GP Resolutions for 2014!

GP Resolutions I DEFINITELY will keep up for 2014

• I will tidy my drawers
• I will tell Mrs X that a long hug after EVERY consultation is just not appropriate. And that she hugs a bit too tightly.
• I will log all my CPD activity on the appraisal toolkit calmly and steadily throughout the year rather than at midnight the night before my appraisal
• I shall not dread duty dr days, but will start each one with a deep breath, a smile and a ‘today is going to be fun and interesting!’
• I will not prescribe ciprofloxacin
• I will attempt to read 10% of the email attachments from the CCG
• I will throw out all the broken, and frankly dangerous, old toys in my toy box and disinfect the rest
• I will be better at coding
• I will remove that Cosmo with  the ‘best sex positions for 2008’ on the cover from the waiting room
• I will ALWAYS wash my hands
• I shall try not to retch when examining Mr Y and will ask him if he could please shower before he comes to see me from now on
• I shall try to have a ‘duty dr day’ and an ‘alcohol free day’ on the same day
• I really really really will go on a ‘sports injuries for GPs’ course…
• I shall smile nicely when the patient says ‘well, I haven’t see you for a year doctor so I’ve saved a few things up’
• I will not nod off when I have my therapeutic ‘5 minute mindfulness meditation’ on my couch in the middle of the day (and will set an alarm on my phone just in case)
• I will not text kids, write shopping lists or fantasise about exotic holidays during practice meetings
• I will no longer say to patients ‘you’re not very fit’ (frequently misunderstood)
• I will get smart new work clothes
• I will do NO ‘google-faffing’ during the working day and definitely NO FB/twitter (#needtogetareallife)
• I shall slowly wean myself down to 6 cups of strong coffee a day
• I will check the expiry dates of the drugs in my bag
• When I seem to be the only dr in the practice I shall say to myself ‘I’m glad my colleagues are having a well earned break, they deserve it!’
• I will improve my posture when sitting at my desk, straight back, not slumped
• I will not prescribe benzodiazepines EVER
• I shall keep up with my patient admin as I go
• I will get my equipment calibrated
• I shall not treat ‘pop man’ the same way I treat ‘pop ups’ selling insurance
• I shall write short, brilliantly succinct and pithy referral letters (rather than rambling current ones which could’ve been written by Joyce and Kafka’s love-child)
• I shall embrace revalidation with a positive attitude and a SMILE 
• I will get better with emis web (everyone else says it’s brilliant so I’m obviously doing something seriously wrong)
• I will not have cakes, biscuits or chocolates at coffee time. Perhaps some dried apricots…
• I shall throw all the free GP papers in the recycling without reading them as they just make me feel depressed and want to resign
• I shall tentatively peep into  my ‘non-urgent in-tray’
• I will finally work out how to be clinically thorough, nice and tick all the boxes in 10 minutes and then…(here comes the drum roll…)
• I SHALL RUN TO TIME!!! EVERY TIME!!!

How are you sleeping? Effective self-help for insomnia

CBT based self help for Insomnia

There are lots of different self help interventions for insomnia, and it may not be obvious which one to recommend to patients. This is a brief guide to some of them, based on my personal experience of managing my own insomnia. 

I tried a variety of CBT based books, and though they helped a bit, nothing REALLY worked until I used a website called 'Sleepio'.   The key is to follow the sleep restriction programme to the letter. I hadn't done this until I followed the website. Once I did, hey presto. I am now pretty much cured.

There are several CBT based books available which are useful and easily found in bookshops and online. Professor Colin Espie is a world authority on CBT treatment on insomnia and has produced some of the most helpful tools for patients to try. He has written a fairly long and detailed book called 'Overcoming Insomnia and Sleep Problems'  which is aimed at patients. It is an excellent guide for health professionals to read but many patients will find it too long and complicated. He has written a much shorter and accessible book called 'An introduction to coping with Insomnia and Sleep Problems'. These are both based on well researched principles and are very helpful. 

 However I would like to recommend Prof Espie's website www.sleepio.com as perhaps the best intervention. It is a CBT based 6 week course that is superb. It's beautifully designed, with a simple cartoon layout. As I said, the key is to follow the 6 week sleep restriction programme. This seeks to improve sleep efficiency (proportion of time in bed spent asleep). It does require commitment and some of the changes involved with the initial sleep restriction can seem daunting. It also requires a fee (£6.99 per week , or a one off of £49.99). It includes:

·        weekly online personalised 20min session with 'The Prof', a speaking cartoon character who talks you through each step. 

·        There are online tools and over 100 articles , with email reminders to help you stick to the programme.

·        There is also an online Sleepio community for those that want it. 

It has been studied in a RCT , so has excellent evidence to back up its use (Espie CA; Kyle SD; Williams C; Ong JC; Douglas NJ; Hames P; Brown JSL. A randomized, placebo-controlled trial of online cognitive behavioral therapy for chronic insomnia disorder delivered via an automated media-rich web application. SLEEP 2012;35(6):769-781.).  

It helped 75% of people with persistent sleep problems, with an average reduction in time taken to fall asleep of 50%, and a 60% reduction in time spent awake during the night. Quality of sleep more than doubled, and energy levels increased by 58%. These improvements with Sleepio were found to be lasting because effects were maintained at the two month follow up point.

I prepared a single A4 summary of options for patients to look at which I give to patients with sleep problems. The other options I include are www.moodjuice.scot.nhs.uk (an excellent website with CBT based handouts on most mental health problems)  and also local counselling services.  It's also useful to staple this handout to those slightly awkward prescription requests for hypnotics- hopefully this reduces reconsultation for sleeping problems and reduces future requests for sleeping tablets. 

 

Dr Ian Kelt, GP Partner, Edinburgh

NB no ‘conflicts of interest’ guarantee: Dr Kelt, Dr Curtis and NB Medical Education have NO financial interest in Sleepio or any other books or products mentioned in our blog or on NB Medical courses.

 

Are you depressed? GP Burnout

How are you doctor?

 I have twice suffered from depression in my medical career. It was horrible, a dark forbidding place I never want to go back to. I felt overwhelmed with fatigue and yet couldn’t sleep. I had profound ‘psychomotor retardation’ (Newton Faulkner has a song Uncomfortably Slow which articulates this feeling perfectly). My brain was so slow my wife could ask me a simple question and I was aware that I was just incapable of articulating a simple response. Just walking felt like wading through wet cement, getting up stairs a Herculean task. I had palpitations, chest pains, every muscle seemed to ache. Simple tasks and decisions became overwhelming. To try to cheer me up one day, she took me out (against my will) to our favourite coffee bar for breakfast. Looking at the pastries (which I knew would all taste of cardboard, as everything did) I just stared and stared and when the waitress gently pushed me to make a choice I was overwhelmed and broke down in tears. My wife had to lead me away, sobbing.

 It was all the more difficult because I was so very deeply ashamed of feeling like this. I had a good career, financial security, a happy marriage, 3 beautiful children – what did I have to complain about? One thing being a GP teaches us is how well people cope with terrible adversity, and yet here I was unable to cope with my ‘nice life’. I felt ashamed, and so hid it longer than I should.

 The first time I had it, I carried on working. I felt able to work even though things outside work were difficult. In retrospect I was on ‘auto-pilot’ a lot of the time and I’m sure I shouldn’t have been working, but one of the curious things about depression is that it changes the way that you think. You can no longer trust your own judgements. You think you can function, and because all your colleagues are stretched to the limit as well everyone colludes that you can. The second time, fortunately, coincided with a ‘between jobs’ period – I definitely couldn’t have worked then. I was helped with support from family, time and space to heal, CBT, exercise and mindfulness. I took sertraline for about 6 months which definitely helped get me re-booted (I really did feel something ‘chemical’ happen after a couple of weeks, just as patients often report), but it caused sufficient niggly side-effects that I didn’t want to take it any longer. However, I’d take it again if it ever came back. A much closer attention to work-life balance, regular exercise, mindfulness and a greater degree of psychological self-awareness, self-knowledge and emotional literacy has kept me well for over 5 years now and I am optimistic that I have beaten it now.

 The reason for this blog is that a recent spate of surveys shows that GPs are under more pressure and stress than ever, and increasing numbers are showing signs of ‘burnout’. I worry how many GPs may be working with depression and risking serious deteriorations in their mental health and addiction problems. A recent Dept of Health Survey shows that job satisfaction in GP is at its lowest, and stress levels at their highest, since 1998. The primary reasons for this are increasing workload and ‘lack of time to do the job justice’. We are working harder than ever, yet GPs are not afraid of hard work (the long working hours of a GP are in 7^th place in the ‘list of stressors’). A recent GPC survey shows similar results, and a Pulse survey revealed this year that almost half of GPs are at risk of burnout.

 Personally, I don’t like the term ‘burnout’. Let’s call it what it is, which is almost invariably depression.  All human beings, indeed all animals in experimental conditions, show the same response on the classic ‘stress-performance’ curve. A degree of stress is good – it motivates us and excites us and we see our performance and energy levels improve. But, eventually our performance starts to plateau and then as stress mounts our performance dips and we exhibit all the classic signs and symptoms of anxiety and depression. GPs show higher rates of mental health problems than other professions; this partly may reflect our personality, partly transference from the suffering of our patients (the ‘wounded healer’ idea) but mostly, I think, just the huge stress of dealing with large numbers of patients, managing uncertainty and shouldering huge responsibility.

 My advice, is that if you are struggling is NOT to trust your own judgement about your ability to cope and continue at work but to seek the help and opinion of others, be that from loved ones, trusted colleagues or other health professionals. And if you feel a colleague may be struggling, please don’t ignore it. Make the time to ask how they really are.

 Being a GP is a tremendous job and a wonderful privilege and I love it,  but it is hard and we are prone as professionals to depression and burnout. If this is you, experience has taught me that with time and treatment not only will you recover fully, but you will come back stronger than before. You will love life, including your job, again. And once recovered not only will you appreciate and enjoy life more, but it will also make you a better doctor. So, be brave and seek help and take some time out to get better. Because you will.

Simon

Resources if you are struggling:

BMA counselling and advice, just call 08459 200 169

BMA links for doctors in difficulty

Doctors & dentists group for addiction problems

Doctors Support Network

The sick doctors trust

Pulse Battling Burnout Campaign