutes per patient. And a pharmacist would only be dealing with medications while the GP has to deal with the actual patient’s agenda, which may be something else entirely. Prescribing outwith the consultation has also become more onerous over the last few years as drug shortages and the increasing prescribing demands of secondary care have to be managed.

Poorly understood conditions/somatisation/chronic pain

Some of the hardest patients to deal with, the most time consuming and emotionally draining, are the ones that don’t fit into neat diagnostic boxes, yet constantly present with suffering and demand answers. These patients are not recognised by, and certainly not treated by secondary care. For example, those people with chronic pain for which we actually have no effective medication. Synthetic opiates, the only treatment out there, do not work and turn them into addicts. Any attempts at psychological reframing of their conditions are seriously resisted by the patients, and to be frank, the medical establishment.

There seems to be a belief that GP is elastic can continuously absorb extra work indefinitely.

The Cartesian dualism that bedevils our concepts of illness means that patients and many doctors think that the ultimate insult is to suggest that their suffering is ‘all in their head’ and for some strange reason does not then exist. Unfortunately GPs are faced with a number of patients who manifest their life distress with physical symptoms, call it somatisation for want of a better term, for whom existing medicine has no treatment and who become bitterly entrenched in their illness behaviour as they feel less and less cared for. The ‘fibromyalgics’, the chronically fatigued, for whom there is no realistic therapy and for which GPs have no training or support. I am not surprised that so many of them turn to snake oil salesman and quacks who at least provide them with attention before exploiting their vulnerabilities.

Outsourcing of secondary care work

Over the years, general practice has been subjected to a form of ‘mission creep’ with secondary care demanding that we increasingly do work that was originally done in hospital medicine. While it may seem reasonable that GPs manage new atrial fibrillation or perform near patient testing, this is added to our already increasing workload. There seems to be a belief that GP is elastic can continuously absorb extra work indefinitely. There is only so much work that we can take before we break.

Housebound patients

While home visit rates have gone down, housebound patients are becoming increasingly complex so that visits can resemble ward rounds in a geriatric hospital. Patients are often on medications and have conditions that need frequent monitoring and repeat visits that we are not resourced to manage. Latterly, I became increasingly concerned about our cohort of usually elderly, frail housebound patients on complex, potentially dangerous treatment regimes who were poorly managed in the community. General practice as it stands is just not equipped to deal with these people.

Conclusion

I think the chief thing to emphasise is that GPs stand alone, and are chronically under resourced. We may work in group practices and have our administration staff, but once the door is closed, it is just the GP and the patient in the room together. And in real time we have no support, indeed we have no formal support networks at all on the ground. There is no-one to catch us as we fall, we have no protection from the ire of the public, anger that is usually caused by a system that fails to deliver what has been promised. We stand and fall by the decisions we make in ten minutes and if things go wrong, the full weight of public and professional opprobrium lands on our heads. There is no safety net, no cavalry coming over the hill to relieve us.

Now, I have retired and I do not miss any of it. I was well thought of by my patients and staff to judge by the feedback I have received over the years and the overwhelming number of cards and presents I received when I retired. I also got on with and liked my partners. Yet a powerful emotion I associate with my time in general practice was one of failure. I had failed to deliver a good service and so now I am just relieved to be free of it. However, what does bother me is that I had a wealth of knowledge and skills, accumulated over lifetime, which I will never use again.

Yet there is no place for me now in my profession, general practice has lost my skills and those of all my retired peers completely.

And what does strike me is that perhaps my profession could benefit from my and my peers’ experience. I could perhaps mentor younger GPs, newly practising partners, and provide them with the support I never had. I can read a face, interpret its subtle movements, be aware of another’s suffering. I can listen actively and frame peoples’ stories empathetically and positively. I can pull out the essential points in a narrative, summarise a conversation, help someone form a plan for the future. I can listen. Yet there is no place for me now in my profession, general practice has lost my skills and those of all my retired peers completely. I feel that this is a shame as we are a resource that could be utilised for the good of the profession.

As for the future of general practice, I do not trust the Scottish NHS and the health boards to deliver the supposed new Scottish GP contract. They mouth platitudes but follow their own agendas rather than those of general practice, they have not trusted GPs to execute the changes and allocated funds seem to have dissipated in a plethora of talking shops and committees. It seems that the further you remove practitioners, the people who actually do the work, from decisions about how the work is done, the less successful the outcome. Unfortunately, GPs have been so busy actually doing their jobs, they have not had the time or emotional energy to fight for a new contract that works for them. I have little hope that the new contract will result in better experiences for patients or their doctors.

However, it can be argued that innovation, out of the box thinking comes from those without an interest in the system, so let’s throw the problem of how to run an NHS out there. Let all and sundry chew on it, because I don’t expect those within the system to come up with any answers. Lets hope someone has thought of something before the inevitable happens to me and I become a patient.

 

Featured photo by Anukrati Omar on Unsplash

18 Comments

    • Hi, I hope you weren’t too depressed by the article. How to change things for the better is the question. Good luck if you’re still working away! Clare

  1. Thank you so very much for putting my sentiments down in such an eloquent way. I left my partnership in Glasgow recently aged 55 for the reasons you have outilined. I waited for the new contract and knew it was inadequate and resigned my partnership.

    “the more compassionate the GP, the more likely they are to be broken by this powerlessness in the face of suffering”- this especially very much summed up my experience.

    I now locum and feel more protected and distanced from the toxic work conditions expected of me by myself, patients, the NHS and the SG. I feel my experience of 30years as a doctor is wasted and I just have to suck it up and not dwell on it. That’s life! A shame when there is so much capacity of compassion and skill to give to people, given the right conditions.

    • Hi, given the current situation, perhaps we should view Active GP as something that you do for a finite time only, as part of a “portfolio career “ not a whole working lifetime. Rather you spend sometime at the frontline, then move onto less stressful jobs having done your bit. The question would be what to move on to that we have the skills and training for, apart from locum work. Also I think most people would agree that the more experienced the doctor the better practitioner they are. Always remembering that experience can just mean making the same mistakes with increasing confidence!

  2. Thank you for sharing. Absolutely agree that there is a wealth of wisdom and skills that the newbie GP’s would benefit from greatly!…mentor me! Perhaps a new business venture? 🙂

  3. I also took early retirement from GP Partnership at 56 and have not regretted it. As I walked out of my surgery for the last time I almost literally felt a weight lifted from my shoulders. I share the author’s regret that I can’t continue to use the wisdom and experience gained over 30 years to help patients and relieve some of the burden from my younger colleagues.

    • Martin – perhaps “Rediscover the Joy of General Practice” might have something to offer you – see my comments below

  4. Wow. Thank you for a brilliant, honest piece. I’m relatively early in my GP career and I recognise ALL of what you say. At the moment, the good outweighs the bad for me in GP, but I do wonder if I have the resilience to stay the distance. The lesson for me is: look after yourself and each other, because everyone else will milk you as dry as you let them.

    I have saved this article for future reference and sharing. Thank you again.

  5. I also took early retirement at 59 now nearly 7 years ago. This article describes my feelings too (OK in England not Scotland). I feel too that stopping work lifted a burden from me and regret at never being able to do the job to the best of my ability due to constant time pressure. The skills I gained in listening to my patients for over 30 years are no longer available to the NHS, as new less experienced doctors are assumed to be of equal value to the NHS. Bums on seats can be counted and that’s what appears to matter to those counting and making the rules.

  6. Thanks for all your comments. Perhaps the RCGP should consider the mentoring idea! I refer to the comment I made above about limited stints at the front line. Sadly, in Scotland there is a shortage of new GPS and practices have had to shut up shop because of this. Clare

  7. Clair, your comments eloquently outline the challenges and unreasonable demands placed on GP’s and 5 years ago I faced the same dilemma in my English practice of 30 years, and at 58 I too decided it was time to leave. I then decided to tackle a different challenge and moved to a much smaller remote and rural practice in the Hebrides as an NHS salaried partner. Surgeries and lists became smaller and I now have the luxury of time to spend with the patients and have the support of fabulous community staff. The experience and knowledge I’ve accumulated has been well used and I’ve truly enjoyed this final phase of my medical career, and I’m still working here 5 years later!
    We are privileged to have the job we do, but time pressures can certainly prevent us giving our patients the service they deserve.

  8. What a brilliantly written article. Comprehensively details why GP is failing and will likely not exist, at least in its current format, in the next 10-15 years. GP is the Walmart of medicine, pile them in, stack them high – all you can fit, anything and everything in a 10min appt. It is popular with politicians as they need cheap medicine by GPs to subsidise the expensive specialists and keep the tax payers happy with lower tax rates.

    Unfortunately the real world is not like the Dr Who Tardis and time does not expand. GPs are human and to remain humane, we need to self care to avoid burnout. For some it will be time to boundary patients, for others it will be time to cut back on sessions and and for many it is time to look for alternative careers. I used to look at GPs as a child in the 1980s with deep respect and awe, they had status and commanded respect from their peers. These times no longer exist. Now each day is a battle for many if not most. I left the NHS year ago and will not return, I wish those of you who remain the best.

    • This has been one of the best short reads describing what GP life has become and I can’t disagree with any of it. Strange thing is, like the Gp reply above, who moved to a small rural practice , and enjoying his last 5 years, I too have honestly rarely ever had a bad day in my 30 years as a GP partner now aged 58 Wales. Small personalised list 2750 (weighted list 3500) in a 2 person (1.5fte) so 4 day week. The single biggest reason I remain happy and peaceful in the midst of the plethora of issues you so eloquently describe is for me they all become so much milder/manageable/solvable when there is someone who armed with a life time knowledge of their small 1300-1500 patients characters, expectations and illnesses, finds decisions and tests ,mail and the whole lot becomes quicker easier, more thorough.Its not that I am not busy ,it’s just not always busy. It’s not that I am better as I am not. From what I see and hear in the profession generally, I can’t see a sustainable way forward for Primary care unless we rapidly move to personalised lists, yes in group partnerships supported by HCSW/Nurses/PA/admin . I mean where you are solely responsible for your own patients, not someone else’s,not strangers,not patients who try and manipulate new GPs. Yes seek 2nd opinions occasionally, Expect yes a day off each week where similar partner /colleagues cover any emergencies.No long waits to be seen . Telephone first less necessary, “Rubbish“ I hear some think,but I maintain it is all very possible because my experience is the time saving and in depth supervision by one GP of an almost totally “known” population really does yield the time and space to let us cope,grow and even thrive. Most complex illnesses become less stressful as you have been with them through it all and know them almost as well as they do. Your previous consultation laid out the actions you would do if they returned. Ten minutes often plenty bar the first new complex illness, no more long history taking by talented GPs who have little knowledge of the patient multiplied a thousand times a year .Less mental stress and clinician anxiety. Add in HCSW, social Prescribing and decent mental health services and it become a real pleasure and something even at 58 I don’t wish to give up. Planning 2 days a week till 65. You asked for a solution. There it is. Not meant to be Patronising. Personalised lists where you and only you ,95% of the time have to make the decisions that will affect your workplace tomorrow and next week Is the way ahead. .Claire, please don’t stay away, seek a small practice as you are incredibly valuable. As for me I am planning 2 days a week till 65.

  9. I am a 50 year old GP working in North West England. I could not agree more with everything that is written in this article. I am a very robust individual and continue to work as a Partner in a large practice with great colleagues. However I have seen many very good people “broken” (alcoholism, Depression, burn out) by the toxic environment of General Practice.Good UK GPs are some of the finest and hard working General Physicians in the world. In the last 10 years I have come to the conclusion that the NHS is not fit for purpose in the current world and never will be. The sooner the NHS becomes a private insurance based service then the sooner GPs will be able to control their workload / quality of care and lead a full rewarding working life that does not “break them”.

  10. A very eloquent summary I agree.
    I too share the regret at not being able or knowing how to use the skills I have acquired after 33y in General Practice. I would like to do something to help

  11. Clair, what a beautifully written article. Thank you.

    Last year I initiated the project “Rediscover the Joy of General Practice” https://www.srmc.scot.nhs.uk/joy-project/ It is specifically designed for GPs like you coming up for retirement but who feel they have more to give, but not under the pressures you describe. It began as a collaboration between NHS Orkney, Shetland, Western Isles and Highland and this year has expanded to include other Scottish Health Boards. It is based on work undertaken in Orkney over the last 10 years.

    We offer contracts of between 6-18+ weeks/year to undertake practice attachments for periods of 1-4 weeks at a time. Travel from a Scottish city and accommodation is paid for, meaning that GPs do not need to relocate. Our philosophy is based on supporting the practices and staff in all aspects of GP work and quality improvement. Have a look at the website to understand the scheme more fully.

    In 2019 we recruited 33 GPs to our Rural GP Support Team, many were retiring GPs who have felt reinvigorated by working with us. This year we have expanded the scheme to involve the whole of Scotland and not just rural practices. Currently we have shortlisted a further 35 GPs. Although we have officially closed, we will still accept late applications and will reopen to applications again once we have established this second team.

    What is interesting is that as our team expands and develops we suddenly find that we have the opportunity to consider how we can tackle what previously seemed intractable problems. All members of the team are encouraged to contribute their ideas of how we could tackle thorny issues and due to the phenomenal depth of experience and expertise among our GPs we find ourselves in an unusually empowered position.

    The project is led by the Primary Care Associate Medical Directors and Managers from the participating Health Boards and has the full backing of the Scottish Government. We are at an early stage and certainly do not have all the answers, but we are determined to try and make a difference. Working together with vision, determination and lateral thinking I believe we can make real changes – however, I am a self-confessed irresponsible optimist!

    Anyone interested, do have a look at the website and please feel free to join us.

    Claire, I would very much like to have a chat with you and to explore some of your ideas. My email is charles.siderfin@nhs.net

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