General practitioner health and well-being: from Brisbane to Los Angeles.

In the late 1940s, William Carlos Williams, family physician and author, began his short story “The Practice” with the following paragraph that captured the human splendor of medicine1: It's the humdrum, day-in, day-out everyday work that is the real satisfaction of the practice of medicine; the million and a half patients a man has seen on his daily visits over a forty-year period of weekdays and Sundays that make up his life. I have never had a money practice; it would have been impossible for me. But the actual calling on people, at all times and under all conditions, the coming to grips with the intimate conditions of their lives; when they were being born, when they were dying, has always absorbed me. He went on to say that the full-time practice of medicine never interfered with his writing but rather served as his “very food and drink.” Clearly, this American general practitioner (GP) saw his practice as a vocation, a life-fulfilling calling. Half a century later, Hartwig and Nichols report on a study of GPs half a world away in Brisbane, Australia, that suggests that for many, medicine is no longer a vocation—a form of food and drink—but rather a stressful job. In response to a survey that found that health and well-being were major concerns for its more than 800 physician members, the Brisbane North Division of General Practice commissioned a study to explore the issues. It found that many GPs would leave the profession if they could, have high stress and low morale, delay use of or refuse medical services when they are sick, and are more likely to suffer mental health problems and marital discord than the general population they serve. The major causes of stress included time pressures to see patients, too much work for too little pay, government bureaucracy, paperwork, and unrealistic expectations by demanding patients. Is general practice a job in Brisbane but a vocation elsewhere? Or are our colleagues elsewhere in the world experiencing the same loss of morale? More than 1,000 family physicians in the Netherlands, many dressed in pajamas, recently traveled to The Hague to tell Parliament that they were overwhelmed with work and gravely underpaid.2 They pleaded for a reduction in their 70-hour week and for more resources to hire additional staff. In California, dominated by managed care and low capitation rates, one repeatedly hears that physician morale is at an all-time low. Physicians speak daily about the workloads and bureaucratic hurdles imposed by managed care. Many bright premed students at UCLA have deferred going to medical school, electing to try a job with a “dot.com” company. I suspect we are experiencing a world epidemic of stress among primary care physicians. Why does this matter? The well-being of a nation's physician workforce affects the quality of care that it can provide. The Brisbane study reported that tension and frustration among GPs led to increased prescription rates and referrals, poorer continuity of care, and decreased satisfaction among patients. As family physicians suffer, so do their patients. What should be done? The Brisbane GPs suggested a number of supportive strategies, including practice management support, assigned locums to ensure time off, and an advocacy network for local GPs. The goal is to develop an alternative model of a healthy GP with high morale and job satisfaction, resulting in high-quality patient care. Sources of satisfaction included problem solving, procedural work, research and teaching, and financial security. An American study of 330 family physicians showed a strong correlation between personal values of benevolence—defined as “preservation and enhancement of the welfare of people with whom one is in frequent close contact”—and job satisfaction.3 Benevolence could be protective for physicians. We must also understand that the medical world is changing rapidly, that it is undergoing both a biomedical transformation and an economic upheaval as costs soar. We are woefully unprepared for the challenges we face. Rather than mourn what has been lost, we need to become adept at working in the new economic, bureaucratic culture of health care.4 As Relman says, physicians need better and more training in the “politics, philosophy, and economics of medical practice.”5 Physicians in the United States have become double agents, struggling to negotiate the opposing practices of controlling costs and caring for patients. The essence of doctoring needs to be redefined in this new setting. Doing something you love almost always outweighs the associated costs. Most primary care physicians in the world entered the practice believing, as did William Carlos Williams, that this was a noble calling—indeed, a vocation. We must not lose sight of the fact that we are lucky to be in a profession in which we do well for ourselves by doing well for others.