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Around a decade ago, the BMJ published an editorial by Richard Smith with the title ‘Why are doctors so unhappy?’1 ‘Where doctors gather,’ Smith pointed out, ‘their conversation turns to misery and talk of early retirement.’ Today, it would be hard to find any doctors who think matters have improved. The majority would probably say that doctors are considerably unhappier now. In a time of major economic recession, the talk is no longer simply of early retirement but of frozen or reduced pensions, cuts to clinical budgets, and the risk of job losses. For many British doctors, the most demoralising thing of all is the cycle of endless organisational change and reconfiguration, taking up inordinate amounts of time in what a colleague of mine has described as ‘feeding the monster’. As an example of this, I spent an entire day this week at two meetings: one was an exercise to anticipate what might go wrong following a major reorganisation of postgraduate medical education. The other was to discuss how a new system of appraisal and revalidation would be affected by the abolition of primary care trusts.
For doctors like me whose primary orientation is clinical or educational, it isn't surprising that doctors are feeling not only unhappy but bewildered and pessimistic. In addition, many are opposed to the core principles that underlie the current changes to the National Health Service—namely competition and the privatisation of services. This adds even further to their unhappiness. It also means that they may look back upon the earlier years of this century as a golden age.
However, a new element has come into the picture as well, and this may be an even bigger concern than unhappiness. It is a sense of disempowerment among doctors and a view of themselves as victims. I can illustrate this with a couple of other experiences from the past few weeks. The first was when I posted a previous article from PMJ on Twitter about the length of time that patients generally have to sit in waiting rooms before seeing a doctor.2 I put forward the proposition that doctors could do more about rearranging appointment systems, and that some of our inaction is due to an imbalance of power between our profession and patients. At the time that I wrote it, I considered my view pretty non-contentious. Yet when I posted the article, the replies from fellow medical tweeters were largely critical. Nearly all the responders placed the blame for long waits in clinics at someone else's door. These included governments (for not giving us enough resources), managers (for arranging appointment systems badly) and patients (for coming late or demanding too much of our time.) Only a couple of responses conceded that some clinics and surgeries do arrange things rather better than others, and doctors bear some responsibility for this.
Power in the health service
My other example of doctors feeling victimised comes from courses I teach where we raise the question of power in the health service and invite people to consider who actually possesses it. Recently, the answers to this question have all been in a similar vein. Doctors—not just some of them, but virtually all—seem to regard power as belonging ‘out there’. They think of it as something only possessed by ministers, civil servants, chief executives and the like. When I have tried to challenge this view by raising the question of whether patients might regard us as having a considerable amount of power ourselves. I have been rebuffed with what now seems a standard medical lament about consumerism, complaints, public disrespect and so forth. Doctors, it seems, now feel powerless.
While I feel as strongly as anyone about the external pressures currently operating on doctors, I also think there is something unhealthy in doctors having such a view of themselves and their relation to power. I believe these may have led to a failure to reflect about the nature of our day-to-day work and the real power that this embodies. When patients walk into my office, for example, they do so because I have chosen that moment to call them in. If I have to consult with them more hastily than I want to, it is almost always me as the doctor who decides which issues to focus on, and when to foreclose the conversation. Even in the era of shared decision making, the vast majority of consultations are led by the doctor's beliefs about what it is right to investigate, how it is best to treat the patient, and when to make an onward referral. All of this power may be different to the kind of power exerted upon us by governments and managers. But it is still power, of a special and privileged kind. If we cannot recognise that it infuses most of the encounters we have during our working lives, we may be at risk of abusing it.
Freedom of movement
There is another dimension to our power as well. I move freely in and out of my office during my working day, in a way that many of my administrative and managerial colleagues cannot, since they are more or less contracted to sit at their desks for the whole time. By and large, I can organise whether and when I attend certain kinds of meetings, make phone calls, teach on courses and so forth. Although there may be variations from one medical post to another, and such freedom generally increases with seniority, I don't think I am particularly exceptional in having such independence. I also earn twice as much as most of the people who work alongside me, and three times as much as some of them. It would take a brave doctor to walk out onto the street, stop the first ten members of the public who pass by, and claim ‘I lack power’.
Given the responses to my views about waiting rooms, I guess I should emphasise that these thoughts do not diminish my sympathy with what many colleagues are going through. However, I am becoming concerned at how easily doctors notice when they are affected by other people's power, and how difficult they find it to acknowledge their own power to make personal choices, influence the lives of others, or to effect change. There are many things we are legitimately unhappy about, but our professional lives should not become dominated or defined by a sense of being victims.
Footnotes
Competing interests None.
Provenance and peer review Commissioned; internally peer reviewed.