Resilience: what is it, why do we need it, and can it help us?

General practice is the ‘Jewel in the Crown’ of our NHS, providing universal, free health care for a smaller proportion of gross domestic product than other developed nations. It is one of the UK’s greatest social and political achievements. In her extensive research, Barbara Starfield clearly demonstrated that the health of a population is directly dependent on the quality of its primary care system.¹ GPs have always been flexible, innovative, and resilient. They are powerful and effective advocates for professional excellence, high-quality medicine, 24-hour care, compassion, ‘family medicine’, and equality and social justice. But GPs en masse are now unable to cope with the administrative, emotional, and human demands they face, and this crisis is compromising our vocation and taxing our humanity.

What are the causes of our distress and how can we work with our patients and colleagues to resolve them? Financial stringency has resulted in systemic changes in UK primary care significantly increasing workload, eroding job satisfaction, and increasing stress (Box 1). One in three GPs have experienced exhaustion and burnout.² A Worcestershire GP aiming at early retirement recently stated:

‘Every surgery in Worcestershire is at or beyond capacity. Most of us are dealing with over 60 patients per day … probably too many. I want to continue but the workload is too great, I’m both physically and emotionally whacked … many older GPs have already gone and there are not enough doctors.’³

Box 1. Systemic changes that have a negative impact in general practice.

Clinical

• Medical complexity and polypharmacy

• Ageing population with multimorbidity

• Pressure on prescribing

• Increasing number of guidelines to follow (and debatable relevance of some guidelines to primary care)

• 10-minute appointments for complex patients

• Increasing workloads due to work moving from secondary to primary care

• Lack of continuity in the community, for example carers and district nurses

• Target pressures, for example cancer referrals

• Increasing public demands and expectations

Managerial

• Decreased funding and resources to run the same or a better service

• Increasing list size

• Poor premises

• Ever changing goalposts: Quality and Outcomes Framework, Local Enhanced Services, Directed Enhanced Services

• Competitive tendering

• Managerial responsibility outside the practice competing for time, for example clinical commissioning groups and federations

Policing and complaints

• Rapidly increasing fear of litigation and increasing complaints directly to the General Medical Council

• ‘Guilty until proven innocent’ approach to complaints

• Appraisal and revalidation

• Care Quality Commission inspections and rankings

Workforce

• Recruitment shortfalls

• GPs dropping sessions/working part-time

• Early retirement

• Emigration

• Portfolio careers

• GP locums (increasing pressure on partners and reducing practice income)

Others

• Negative public opinion, including the media

• Feeling unrepresented or misrepresented by professional bodies, for example the BMA General Practitioners Committee (GPC), GMC, or RCGP

• Increasing pension contributions and pension change

• Increased medical indemnity fees

The results of the 2015 BMA GP Survey,⁴ which explored GPs’ views of their roles and working lives, are summarised in Box 2.

Box 2. BMA GP Survey 2015 results⁴.

• 93% of GPs say that their heavy workload has had a negative impact on the quality of patient services

• Only 8% of GPs feel that the standard 10-minute consultation is adequate

• 94% of GPs do not support 7-day opening

• 1 in 3 GPs considering retirement within the next 5 years

• Almost 3 in 10 GPs (28%) who are currently working full-time said they are thinking about moving to part-time

• 20% of GP trainees are considering working abroad before 2020

• Over two-thirds of GPs (68%) state that, while manageable, they experience a significant amount of work-related stress. However, 1 in 6 (16%) feel their stress is significant and unmanageable

• GPs cite various factors that have a negative impact on their commitment to being a GP, including excessive workload (71%), unresourced work being moved into general practice (54%), and not enough time with their patients (43%)

• Despite the pressures on general practice just under one-half (47%) of GPs would recommend a career as a GP, but one-third (35%) would not advocate working in general practice.

There is a crisis in GP numbers: many GP training posts are unfilled; young GPs seeking higher incomes, lower workload, and greater professional autonomy emigrate; female GPs in mid-career who are unable to juggle family life and work are leaving the profession; and older GPs are retiring early despite loss of pension income. Based on current recruitment and retirement the Royal College of General Practitioners (RCGP) estimates it could take 30 years for the GP workforce to recover.⁵ Yet despite shrinking GP numbers and widespread burnout, more work and responsibility are demanded of those still working.

WHAT IS RESILIENCE?

When we are stressed we find it much more difficult to empathise with family and strangers as our stress responses turn off compassion and empathy.⁶ Unstressed doctors are safer and better at their job.⁷

There are many definitions of resilience but it is best considered as the individual’s ability to adapt to and manage stress and adversity: essential qualities for GPs. Our responsibility is to maintain compassion and manage complex, day-to-day, clinical, and managerial situations successfully. While the NHS needs to transform we too have a duty of care to protect primary care’s vital human capital: ourselves and our staff.

Close face-to-face contact with suffering is instinctually disturbing. When we feel resilient, a clinical encounter will trigger an appropriately caring response;⁸ but if we are feeling stressed, struggling with our own emotions and exhausted, the same meeting is likely to evoke threat-avoidance reactions. This becomes all the more pronounced against a backdrop of turbulence from paperwork, partners, targets, and finances.

Initially, unrelenting sympathetic system arousal makes us more emotionally labile and narrows thought processes down to the few needed for threat avoidance and goal seeking. Ultimately this triggers pro-inflammatory pathways and immune dysfunction. Gradually, as it de-tunes the way that our unconscious ‘mirroring’ pre-motor cortex sensitises us to other people’s expressions and gestures, it make us less empathic and perceptive (burnout stages 1 and 2). This ‘dumbing-down’, although it might protect us through ‘professional numbing’, has obvious downsides for patient-centred care and safety. Unless there can be respite from the remorseless bodily processes of arousal and struggle, the body and mind will eventually defend against perceived overwhelm by shifting into freeze-dissociation (burnout stage 3).⁹

WHAT MAKES A GP RESILIENT?

Resilience is not a static trait that some have and others lack. Nature and nurture play a part but it depends greatly on circumstances, knowledge, skills, and attitudes. The claim that modern GPs lack resilience deflects the blame from a broken system onto the individuals working within it. In fact GPs have shown themselves to be inherently resilient, readily adapting to shifting work requirements. Indeed, traditional primary care practices, managed and run by GPs, are so resilient that even in the face of the current adversity they outperform commercially run alternative providers.¹⁰

Five personality traits correlate strongly with GPs’ resilience because they facilitate safe adaption: self-directedness, cooperativeness, harm avoidance, persistence,⁹ and general wellbeing.¹¹ Charney and Southwick identified 10 factors associated with stronger resilience (Box 3).¹²

Box 3. Psychological and social factors associated with stronger resilience.

• Facing fear

• Having a moral compass

• Drawing on faith

• Using social support

• Having good role models

• Being physically fit

• Making sure your brain is challenged

• Having ‘cognitive and emotional flexibility’

• Having ‘meaning, purpose, and growth’ in life

• ‘Realistic’ optimism

HOW CAN WE DEVELOP RESILIENCE IN PRIMARY CARE?

The system is unlikely to change fast without political debate so how can we develop ‘resilience’ skills that will sustain us? Resilience involves effective adaptation, learning through adversity, and bouncing forward. One kind of exhausted response is protective withdrawal while we wait for system change; another is to become change agents. The research literature supplies examples of self-care techniques that enhance self-regulation and improve work efficiency, such as: regular breaks, mindfulness, co-mentoring, positive psychology, and biofeedback training. Employing these techniques could help us maintain our capacity to care, engage, and resist further damage to the NHS.

Individual resilience

Even though doctors are literally dying for a lack of them, self-care skills seldom feature on the medical curriculum. We distance ourselves from the suffering of our patients by ‘always being well’. This behaviour places us ‘apart’ from our patients, categorising us as invulnerable and making it difficult to admit we need help or may be depressed.

Basic but effective resilience strategies can be taught one to one in as little as 90 minutes.¹³ An initiative to help GPs foster resilience in primary care is underway and the RCGP is working to develop resources to directly support GPs in their working lives, manage stress, and improve their working environments.

Collective resilience

To address the current GP pressures we need proper public debate. We must stand together and ensure our representative bodies (RCGP; GPC) listen to GPs at the coalface. Primary care must reconfigure to deliver with a sustainable workforce.

Winning hearts and minds

We are more resilient when our hard work feels worthwhile and seems to be making a difference. The underworked and overpaid GP, familiar from the tabloids, is far from the truth. GPs are working 12–14-hour days as take-home pay shrinks. Despite occasional disparaging comments by hospital specialists, GP generalists are needed more than ever as hospital consultants become more specialised. Almost everyone wants the NHS to survive. We need to engage with the media so that people outside our profession understand the issues.

CONCLUSION

General practice is the cornerstone of the NHS. It makes the NHS sustainable, dealing with 90% of the work on less than 8% of the budget. The extraordinary changes that have taken place over the past 5 years mean that the crisis in general practice now threatens the very existence of the NHS. The Rowland Report¹⁴ was tasked with examining new models of care, aiming to deliver services for the future. This could radically change the GP’s role from personally providing hands-on comprehensive care, to one in which there is more focus on coordinating and supervising others to perform that task. GP numbers and maintaining the GP workforce were never part of its remit but clearly these changes could impact on both.

It is disappointing that the need for a strong workforce of motivated and engaged GPs, which is crucial for the recommendations of the Rowland Report to stand any chance of success, was not highlighted more prominently in that report. We hope that the forthcoming government inquiry into patient demand and access, workforce, and funding will better address these issues.¹⁵

Meanwhile, we need to work with our colleagues and patients to effect change and alter the negative public stereotypes that provide a smokescreen for the slow, covert destruction of our publicly funded healthcare system. We need to sustain ourselves while solutions are found by finding ways of boosting our resilience and improving our working environments.

Provenance

Commissioned; not externally peer reviewed.

Competing interests

The authors have declared no competing interests.