Resilience, respite and general practice: taking a mindful approach to culture change

Demand for primary care services is high, with more patients and fewer practitioners leading to concerns that primary care physicians are struggling to cope with patient demand ( 1 ). General practice workload is seen as a potential risk to patients, simply because GPs are overworked ( 2 ). It may be time to be concerned about the long-term future of the family doctor—and to think personally, as well as professionally. These pressures clearly have an effect on those who currently practice in primary care. It is not just patients that are at risk; high levels of stress caused by unmanageable workloads are affecting practitioners too ( 3 ). The phenomenon of ‘burnout’ has been widely studied in medicine, linking chronic job-related stress and exhaustion, depersonalization and frustration ( 4 , 5 ). High levels of burnout have been found amongst family doctors across Europe, with up to two-thirds of doctors surveyed experiencing feelings contributing to burnout including being emotionally drained and unable to deal with problems calmly ( 6 ). Similar patterns have been observed in the USA ( 7 ) and Canada ( 8 ) and repeated across further studies ( 9 , 10 ). The situation only seems to be getting worse. To take one example: in the UK, a recent survey reports that up to one in three GPs are planning to retire within the next 5 years, equating to a drop of around 10000 members of experienced staff ( 11 ). Fewer trainees are taking up the general practice gauntlet, with some trainee slots left empty ( 12 ). Of those who are joining the ranks, reports suggest that one in five is planning to go abroad to practice ( 13 ). This can only exacerbate the issues identified above, and addressing this crisis in recruitment is crucial to reducing pressures on general practice ( 11 ). High demand is a widespread and inherent issue in the system and will not easily be resolved. Recognizing the impact that these pressures may have on the individual doctor will also not solve the underlying problem of demand, but it might mitigate some of the stressors. Practical solutions need to be found to ensure that family doctors can manage their workload ( 14 ). I would argue that this needs to be taken one step further; there needs to be a culture shift in general practice. There is evidence that this culture shift is feasible and desirable. In the USA, the proposition to extend the Triple Aim to be a ‘Quadruple Aim’, with improving physician health as the fourth aim, recognizes the need to make drastic changes in practice ( 15 ). Similarly in the UK, a recently announced initiative across the National Health Service aims to focus on the health and well-being of all staff, providing funding in particular for a new occupational health service for GPs experiencing burnout ( 16 ). While these initial steps recognize the need for a focus on practitioner health and well-being, helping professionals to think differently about their professional practice might be also helpful. One approach that has shown promise is mindfulness. The popularity of mindfulness has grown exponentially in recent years, but its core message—that how we react to everyday situations affects our experience of them—is still a useful one. Mindfulness can be defined as the focus of attention on the present moment, or current experience, taking a non-judgemental attitude to what is experienced ( 17 ). In health care practitioners, including those working in primary care, mindfulness has been shown to be effective in reducing feelings of burnout and increasing positive emotions associated with good well-being ( 18 ). In a difficult work environment, having better self-awareness, insight and techniques to increase resilience may be beneficial for current practitioners ( 19 ). It is also crucial to ensure that those entering the profession have the skills to manage in a challenging setting and much of the current attention on mindfulness training has focused on medical education. Several medical schools internationally offer optional training sessions ( 20 ), but evidence from Australia suggests that building mindfulness training into the core curriculum has a positive effect on stress levels ( 21 ). There is growing interest in replicating this impact in the UK context, with the University of Leicester Medical School introducing a full training programme into the core curriculum in autumn 2016. The programme is based on the Health Enhancement Programme (HEP), which was introduced at Monash University, Australia, in 2002 and its presence on the core curriculum not only aims to teach students techniques to maintain good well-being but also demonstrates the value of prioritizing personal well-being in a stressful sector. The programme takes an experiential approach and allows students to make up their own mind if mindfulness is right for them, but making it a core element of the curriculum sends a powerful message that taking care of oneself is as important as taking care of others. Perhaps medical students coming into general practice will be able to cascade the tools and techniques required to more experienced staff. Observing and evaluating the implementation of the HEP programme, with its emphasis on mindfulness, will show how this new approach might be optimized to ensure family doctors entering a profession undergoing significant challenges can be best equipped to cope. Focusing on the roles, relationships and training needed for a more mindful culture is not a universal panacea for the current problems in general practice, but may be a part of wider cultural change that is needed. Funding: none. Ethical approval: none. Conflict of interest: none. With thanks to Jonathan Hayles, University of Leicester, and Craig Hassad, Monash University.

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