Sunday, 18 March 2007


In this week's "Pulse", a candidly honest GP talks openly about his experience of depression. He says "I have been on antidepressants three times in the past. Though they helped when I was taking them, I don't think there were the answer. The problem is the stress of being a doctor and how I cope with it". I think he is right.

During my recent appraisal my appraiser told me about how he got hopelessly bogged down and stressed by the demands of the patients in his previous practice. He changed practices, and now keeps strictly to time and limits the depth of engagement with his patients. Reading between the lines I think he is still stressed, but manages to cope. Moreover, his patients do not seem to suffer. To adapt the phrase of the paediatrician Winnecott, he is a "good enough doctor".

My own experience is that engagement with patients is draining. To be effective we have to engage at an emotional level to some extent. Every patient has not only a different set of circumstances but also a different view of life. To engage effectively with widely different people five times an hour for over three hours, with interruptions and only a snatched cup of tea, is hard work. We have to give of ourselves, and I take some comfort from the fact that Jesus Christ felt the same (Luke 8:40-48).

I think that I had been mildly depressed for several years, and that this got significantly worse and reached crisis point in the summer of last year. A course of an antidepressant helped, but so did a heart-to-heart talk with my wife who really hadn't understood why her husband was behaving so unreasonably. My home life had been severely affected because I was worn out and good for nothing when I got home. Often I would just fall asleep on the settee. I would pick up a little over the weekend, but then feel dreadful again by Sunday evening. Work was a nightmare, an unending slog. At the start of the day I didn't know how I was going to get through the morning surgery, never mind the rest of the day. It was an odd sort of depression, because it was completely work-related. During holidays I felt fine.

I have indeed been a fortunate man, helped by my understanding wife and family, by colleagues at the practice, and by an appraiser who had dealt with similar problems himself. Looking back, I think the main cause was a feeling of lack of control. Back in 2003 I had strongly opposed the New Contract, and played a small part in trying to oppose it. But the New Contract came into force anyway, and since then there has been an inexorable series of changes which have been hard to cope with. My locus of control was definitely external. My recovery has involved realising the truth of the saying that it is not things that are bad in themselves, but the view that we take of them. I am trying to reduce stress at work as much as possible, and to make the best of things. Like my appraiser I want to be a "good enough" doctor, with enough energy left over for me and my family.


Anonymous said...

Good for you! I suspect that as GPs we are sitting somewhere in the unhappy to mild depression end of the well being spectrum. It struck me the other day as I was doing the depression screening questionnaire for diabetes that I would value someone taking the time and trouble to talk with me about how I felt about the work related changes. PHQ9 perhaps - but then as an appraiser what will I make of the reults?

Dr Andrew Brown said...

I agree that this is probably true for a significant proportion of GPs. Some GPs are gung-ho and robust and entrepreneurial - and good luck to them. But a large number are more fragile. It may be that these more sensitive doctors are better (for "only the wounded physician heals") but the way the NHS is currently constituted does not support them at all.

Appraisal should in theory be a helpful supportive mechanism, and sometimes it is (as it was for me recently), but often it is seen as threatening. And the talk is that it is to be "toughened up" to meet the "public demand" for the policing of doctors. Any suggestion of weakness or depression might then put our medical licence in jeopardy. So we will deny that there is any problem.

Merys said...

what you describe is the same for me with university. I hate the place my medical school is based, and feel horrifically low when I'm here. But over the easter holidays I've been ecstatically happy to be somewhere else (even though I've been working every hour god sends to supplement my student loan).
I don't yet know whether fluoexetine is helping, but I guess only time will tell.

Dr Andrew Brown said...

Medical school can be a hard slog, particularly if you have to do part-time work as well.

Do you think that it's the university town that gets you down, living away from home, or the course that you're doing? The first two may well improve, but the third will probably not.