A Snapshot Survey of Rural Doctors' Health and Analysis of a General Practitioner Well Being Program

Abrar Rana Waliuddin BMed
Junior Medical Officer
Hunter New England Health

Address:
NSW
Australia

Shuba Jeya-Dev
Final Year Medical Student
University of Newcastle

Address:
NSW
Australia

Citation: A. R. Waliuddin & S. Jeya-Dev : A Snapshot Survey of Rural Doctors' Health and Analysis of a General Practitioner Well Being Program . The Internet Journal of Family Practice. 2009 Volume 7 Number 1

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Keywords: general practitioner | doctors' health | physician well being | doctors' mental health

Abstract

Aims: To ascertain physical and mental health issues amongst General Practitioners and evaluate an existing wellbeing program in Australia.
Methods: Likert scale survey of General Practitioners in the Ballarat and surrounding districts of regional Victoria, Australia. Survey included sections on Work, Physical and Emotional Health along with evaluation of parts of the GP wellbeing program run by the local division of general practice. Surveys returned by 40 of the 70 doctors surveyed. .
Conclusions: Several positive and negative trends were noticed. The survey highlighted the number of doctors who are very busy and isolated, work through sickness, do not have their own general practitioner, have not had regular health check-ups and feel work affects their personal life negatively. However positive trends were also noticed - doctors in general exercised regularly, consumed appropriate levels of alcohol and were non-smokers.

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Doctors' health is an issue that seems to attract increasing attention these days within our profession. This is evident by the Annual Doctors' Health Conference in Australia entirely dedicated to discussion of this very issue. Are doctors physically healthier than the average person? What role does mental and emotional stress play in doctors' wellbeing? What does the profession do for it's own members in this area?

The literature reviews on Doctors' Health shows us a lot of the problems that face this group, but there is little to nothing on rural GPs as a special group. Below is an analysis of the factors we need to consider:

Physical Health

• Doctors show good health on measures such as mortality rates. Mortality patterns in the UK and Australia both show low standardized mortality rates (83%) when compared to the general population. Some of this has been attributed to socio-economic status rather than being doctors ⁴ .
• Within the profession itself, GPs have a higher mortality rate and lowest life expectancy of all doctors ^5,6
• The disease profile among doctors is different to the general population depending on the data you study. In the UK, there is a lower incidence of cardiovascular disease and cancer whereas a study of Victorian doctors ⁷ , showed high incidence of these disorders. One thing is for certain – the standardized mortality ratios for mental disorders (including drug and alcohol dependence) and suicide were much higher than expected.
• Lung cancer is one disease where occupation of medicine may play a significant role in prevention. Rates of lung cancer among doctors are low, which reflects the lower rates of smoking. This decline in smoking among doctors reflects both population wide trends and trends within the health industry ⁴ .
• A study conducted in New Zealand showed population wide decline in smoking from 65% to 25%, with the decline even greater among doctors, to 6.7% in 1999 ⁸ . Similar figures have been found in Western Australia (5.9%) and Victoria (4%) with the population wide smoking levels at 24% (ABS 2001).
• The levels of exercise or physical activity among doctors is less certain. It has been reported that 55% of Victorian GPs exercised less than the general population ⁴ . Similarly in WA, 56.8% of GPs did not exercise regularly ⁴ . It is hard to make sense of such data without having a consensus as to what levels of exercise can be considered beneficial for GPs.
• When it comes to diet and body weight, anecdotal evidence may suggest that doctors fare well in this area. More concrete evidence such as in the study by Nyman (1991), suggests that 16% of WA GPs were overweight. McCall (1999) looks at this differently by showing that upto 42% of GPs are either following a weight-loss diet or a reduced fat diet. These figures compare favourably with the Australian average of 48% overweight according to ABS (2001).
• Doctors face slightly increased risk of injury compared to the general population. This comes in the form of increased risk of exposure to infectious diseases such as TB, HIV, Influenza and Hepatitis B or C ⁴ .

Emotional health

• Many surveys highlight job dissatisfaction among GPs.
• Dissatisfaction may be greater among rural GPs where there may be a lack of personal and professional support services.
• A UK study showed that GPs have the highest levels of workplace anxiety and are more likely to be depressed or suicidal ⁴ .
• The high work load and on-call nature of rural general practice may place a burden on personal relationships. This may get exacerbated when there is a lack of supporting services or difficulty is encountered recruiting locums in rural areas ⁴ .
• Isolation from the extended family is seen as a key issue in rural general practice.
• Working as a GP has been linked to marital difficulties and a higher divorce rate than the general population. Studies in Australia and the UK have shown almost 19-21% of GPs have had marital difficulties due to their work ⁴ .
• Female doctors are more likely to work part-time which better suits family commitments.
• Alcohol consumption is a controversial area in GPs. Some studies such as that done in Finland show heavy alcohol consumption among 19% of GPs, which is higher than the general population ⁴ . Studies of NZ and Australian GPs (esp NSW and WA) show heavy alcohol consumption in only 3-8% of GPs ⁴ .
• Drug misuse is tough to assess as there can be professional penalties. The estimates of drug misuse among GPs varies quite a lot (0.5 to 10%).
• Clinical depression or psychological distress figures among GPs range between 14% to 30%. The most worrying Australian statistic has to be the 50% of GPs in WA, who reported psychological distress ⁴ .
• There are heightened levels of suicide risk among doctors. GPs in NSW have a rate of 19.1 suicides per 100,000 deaths which is higher than the population average of 12 suicides per 100,000 ⁴ .
• Despite a strong link between depression and suicide, it proves very hard to study it in GPs. It may be influenced by how emotionally open a GP is – the general theory being that female GPs may be more likely to report emotional difficulties than male GPs.

Self-Care

Anecdotal and some study evidence has long suggested that:

• GPs are very busy most of the time.
• GPs may overwork or work through an illness.
• GPs may take fewer sick leaves when compared to other health professionals.
• GPs may have less interest in their own health, with a significant number of them not having their own GPs or nominating their practice partner. This number is as high as 57% in Victoria and 75% in Western Australia ⁴ .
• Generally doctors rate well on preventative health activities such as having their blood pressure and cholesterol checked.
• Health habits of doctors are associated with advice they give their patients. An example is the decline in smoking in the population preceded by a similar decline among medical practitioners.
• It is said that in Australia many GPs lack the skills to successfully deal with mental health problems.

The Health and Equity placement offered by the University of Newcastle was in Ballarat, Victoria, Australia primarily based at the Ballarat & District Division of General Practice (BDDGP). The division had a General Practitioner (GP) wellbeing program set up and a snapshot survey offered a brilliant opportunity to study the different factors in GP health and whether or not the wellbeing program was working. The project was undertaken in September-October 2005 and as such all data comparisons are correct for that period.

What population are we talking about?

The Ballarat & District Division covers an area of approximately 8100 square kilometers with an estimated population of 122,222 people, according to the 2001 census. The divisional boundaries cover the city of Ballarat and the shires of Pyrenees, Hepburn, Moorabul and Golden Plains. Population centres covered by the Division include Ballarat, Ballan, Creswick, Skipton, Clunes, Trentham and Daylesford. All these centres are served by a total of 102 general practitioners (including 8 GP registrars).

Following is a breakdown of the workforce in Ballarat & District Division:

• Total of 102 GPs
• Total of 79.2 EFT (effective full-time) – 64.9 EFT in Ballarat, 14.3 EFT in surrounding areas.
• 71 male GPs (61.4 EFT), 31 female GPs (17.8 EFT).
• 59 full time GPs (51 male, 8 female) and 43 part time GPs (20 male, 23 female)
• GP:Population ratio = 1:1543.
• Generally accepted ratio is 1:1200 (BDDGP would require an additional 22.6 EFT to achieve this ratio, with practices currently reporting 4.5 EFT active vacancies).
• 38 GPs over 50 years of age; I came across anecdotal evidence that a number of these GPs will be reducing workload over next 5-10 years with a view to retirement.
• 1 of 29 practices reported “closed books” – unable to see new patients. However another 12 practices reported a limited capacity to see new patients. Anecdotally, it was common to hear from patients that access to GPs was difficult.
• The Ballarat Bulk billing rate of 75% was reported for 2005 (Victorian 74.3%, nationally 76.6%).

(From: http://www.health.gov.au/internet/main/publishing.nsf/Content/medicare+statistics-1)

From the figures above we can see that female GPs are a minority, with most of them working part time only. The GP to Population ratio is higher than what is acceptable. There is a large number (38) of GPs over 50 years age who may reduce workload with view to retirement. A number of practices reported a limited capacity to see new patients, which is not surprising considering only 59 out of 102 GPs work fulltime.

Methods

Three main areas (work, physical and emotional) were chosen as a focus with only a limited number of issues in each section which were identified during the first 2 weeks on placement. Selection of these issues was made in consultation with GP division advisors and existing literature. The survey was modeled on a questionnaire used to evaluate GP well being in rural South Australia by Dr. Roger Sexton).

Results and Analysis

Out of 70 GPs surveyed, it was filled out by 40 GPs (25 male, 15 female), giving a response rate of around 57%. Below are the results of the survey:

Work

• 87.5% of GPs feel that they are always very busy.
• Only 10% of GPs feel professionally and personally isolated.
• 80% of GPs soldier on when sick rather than taking a break.
• 45% of GPs report a tendency to protect colleagues by working through illness until they simply cannot walk.
• 57.5% of GPs say they are happy with the times they work in private practice and 65% say they are happy with the number of hours they work.

Physical

• 85% of GPs feel they take good care of their health.
• 37.5% of GPs have NOT had regular check ups in the last 3 years.
• 20% of GPs feel they are at an increased risk of injury because of their work.
• 32.5% of GPs treat themselves when they get sick.
• 82.5% of GPs have several alcohol free days each week.
• 100% of GPs are non-smokers.
• 65% of GPs feel their health is NOT suffering due to being a rural GP.
• 40% of GPs do not have their own GP.
• 75% of GPs are involved in mild-moderate physical activity on most days.
• 60% of GPs feel they are NOT the primary source of medical care for their family.
• 50% of GPs' families consult a GP who works in the same practice.

Emotional

• 25% of GPs feel that their work affects their personal life negatively. 20% of GPs report that their mental health is suffering as a rural GP.
• 20% of GPs report being clinical depressed or psychologically distressed at times.
• 75% of GPs feel bright, happy and motivated overall.
• 75% of GPs report high levels of anxiety at work.
• Only 12.5% of GPs feel their work/home is unacceptably far from relatives.
• 27.5% of GPs agree that working as a GP causes marital difficulties.
• 72.5% of all GPs feel they have a high level of social support.

The survey highlights certain trends, showing the number of GPs who:

are very busy and isolated. try to protect colleagues by soldiering on with work when sick. treat themselves when they get sick. do not have their own GP. Have not had regular check ups in the last 3 years. feel their personal life is affected negatively due to work. report being depressed or whose mental health suffers due to work as a rural GP. feel working as a GP causes marital difficulties.

However there are several positive trends that were found from this survey, mainly the fact that GPs in general exercise regularly, consume appropriate levels of alcohol and are non-smokers. We need to remember however, that it is possible most of the responses to the survey may have come from GPs who already take good care of their health. A big number of GPs also feel they have a high level of social support and a significant number are happy with the times and hours they work despite being very busy. By now it's abundantly clear that most of health concerns amongst rural GPs lie in the emotional health category with the physical health seemingly not really a major concern.

Although the numbers don't quite match up, similar trends were also seen in a comprehensive survey study of rural GPs in South Australia, where the Dr. Doc program was evaluated ¹¹ . In that study, it was shown that:

• only 37% had their own GP
• 60% of GPs had not had a check up for 3 years.
• 59-63% of GPs felt their physical/mental health was deteriorating as a rural GP.

There is not much evidence at to the reasons for the above findings. The statements used in the emotional health section of our survey were taken from previous research which shows they can be an indicator of worsening mental health. We can look at the stressors in two different ways – stress due to personality traits and stress due to the health care profession or direct patient care.

It has been speculated that the selection criteria for entry to medicine may be to blame. Many of the current GPs entered their medical course in an era where selection was overwhelmingly in favour of academic success very early in life. Factors such as being a high achiever, workaholic tendencies, a fear of death and need to control illness have been brought up. Medical training itself is a very stressful process and interpersonal support during training can go a long way to aiding good mental health. Some other stressors which have come to attention because of our survey are the stress of being on-call, being on low remuneration, marital difficulties, bureaucratic changes and time pressures of seeing patients. Among these the most frequently cited stressor, by GPs in Ballarat and rural areas, was time pressure of seeing patients.

What is being done to solve the problem?

The activities of the GP Well Being program in Ballarat were already in place for 18 months before this survey was commenced. All GPs have been provided with a GP Well Being kit which points them to all the different services. Below are the main features of the program:

Doctors for Doctors: This program provides a list of 13 GPs who have indicated a willingness to provide their services to other GPs. It's also promoted to medical students, hospital doctors and specialists. It acknowledges that there are challenges for GPs in balancing the ‘patient' role with their own medical knowledge and expertise. Female GP Network: This network set up for female GPs provides an opportunity for women to get together and explore issues pertinent to their role. The group meets three times a year currently. Personal and Critical Incident Counselling:This service encourages GPs to use counseling to help relieve pressure and assist in identifying self-management strategies for ongoing good mental health. The Division offers 3 subsidized psychologist counseling visits per annum (upto $90 per session) to assist with the cost. GPs are able to chose their own psychologist either on their own or using a list of psychologists available on the website. The use of an anonymous token system ensures that privacy is maintained at all times. Corporate Discounts Card: The Division has sought out a number of opportunities for discounted services from a number of companies in the region. The type of discounts available range from automotive, clothing, homewares to entertainment, fitness centres, restaurants and travel. Family CPD Conference: This is a CPD conference organized once a year at which GPs are encouraged to attend with their families. The main aim is to be able to provide education but also opportunity to spend quality time with their families and socialize with other GPs in the area. Literature on website and newsletters: The Division provides a variety of literature on GP well being both on it's website and via newsletters to GPs.

Are these initiatives working?

As part of our survey, we also tried to find out how well the GP Well Being program was received by the GPs and what parts of the program were making a positive difference in their health.

It was found that majority of the respondents were aware of the Well Being program and had found the regular division newsletters and ‘kit' helpful. It did show that some GPs had not received the kit or were unaware of the program probably due to not exploring the contents of the kit very much. As a result of this, the division is now planning on a re-issue of Well Being kits and possibly advertising the service further.

Around 24 GPs had their own GP, majority of them having a GP well before they were even introduced to the Doctors for Doctors service. It did show that majority of the GPs did not find their GP using the list on the division website. We found that a significant proportion (37.5%) were more aware of the importance of taking care of one's own health as a GP. And 7 GPs were encouraged to consult their GP more often as a result of exposure to this service, which is a great result.

Responses about the Female GP network showed, it helps to increase the business/social contact between female GPs and for 1 out of every 3 female GPs, it helps them cope with work or family pressures. There was found to be a clear need for more meetings of this network each year and the division is responding to this by increasing the number of meetings to 4 next year.

A majority of GPs (65%) do feel a Personal and Critical Incident counseling service is important in relieving pressure and maintaining good mental health. Some GPs didn't know about the service, which is again something to do with promoting the service on an ongoing basis. 14 GPs felt that more such visits need to be subsidized. We were been informed however that in the past 18 months, the uptake of this service has been very low with only 2 tokens returned so far (this means that a maximum of 2 GPs may have used it). It was reported there was a need for contacts of more out of town psychologists, as in some cases GPs were reluctant to visit someone in the same town that they refer patients to. Majority of the GPs found their privacy was ensured using the token system, which de-identifies them when paying for the service.

Majority of the respondents (72.5%) had not taken advantage of the Corporate Discounts Card and didn't feel that it made a positive difference to their well being. There were some cases where they simply were not in the habit of carrying the card and using it. It may also be that discounts may not make much of a difference to GPs who may already have significant earning power.

Feedback about the GP Family CPD conference was very positive with the majority of GPs (60%) feeling the conference was well organized and was a good opportunity to spend time with the family. It was found that most GPs had not accessed any literature on GP Well Being that was available to them on the website. This is not surprising and more needs to be done to bring it to the attention of all GPs, possibly by including the articles regularly in newsletters.

What else can be done to improve GP Well Being?

The efforts of the BDDGP in implementing a GP Well Being program are commendable, but as with anything in life, we need to continue moving forward and look to the future. Something like additional promotion of the program is one such thing I just mentioned earlier. We came across some other initiatives which are in use in other parts of rural Australia. The worth and effectiveness of these ideas will need to be investigated in the future:

• Concept of ‘Link GPs', essentially volunteers who look after GPs and their families in times of crisis ¹¹ . These GPs could be specially trained to handle such matters. This could be an extension of the Doctors for Doctors program.
• Stress and anxiety management seminars on a routine basis.
• Mental health check ups by visiting psychologists.
• Long Service Medal program for GPs and their spouses working in rural areas for 20 years or more ¹¹ .
• Use of Instant Messaging services such as MSN Messenger to help GPs keep in contact with other GPs in the region. This idea is already in place in one clinic, with very good results in cutting down the effect of professional and personal isolation.
• The idea of a Rural Retreat, which would be for GPs who are not yet in crisis but clearly need a weekend away from work ¹¹ . It could have targeted activities such as stress relief, practice management and goal setting, which would allow the doctor to return refreshed and reinvigorated ¹¹ .
• GP Well Being Education seminar for visiting medical students who are routinely placed in Ballarat for electives and clinical placements.

Conclusion

As a result of our placement, exposure was gained to the working conditions of rural GPs and the specific difficulties they face in day to day life. They are governed by a unique set of pressures that city GPs do not face. This can have a significant impact on mental health. How can a GP whose well being has been compromised, serve his/her patients? Although our report paints a negative picture of rural practice and GP health, there are many positives to be taken. For example, we interviewed GPs at one practice who were polar opposites to the trends observed in our study. In the end though, one has to focus on a set of learning experiences, those little incidents or encounters, which leave a long lasting impression. One is struck by the resilience and positive outlook displayed by most GPs in the face of adversity. The work by the local division of general practice is crucial in fostering this spirit. We end this report with the following quote.

It cannot be too often or too forcibly brought home to us that the hope of the profession is with the men who do it's daily work in general practice – Sir William Osler

Acknowledgements

We would like to acknowledge the support provided to us by the Ballarat and Districts Division of General Practice.

Corresponding Author

Abrar Rana Waliuddin
23, Sunset Boulevard
North Lambton, NSW 2299
Australia
Email: [abrar.waliuddin@hnehealth.nsw.g ... ]
Phone: +61 415 107433

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