February 2022

Clinical Snippets February 2022

1.  Peripheral artery disease and walking

From a recent Tools for Practice:  In patients with PAD, exercise therapy improves maximum walking distance and pain-free walking distance by up to ~200 meters over 2 to 78 weeks compared to usual care. No benefit has been demonstrated for amputation or mortality. The most commonly studied exercise is supervised walking 2-3 times per week for 30-60 minutes, although other supervised activities (example resistance training) may be beneficial in those who cannot tolerate walking.

• Patient understanding of physical activity for PAD should be explored:
• 63% identified walking as the primary aetiology for their pain, 90% thought walking would worsen symptoms.

2.  Electronic communication and the internet

Last year MCNZ released an updated statement on Use of the internet and electronic communication  which includes the following points (and I recommend reviewing the whole document):

• Inappropriate communication, including use of social media, can be considered unprofessional, whether this is directly related to a doctor’s work or not.
• Patients who get information from the internet may wish to discuss this with you. You should use this as an opportunity to talk about how sometimes the information obtained from these sources may be of poor quality, incorrect, or create unrealistic expectations. Provide sound reasons for the views you express and, where possible, provide documentation, to support the alternative advice or treatment that you are recommending.
• There are security issues specific to the use of email. It is difficult to verify a person’s identity from an email; some families and groups share a common email address; and computers (particularly family computers) may be accessed by a number of different people. For these reasons, check with the patient before sending them sensitive information by email.

3.  Aotearoa New Zealand STI Management Guidelines – Chlamydia

• There is growing evidence that sexually transmitted Chlamydia trachomatis establishes a persistent rectal reservoir that is refractory to treatment with azithromycin stat.
• The evidence is very strong for men who have sex with men, but is growing for women too.
• Contemporary guidelines are abandoning azithromycin stat and reverting to doxycycline 100mg BD for seven days with stat azithromycin only if doxycycline contraindicated or patient is highly likely to be non-adherent.
• Symptomatic anorectal infection generally requires specialist advice as further testing and management is complex

4.  Recurrent Bacterial Vaginosis (BV)

A recent article in NZ Doctor includes the following key points on recurrent BV:

• There have been no major advances in the treatment and cure of bacterial vaginosis, perhaps because the pathophysiology is complex, multifactorial and not fully understood.
• Standard therapy is seven days of twice-daily metronidazole, but many women are looking for alternative treatments that may provide longer duration between recurrences.
• Intravaginal boric acid capsules have been used historically and may be considered an alternative, though unfunded, treatment to use in conjunction with antibiotic therapy.

DermnetNZ lists a number of alternative treatments including gels to reduce vaginal pH and a vaginal antiseptic dequalinium.  It does not appear any of the recommended products are in NZF but Aci-Jel is available OTC (around $30 per 100g tube).    Boric acid vaginal pessaries can be bought on-line – eg pHD $199 for 72 caps (about five courses)

A 2009 Cochrane review concluded that research at that time research did not provide conclusive evidence that probiotics are superior to or enhance the effectiveness of antibiotics in the treatment of BV.  However, a 2019 meta-analysis concluded that probiotic regimes are safe and may exhibit a short-term and long-term beneficial effect for BV treatment.  There are many OTC preparations available.  Probiotics do not form part of HealthPathways or Aotearoa New Zealand STI Management Guidelines recommendations for management of BV. 

DermnetNZ also discusses cytolytic vaginosis as a cause of possible of persistent vaginal discharge.  This is the result of a hyperacidic vaginal environment due to overgrowth of lactic acid producing bacilli, with management aiming to reduce vaginal pH (baking soda douching). 

5.  Extended use of intrauterine devices

Tools for Practice examined the evidence around effectiveness of intrauterine devices for prevention of pregnancy when used beyond the manufacturer recommended use period.  The conclusion was:

If it is not possible or desirable to replace a levonorgestrel 52mg or copper-T380A intrauterine device (IUD) at the end of the approved duration of use, small observational studies demonstrated similar efficacy and safety for up to two additional years, with little evidence afterwards. Guidelines suggest that with patient-informed discussion, deferral of IUD replacement for up to twelve months is reasonable.

6.  Antipsychotic switching tool

A useful tool is available from NPS Australia that assists prescribers when changing a patient’s antipsychotic treatment. Using the interactive tool, the prescriber enters the formulation (oral or depot), the current medicine the patient is prescribed and the medicine they want to switch the patient to. This then generates prescribing information about how to stop one medicine and start the next, along with key clinical issues to be aware of. All antipsychotic medicines currently funded in New Zealand are included in the tool.

7.  Serotonin syndrome – a reminder

A relatively common prescribing complaint I see relates to patients concerned they were not warned of the risk of serotonin syndrome, or that they experienced serotonin syndrome, usually secondary to co-prescribing of two serotonergic agents.  The most common combinations I see are tramadol and SSRI, SNRI or TCA, or when a TCA is added to an existing antidepressant regime.  A 2015 communication from Medsafe discusses the issue in more detail and is worth a quick review. 

podcasts.apple.com/nz/podcast/the-new-zealand-general-practice-podcast/id1457506728

Lucy O’Hagan is the latest contributor to the podcast, sharing her story of dealing with the pressures of General Practice.

Being in roles that focus on advocacy and service improvement naturally starts with conversations about problems.

I started this project to balance the negative noise that inevitably accompanies a desire to do things better.

I hope that listeners will gain an understanding of their GPs, knowing what makes your gp tick will I hope improve doctor patient relationships.

I hope that GPs listening will be inspired to reflect on what brings them most pleasure from their work, and find some tips and tricks to enhance the joy of General Practice.

Jo

There are plenty of reasons that face to face consultations are valuable, not only to provide examinations and procedures. The limbic link that connects people and that is so important in communication is dramatically filtered when made through a screen.

“Virtual first” processes allow for better infection control, and as a minimum patients and staff will expect excellent infection control in health services.

It will never again be acceptable to sit next to a coughing patient in a waiting room, or to be sneezed on when you are doing a diabetes check.

“Virtual first” also provides opportunities for improved access through the wider open door afforded by virtual systems and for efficient service delivery through planned consultations and direction to the best source of help.

To me, it’s a no-brainer. I know the concept of change is hard, and many GPs and hospital services just want everything to be back the way it was.

Unfortunately the way it was was not working for the most disadvantaged.

The way it was was not working for many primary care services and clinicians who were over worked, under paid, and frustrated with the quality of care they were able to provide because of poor access.

The way it was was not working for many rural communities.

Let’s see if virtual first approaches can make the way it was into the way it can be.

More reading on limbic connections here : https://www.goodreads.com/book/show/35711

Evidence that “virtual first” approaches can improve access and outcomes can be found here: https://www.healthcarehome.org.nz/

The “New Normal” – looking forward to the next phase in healthcare.

The impact of the pandemic is going to be with us for the next 18-36 months if not longer, and whilst this is a challenge it is also an opportunity.

Moving backwards is rarely the right choice in medicine, and in this situation not an option.

We need to look forward to what is now becoming the “new normal” way we do things.   

What won’t change ?

Primary care has been described as  “the provision of integrated, accessible health care services by clinicians who are accountable for addressing a large majority of personal health care needs, developing a sustained partnership with patients, and practicing in the context of family and community.” 

It is measured as “good” against four elements:

1. First-contact access for each need;
2. Long-term person- (not disease) focused care;
3. Comprehensive care for most health needs; and
4. Coordinated care when it must be sought elsewhere

In some measures the degree of family or community care is also included. [1]

None of this is changing.

Nor is the fact that primary care is all about relationships.

General Practice team members are experts in relationships.  We are experts in communication. We are experts in risk management. We are experts in healthcare.

Why do we need to change ?

For the foreseeable future we will be swabbing a large proportion of those who have respiratory symptoms for covid19, we will need to keep our other patients, and our staff safe from this disease.

There will be local and regional and potentially national outbreaks over this time.

This will be happening on the background of a world in economic crisis, challenges to businesses in all sectors, and a high level of patient and provider anxiety.

 As a minimum we have to adapt to the “new normal” by :  

1. Providing virtual triage for all patients to identify the potential covid19 from the non-potential covid19.
2. Having systems that keep infectious people away from others when we are seeing them face to face.
3. Providing safe systems to protect staff.
4. Having the ability to scale up a local response to manage an outbreak  
5. Having systems for monitoring covid19 disease progress in the community and clear referral and management pathways

What is the New Normal ?

In the “new normal” general practice will continue to do what it does best with more virtual care, in cleaner environments with better infection control mechanisms, and with staff with more flexible working conditions.

In the new normal practices will need to either be “green zones” and have nothing to do with anyone with a respiratory infection or ‘flu like illness , or to have “green” and “red” zones and processes that allow them to continue to manage patients with respiratory infections and ‘flu like illness safely.

In the new normal “virtual first” becomes the primary point of contact for patients who need to use the health system. This will impact on the working conditions of all staff, as we shift our ability to provide effective efficient home based care.

In the new normal, personal protective equipment is worn, not kept in box in case of emergencies.

Community Based Assessment Centres (CBACs) have a role in supporting communities whose practices cannot provide “green” and “red” safe zoning, and to provide covid19 services to communities that have low GP penetration / poor access.

CBACs in the future have a role in stepping up to support practices dealing with an outbreak in a locality that threatens to overwhelm the local service.  They will need to be able to be rapidly set up within 24-48 hrs, and to be in place for at least 28 days.

And the future ?

We have already demonstrated our ability to adapt to the new normal, as practices and as networks.

The new normal brings with it challenges and opportunities to do much more than just the bare minimum.

There have been palpable improvements in access to services through the switch to virtual care, yes with inequities evident; the digital divide is shown to be wider than was thought – but that’s just a problem, it’s not insurmountable.

There have been palpable improvements in working conditions for practice teams – yes, with challenges to the business model and income expectations, change in working patterns, and different stressors but these are just issues, they are not insurmountable.

Yes, we are worried that patient outcomes may be compromised somehow- but we have never been very good at measuring them and this is an opportunity for that to change.

Let’s embrace the new normal, look forward, learn from each other, build on the power of networks, and collaborate to provide better first contact, comprehensive, coordinated, person-centred care. 

To be honest, it’s not like we have much choice.

Jo Scott-Jones   

1. Contribution of Primary Care to Health Systems and Health, Starfield, Shi, Macinko 2005.  https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2690145/

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Change is hard.

The commonest end point of a significant pivot in the way we do things is for us to return to our original behaviour over time.

Look at every new year’s resolution, every idea you bring back from a conference, even the range of medications you prescribe.

We don’t like change.

We lose focus on change that must happen over time, we don’t review and embed change.

We need others to help us, and we often rely on people who don’t really understand what needs to happen.

We lack commitment ourselves to see change through, we fail to inspire others to commit to change.

We lose energy and find it hard to maintain the effort required to embed change.

So why is the change caused by COVID19 going to be different?

1. SARS-Cov2 is not a short-lived phenomenon.

It emerged only in December 2019, NZ’s first case was in February, just 2 months ago. The graphs usually show an exaggerated bell curve, with a rapid fall in cases after a peak.

The rhetoric describes this as a fight. Wars are fought, battles are won and lost but eventually we will defeat this. We will “get through.” 

The reality is that the only infectious disease that the world has managed to eradicate is smallpox.

Discussed from 1945, completed in 1979 this relied on a determined global campaign over 13 years, an effective vaccine, case identification, contract tracing and quarantine.

It is unlikely this illness will “burn itself out” as appears to have happened to SARS-Cov-1, this virus is much more infectious, and unlike SARS-Cov-1 does not appear to be limited in who it can affect.    

“Herd immunity” (if achievable) is not a cure, it is an acceptance of prevalence.      

• Societal attitudes have changed.

Doctor’s waiting rooms have long been seen as a source of infection.

I am certain that every GP has had a patient in the past express that they don’t like sitting in the waiting room because it’s full of sick people.

This was usually dismissed with a shrug of the shoulders, a smile, a “What can you do, eh?”

Some of us would have apologised for keeping the patient waiting, assuming that was the underlying reason for stating of the blinking obvious.

There was an acceptance that risk was low enough, that consequences were minor, hidden or infrequent enough for us to dismiss.

We are now facing a “Semmelweis Moment.”

In 1847 Semmelweis recognised that handwashing reduced maternal mortality [1]. We have recognised that separating out infectious from non-infectious patients reduces transmission of COVID19 disease.

This isn’t new science.

What is new is our understanding of the need to change and we now need to act.

Semmelweis found it hard to ensure that cleaning hands between patients became the new normal, perhaps because change was imposed rather than developed through collaboration and engaging the hearts and minds of colleagues.

We are less likely to repeat that mistake because the general public will not let us.  

More people across the world are contemplating routinely wearing face coverings, people are interested in the difference between aerosols and droplets, and the distance and speed at which viruses spread after a cough or a sneeze, they are asking questions about the length of time infectious particles can survive on plastic, metal, wood and paper.

It is never going to be acceptable again to sit in a place where lots of sick people have gathered and not to be provided with assurance that everything is being done to reduce transmission of disease between people.

• It is unlikely there will ever be a cure.  

History tells us that viruses and bacteria develop resistance to any “cure” we have created in the past, SARS-Cov2 is not going to be any different.

There may be medications that mitigate the impact of the disease, remdesivir and antiretroviral agents may interfere with viral replication, hydroxychloroquine and chloroquine may reduce the ability of the virus to enter cells, “convalescent plasma” containing antibodies generated by a person who has survived the disease may “boost” the immune system.

There is no doubt that we will develop better ways of intervening that will improve outcomes for people needing hospital care.

But it is very unlikely that we are going to be able to “cure” people of this illness with medication.

• It is unknown if we develop or can induce long lasting immunity.

We hope that when we reach “herd immunity” either through a vaccine or natural immunity of 80% of the population, we will have reduced the risks to an acceptable level.

The fact is that immunity, whether vaccine induced or naturally gained is an unknown quantity.

If this coronavirus is like the others that cause 2o% of common colds, immunity may last 2-4 weeks, if it has similar properties to SARS-Cov-1 immunity it may last 2-3 years.

We don’t think the virus mutates as frequently as the influenza virus.

We don’t know if a safe vaccine will be found, or how long-lasting a vaccine will be.

What is clear is that vaccine development is not going to be quick.

• The public response

Each year in New Zealand we accept that around 10 people will die from HIV, 20 people die from TB, we may not like it, but we accept that 2-3% of deaths in this country are due to lower respiratory tract infections.

COVID19 will become another blip in the numbers eventually, and its impact on healthcare will become part of the way we do things ‘round here.    

People at high risk of other viral illnesses with no cure and no immunity, like Herpes and HIV, have changed behaviour to reduce the risk of catching and transmitting the virus.

This illness is going to gradually settle in the mind of the public into one of the risks that we take when we interact with others, but its global impact is not going to quickly go away in the mind of the public.

Although we rationalise the numbers of people who die each day from poverty, malaria, road traffic accidents, and medical errors the personal impact of seeing mass graves being dug in New York, the dying in hospital corridors in Italy, bodies in the street in Turkey that feels like this will stick.

The case load of SARs-Cov2 is following the same pattern of other respiratory infectious diseases.

We have seen a surge of known cases settle into a background incidence as a result of public health measures. It seems likely that this level of disease will flare and settle over time, both in the public consciousness and in the pressure,  it causes on the health system.

How well we cope as a system will depend on the ability, we must keep that case load within the limits of the what the health system can cope with.

We may drift back to an acceptance of the risk when gathering to watch sports, concerts and theatre, to party and carnival, but the acceptance of risk is not going to extend to health care services.

Nor should it. 

Dr Jo Scott-Jones FRNZCGP MMSc DipClinED DipSports DipObs DipGerMed

More reading on:  

Change management

HBR item on DICE scoring (duration, integrity, commitment and effort.)

https://hbr.org/2005/10/the-hard-side-of-change-management

Smallpox

WHO archives https://www.who.int/archives/fonds_collections/bytitle/fonds_6/en/

What medical students are now taught about the immune system? 

Immunology from osmosis.org (https://www.youtube.com/watch?v=wHCJUMBKgyo&vl=en)

and:

COVID specific information from “Ninja Nerd Science”

Epidemiology, pathophysiology and diagnosis.

(https://www.youtube.com/watch?v=PWzbArPgo-o)

Monitoring, treatment, prognosis and prevention. 

View at Medium.com

View at Medium.com

More scholarly reading on immune response to SARS-Cov2

Coronavirus infections and immune responses Geng Li et al Journal of Medical Virology 

https://onlinelibrary.wiley.com/doi/full/10.1002/jmv.25685

Coronavirus infections: Epidemiological, clinical and immunological features and hypotheses

Raoutl et al in Cell Stress

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7146059/

Global Burden of Disease

http://www.healthdata.org/data-visualization/gbd-compare

For a public explanation of the current understanding of immunity and covid19

Wired magazine and Dr Seema Yazmin from Stanford

https://www.wired.com/story/covid-19-immunity/

View at Medium.com

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[1] https://www.ncbi.nlm.nih.gov/books/NBK144018/

We are very concerned at the possibility that the Rural Health Alliance Aotearoa NZ (RHAANZ) will have to cease operations due to its precarious financial sustainability.

Over the past five years RHAANZ has rapidly become an important voice for our rural communities and has committed resources to envisioning and carrying out a programme of positive change for rural health in New Zealand. This has been done in close alignment and collaboration with the Ministries of Health and Primary Industries. Great possibilities lie ahead. However, the pressure on RHAANZ’s very small staff and the limitations of available funding sources mean that future is under threat.

RHAANZ has put a proposal to government via these Ministries for a contribution in part to core office functions and partly directed to specific projects on their agenda for rural wellbeing. Due to unfortunate delays, it remains unclear whether this bid will be successful. If it is not, then RHAANZ must cease operations on 1 July 2018. And in the meantime has had to stop all activities beyond completing its current contractual commitments.

We believe RHAANZ has a vital function in bringing a cross-sectoral rural community voice to both enunciate rural health issues and to identify and resource solutions. For the organisation to disappear from the scene, at a time when rural health itself is as precarious as ever, would be a terrible loss of goodwill, synergy and expertise.

Overseas rural health alliances have all received central funding in recognition of their value to both government and communities. New Zealand needs to follow that lead.

Anything that you can do to support the proposal for central government funding would be a boon for our rural communities and their future health.

http://www.rhaanz.org.nz

#rhanz #fundrhaz

Having a conversation with a GP before you consult with them makes a lot of sense, empirically.

I am sure we can all imagine the benefits.

Maybe the issue we have can be sorted out on the phone and not need us to make an apppointment, take time out of work, travel, wait, and in many countries pay for a consultation.

Maybe the issue we have will need some investigations, which could be organised before the face to face consultation so that the GP can help us more effectively when we do meet face to face.

Maybe we can be directed to see a nurse, pharmacist or counsellor who is better suited to deal with our problem.

Maybe the GP will be happier when we do see them because they are prepared for the consultation, and not be feeling that their hard earned skills are being used for low acuity problems.

I have to declare a bias towards the idea of GP led telephone triage, based on the fact that as a working GP I have personal experience of the overwhelming demand patients can create in our traditional model practice that was designed for a time when we had fewer people to care for, who had less complex multimorbidities, lower expectations of the capacity and capability of health services, and higher levels of self and family care.

The “doctor-in-a-box” model that developed in the 1900s has to change to meet the needs of the 21st century patient, and has opportunities to do so in a tech-enabled world that Anuerin Bevan would never have dreamed about.

I value academic study of our profession, I believe that making informed choices about how we progress our services relies on unbiased evaluation of what works well and what doesn’t.

The word unbiased is an essential part of that statement and it’s really frustrating when academic studies of “telephone triage” by GPs present their findings with apparent focus on the negative aspects of the service, and when results do detail positive outcomes, authors and commentators emphasise the negative aspects in discussions and abstracts.

NZ commentators reading : http://www.bmj.com/content/358/bmj.j4345, and http://www.bmj.com/content/358/bmj.j4197 put focus on an INCREASE in the number of consultations found in “telephone first” services, despite the fact that the “change was made up of a substantial reduction in face to face consultations, which reduced from a mean of 13.0 (SD 4.5) to 9.3 (SD 5.5), and an increase in telephone consultations from a mean of 3.0 (SD 4.5) to 12.2 (SD 7.5) telephone consultations/day/1000 patients.”

These systems provide many more opportunities for patients to access care.

NZ commentators focus on an overall increase of 2% in ED attendences but ignore the fact that “Heterogeneity identified with a random effect shows that these figures mask considerable differences between individual practices, some of which had large increases in emergency department attendances, with others showing large decreases.”

They focus on the negative aspects of patient experience in that “just under a quarter reported that it was more difficult to communicate with the GP on the phone, the main reasons being given that it was difficult to explain the problem or that the doctor could not see the problem” and ignore the fact that “nearly two thirds found it made no difference, and 11.7% found it easier to communicate on the phone.”

They ignore the fact that the authors found an “improvement in patients’ rating of time to be seen or spoken to (increase of 20 points on a 0-100 point scale) compared with national trends” and that this was “large and immediate”.

They focus on the “estimated ..overall increase of 8% in the mean time spent consulting by GPs” and ignore the fact that “the average workload figures mask wide variation between practices, with some practices experiencing a substantial reduction in workload and others a large increase” – and that the estimate came with “large uncertainty” (95% confidence interval −1% to 17%; P<0.09)

They don’t mention the fact that there was a “small increase in continuity of care index after the introduction of the new system.”

I wouldn’t be surprised if NZ commentators looked at Catherine Bell’s article in the BMJ “Does Peppa Pig encourage inappropriate use of primary care resources?” BMJ 2017; 359 doi: https://doi.org/10.1136/bmj.j5397 (Published 11 December 2017) and argued that it too demonstrates that telephone triage clearly is a waste of resources.

NZ commentators ignore the fact that our system is very different from that in the UK and the fact of a patient co-payment makes comparisons between the outcomes of trials like this difficult to translate to the NZ context.

The UK system does not filter patients who have to speak to the a doctor on the telephone, every patient HAS to have a phone call with a GP before they can be offered an appointment. This process is not the same as NZ telephone triage where patients are able to make enquiries and be directed to admin or nursing services, they can make delayed consultations if they wish and telephone triage by GPs means they are calling back patients who are seeking same day consultations (or requesting a telephone consultation.)

I could go on and on…but in summary – let’s study the impacts in NZ and not rely on overseas based studies to draw conclusions about our health system, and when the outcomes of a study don’t make empirical sense, let’s consider it a warning to look really carefully at the methodology and results.

Jo Scott-Jones

Burnout: “A syndrome of emotional exhaustion, depersonalisation, and sense of low personal accomplishment that leads to decreased effectiveness at work.” ( Maslach 1996)

Surveys of prevalence of burnout internationally suggest that over 50% of primary care physicians admit to one or more symptoms of burnout  and it’s getting worse with time[1]. This is reflected in our collective view of our profession in the RNZCGP annual workforce survey 2015 when less than 20% of respondents were “extremely likely” to recommend GP as a career [2] .

There may be a multitude of reasons for this lack of enthusiasm for our specialty, God knows we don’t do it for the money, but perhaps it also reflects exhaustion and a sense of low accomplishment many of us feel at the end of the day? You tell me – I’m too tired to think about it too much.

Symptoms of burnout include:

Signs of physical and emotional exhaustion – chronic fatigue, insomnia, weakness, poor appetite, depression, anxiety.

Signs of emotional detachment – anger, isolation, pessimism, lack of enjoyment in work.

Signs of reduced effectiveness – complaints from patients and colleagues, poor performance, irritability, apathy. [3]

My own first experience of burnout came as a junior doctor, the only on-site doctor for a community of 30,000 in a 50 bed hospital unit. I was working only the 12 hour night shifts so I could play with my young children during the day, and consequently was sleeping only for a few hours in the middle of the day for months on end.

I can easily put myself back into the emotional space I felt when a poor patient with chest pain arrived at 2 am one morning towards the end of this time.

My only feeling was of resentment that this man was going to be taking up my time which could have been spent having a few minutes sleep. I did the necessary, but had no compassion or ability to empathise left in me.

The only option I could see at the time was to change my job which I did shortly afterwards, out of the frying pan into the fire as it turned out, but that’s another story.

One definition of “stress” is the emotional result of having a gap between how you want or expect the world to be and the reality of lived experience. This means that if we want our patients to be good communicators, who get better as a result of our interventions, and who are cared for in a system that is efficient and responsive we are going to be subject to stress, because patients find it hard to communicate, and the health system is not efficient or responsive.

Add to this reduced resilience through poor sleep, long work hours, the pressures of bureaucracy , a lack of general self-care and you have a recipe for disaster.

So what can you do about burnout?

Prevention is better than cure – stay well, exercise regularly, eat healthy foods, don’t abuse alcohol or other drugs, get plenty of sleep, maintain interests out of medicine, read fiction, be creative, have strong interpersonal relationships and take regular holidays – it ain’t rocket science is it?

If you recognise the symptoms – talk to your own GP – you should have one and get one if you don’t.

Remember “The physician who treats himself has a fool for a patient” (William Osler). Take the advice your GP gives you, even if it involves medication or having a long break from work.

Listen to “The Doctor Paradox” podcast and learn from others how they have coped with burnout [4] – often it involves making a significant change in the way you approach work – I know – this is NOT easy which is why preventing burnout in the first place is a better approach.

Above all else “First you save yourself” – there is no point handing out the oxygen masks to everyone around you whilst you become slowly unconscious. As a profession we have twice the risk of death by suicide compared to the general population and female doctors a four-fold increase in suicide risk[5] – so be careful out there, listen to your body, be mindful of your mood.

Consider whether or not the increasing number of complaints you are receiving is a result of your lack of engagement and not a reflection of the ignorant low life you are obliged to serve – if you think this way it is a symptom of “de-personalisation” and a sign you have a problem, not them.

If you have a lot of  “heart-sink patients” (those whose name in the appointment book makes your heart sink because you feel defeated, overwhelmed and exasperated by their constant demands and unsolvable problems [6])  consider re-framing the problem as being a sign that it’s time for taking a holiday, reading a good book and learning how to play the clarinet.

Dr Jo Scott-Jones

 

 

 

 

 

 

[1] http://www.medscape.com/viewarticle/838437

[2] http://www.rnzcgp.org.nz/RNZCGP/Publications/The_GP_workforce/RNZCGP/Publications/GP_workforce.aspx?hkey=a7341975-3f92-4d84-98ec-8c72f7c8e151

[3] https://www.psychologytoday.com/blog/high-octane-women/201311/the-tell-tale-signs-burnout-do-you-have-them

[4] http://thedoctorparadox.com/

[5] https://www.mcnz.org.nz/assets/News-and-Publications/Newsletter/DEC08.pdf

[6] http://www.bmj.com/content/297/6647/528