The unhappiness of doctors: policy implications

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The unhappiness of doctors policy implications

• Richard Smith, BMJ

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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?

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League of unhappiness
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Why might doctors be unhappy?
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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 isnt overworked?

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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

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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

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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)

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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

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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

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Why might doctors be unhappy?

• They are increasingly accountable
• They are, but they were probably insufficiently
  accountable before

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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.

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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

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Why might doctors be unhappy?

• Close contact with patients are disrupted
• Little support for this explanation

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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

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Why might doctors be unhappy?

• Patients are too demanding
• Politicians are stoking patients expectations
• Modern medicine promises more than it delivers

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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

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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

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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

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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

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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)

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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

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Possible implications for policy

• Politicians should avoid stoking patient
  expectation
• Politicians can help encourage a new contract