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SUPPLEMENTAL: Survey: why are doctors unhappy? [Full text]

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Physician under attack

Chidam Yegappan   (4 May 2001)

what's new?

Faridah   (4 May 2001)

Surprise, surprise - we're pathetic!

Frank Brennan   (4 May 2001)

Sabbatical

J Thurm   (4 May 2001)

methodology query

Bernadette Coles   (5 May 2001)

We have conceded our autonomy

Stephen Workman   (5 May 2001)

Opportunities and availability of training

Lip Lee   (5 May 2001)

Something needs to change - some suggestions

Andrew Marshall   (5 May 2001)

Why we are unhappy - failed expectations!

Keith McCollum   (5 May 2001)

can you make the correct diagnosis?

Gary Gorlick   (5 May 2001)

Happiness is a State of Mind

Andrew Burd   (5 May 2001)

Why are doctors so happy?

Joseph Watine   (5 May 2001)

Our own worst enemies

P K Morrish   (6 May 2001)

Who wants to be an SHO?

Andrew Williams   (6 May 2001)

doctors need more training opportunities

Victor Mendes   (6 May 2001)

Postgraduate Exams

J Bryant   (6 May 2001)

IF THIS HAPPENS IN UK IMAGINE THE PLIGHT OF FULL TIME PRACTIONERS CATERING RURAL POPULATION

K V Arulalan   (6 May 2001)

Medical profession should be more united in addressing problems

Simon Smith   (6 May 2001)

Ample reason to be unhappy

Mark Berelowitz   (6 May 2001)

We are picking up pieces of society's meltdown

S P Prabhu   (6 May 2001)

Tackle the cause

I Gulamali   (6 May 2001)

Judgemental doctors in error

Norman E Crumpton   (6 May 2001)

Stop whinging and move

Andrew Haig   (6 May 2001)

It's a nurse thing.

Sohail Muzammil   (6 May 2001)

Re: Stop whinging and move

Joseph Watine   (7 May 2001)

Re: Ample reason to be unhappy

Ian Nesbitt   (7 May 2001)

Restoring the soul of medicine

Brian McMullen   (7 May 2001)

Its not all doom and gloom

Nicola Jakeman   (7 May 2001)

not happy or unhappy but concerned...

David Seddon   (7 May 2001)

Pull together with patients and staff

Robert J MacFadyen   (7 May 2001)

Re: Surprise, surprise - we're pathetic!

Fauzi   (7 May 2001)

I haven't Toxol.

Alexandr Spitsky   (8 May 2001)

The Buck Stops Here

John Powell   (8 May 2001)

Belief in ourselves

David Simpson   (8 May 2001)

Why are doctors so unhappy?

Huma Khurram   (8 May 2001)

Economic liberalism: Human disaster all over the world

R Blamey   (9 May 2001)

De-politicise the NHS!

Nicola Cooper   (9 May 2001)

What happened

Rakesh Bhargava   (9 May 2001)

doctors picture should change

G O Ahmed   (9 May 2001)

Re: Why are doctors so unhappy?

David Kernick   (9 May 2001)

Try reducing your hours

Mike Laurence   (9 May 2001)

Juniors and Safe Care

Jeremy Newman   (10 May 2001)

WHY ARE DOCTORS UNHAPPY?

Fauzi   (10 May 2001)

Give me a number!

Clare Rogers   (10 May 2001)

Civic Society makes happy or unhappy people

Paras K Pokharel   (10 May 2001)

PROFESSIONAL SATISFACTION IS A MYTH!

S C Pradhan   (10 May 2001)

How not to be unhappy?

B Venugopalan   (10 May 2001)

more happy less unhappy

Mohan Devegowda   (11 May 2001)

Could someone please educate Richard Smith?

Declan Fox   (11 May 2001)

Ask and you can't recieve

Prashanth Gupta   (11 May 2001)

Re: Re: Stop whinging and move

Alastair D Short   (12 May 2001)

A reply to Richard Smith

Marion Newman, Gerhard Wilke   (13 May 2001)

A Desert perspective

Richard Knight   (15 May 2001)

Have a heart, not a swinging brick!

Chrystal D Frost   (15 May 2001)

Are doctors the scapegoats???

Annapoorani   (15 May 2001)

What precisely are you doing?

L Reinecke   (16 May 2001)

Doctor unhappiness in the NHS

Jonathan Rhodes   (16 May 2001)

An outsider's view

P A West   (16 May 2001)

Are They Unhappy Because they are depressed?

A Karim Jasim Al-Sheikhli   (17 May 2001)

Papering over the cracks is never going to be easy

Mark Oliver   (18 May 2001)

Change System of Medical Education

Parth Gokhale   (18 May 2001)

Desires and the reality of being Doctor

Suely Grosseman   (20 May 2001)

FIND OUT CAUSE OF HAPPINESS TOO

K R Sethuraman   (20 May 2001)

It's Nice to be Employed, it Makes Some People Very Happy!

T Carol   (22 May 2001)

Keep politics out of medicine

Indranil Kundu   (24 May 2001)

The next 6 years - Do I Go On?

Roonio Baskaradarcchi   (28 May 2001)

Re: The next 6 years - Do I Go On?

C K   (29 May 2001)

Beating round the bush!

A N Ghanem   (29 May 2001)

Re: The next 6 years - Do I Go On?

Andy Evans   (30 May 2001)

doctors you too have a spine and brain

Prahladhan   (30 May 2001)

Re: unhappy GPs

Andrew Falloon   (1 June 2001)

People make fun of medical students these days

Ravindra Arya   (2 June 2001)

Unhappy, or war-weary?

Andrew Bamji   (5 June 2001)

Workload - a social construct

C Gunstone   (5 June 2001)

The NHS should be politically independant

Mark Norman   (7 June 2001)

Re: The NHS being politically independant, is there a better system?

Peter Bradley   (12 June 2001)

My 2pence worth..

Richard Middleton   (17 June 2001)

If the UK's so bad why not come to Australia?

Cassandra E Sharrock   (8 January 2002)

Rediscover human values everyone!

Narayanan Muthuswamy   (7 April 2002)

Reasons why Doctors are unhappy

Jayaram M Nambiar   (16 January 2003)

Physician under attack 4 May 2001
Chidam Yegappan, Clinical Asst.Prof of Med Mcmaster canada Ontario Canada Send response to journal: Re: Physician under attack	Science has been advancing in leaps and bounds. Doctors responsibilities have also proportionately increased along with the knowledge. Doctors are pressurised from many angles. First, pecuniary benefits from on call and consultation are less when compared to other professions. Working hard with less remuneration is frustrating to many doctors around the globe. Second, health restructure in many countries with amalgamation and budget reduction have tied the doctors in many aspects. They cannot do what they want to complete the investigation in a timely manner.In some countries the budget reduction have also tied the hands of family practioners in ordering investigations. Third, knowledge of patients regarding maladies have increased. Hence they expect the latest and advanced diagnostic and therapeutic modality for their kith and kins. Doctors being restricted by the above cannot satisfy their patient, family or themselves. Fourth, malpractice payment have substantially increased in many countries without reasonable support from the governments. This increases the pressure on the already overburdened physician.
what's new? 4 May 2001
Faridah , medical officer hospital k. trg, malaysia Send response to journal: Re: what's new?	i love my profession, but there are times when i'm really unhappy, such as: .when the patients are very stubborn and act as if they knew all. .overworking .no appreciation for what we did .my family cannot cope with my demanding job
Surprise, surprise - we're pathetic! 4 May 2001
Frank Brennan, Locum GP Kazakhstan Send response to journal: Re: Surprise, surprise - we're pathetic!	Doctors are unhappy for a myriad of reasons, many of which have been highlighted in the survey. However, we have nobody to blame but ourselves. We may be intelligent but we are neither shrewd nor courageous. For far too long we have let our destiny be determined by others – namely politicians, bureaucrats, lawyers, journalists – and oh, I nearly forgot, the public. We kowtow when pressurised from all of the above and seem oblivious to the machinations of politicians, who stealthily move the goalposts sufficiently frequently to achieve their aims. In order to turn the tide, we should seize control of our working lives. Tearing up all contracts would be a good start. However, I doubt this will ever happen because let’s face it, we are an ineffective, inadequate bunch while both depression and disillusionment are our default mood states.
Sabbatical 4 May 2001
J Thurm USA Send response to journal: Re: Sabbatical	Future shock has invaded medicine as everything else. The need for "retooling" of physicians (sabbatical)is apparent to any practitioner after a decade. A mechanism must be found to allow a time period (? 6-9 months) for reeducation on the collegial level every 7-9 yrs with governmental support to rejuvenate the care givers and bring their experience and quandries to the forum.
methodology query 5 May 2001
Bernadette Coles, Librarian NHS Trust Send response to journal: Re: methodology query	Hello I'm sure your survey will show up some interesting results. However your decision to only count one vote per IP address effectivly means that if 250 individuals reply from a single academic institution only the first lucky participant will be counted. Also as I am working on a NHS intranet/internet connection my IP address changes for each internet session so I could merrily log on and answer a new survey every day!
We have conceded our autonomy 5 May 2001
Stephen Workman, Assistant professor Dalhousie University Send response to journal: Re: We have conceded our autonomy	As both the results and the DESIGN of the survey clearly show, physicians are unhappy because they have come to believe that their unhappiness is caused by external and uncontrollable forces. And in accepting this view have lost the joy that come from working as a professional, replacing independence and professionalism with the headaches and discontents of being a middle manager. This change is indeed voluntary. I recently gave a talk about CPR (cardiopulmonary recuscitation) to surgical residents. "Do we have to ask the patients permission in order NOT to perform CPR?" they asked, seeming distressed at the possiblity of having to make a considered and potentially ethical decision themselves, freed from some complex but unwritten set of rules. My answer to them, somewhat of a surprise to me at the time, can be applied to many many areas of physician helplessnes and angst. "You don't 'HAVE' to do anything. You're a professional. You must make a considered decision, be willing to defend it, and accept responsibility for your actions. Therein lies the easily overlooked pleasures and joy of medicine.
Opportunities and availability of training 5 May 2001
Lip Lee, SHO Medical oncology Manchester Send response to journal: Re: Opportunities and availability of training	I agree with most of the suggested answers, that doctors are unhappy because they are overworked, underpaid, undersupported, unrealistic expectations from relatives and government etc etc. On top of that I find one aspect particularly stressful: the opportunities and availabilities of training. Most junior doctors are so overworked they have little time to learn the skills and knowledge they need in their job. Yes, formally training and educational meetings are organised in most hospital, but the pressures of work mean that only a minority can get to the training sessions. On top of that the competition for career advancement is very stressful, forcing many junior doctors to go through posts that do not interest them because there is such a limitation in higher posts. The above makes me feel very vulnerable and inadequate at work.
Something needs to change - some suggestions 5 May 2001
Andrew Marshall, GP Principal Glasgow Send response to journal: Re: Something needs to change - some suggestions	Doctors want to do their job well. But the time pressures and deficiencies in the NHS constantly frustrate this desire. We have to make good decisions under enormous pressure of time in an unforgiving climate of patient expectations. Within a brief general practice consultation several problems are often raised which in turn can raise several diagnostic and therapeutic decisions requiring high levels of accuracy on each occasion. Decisions about investigation often have to be made in the light of availability of resources. Guidelines may indicate that an endoscopy is indicated in a 6o year old with recent onset dyspepsia to rule out malignancy but if the waiting list is 9 months it makes little sense. The truth is that it is becoming humanly impossible to balance availability with decent appointment length to allow quality. There is just too much medicine being squashed into too little time. I agree with Richard Smith's editorial that the first thing that needs to happen is more honesty about what the NHS can and cannot provide. We can't create more doctors overnight and I doubt that solutions involving nurses are a short or medium term answer either. Rather than mass resignation, should we only agree to continue working in the NHS if NHS patients sign a disclaimer to acknowledge that NHS doctors are working under conditions that mitigate against good, careful, high quality practice, and expose us to an unfair risk of making mistakes? Or should we really be backing the unthinkable ? Is a free nhs really sustainable now ? Maybe we should be paying for primary care at the point of access, but with free chronic disease management(probably nurse led) and with a annual lump sum grant to those on benefit to pay for primary care if they chose to spend it this way. At least if money was changing hands for primary care consultations at the point of demand it would reintroduce some sense of value. We don't value things that are free. It might reduce unnecessary consultations and cut us a little slack. Something needs to change soon.
Why we are unhappy - failed expectations! 5 May 2001
Keith McCollum, GP Keady, Co Armagh, N.Ireland Send response to journal: Re: Why we are unhappy - failed expectations!	I believe the reason why we are so unhappy has its origins in the very reason we decided to become doctors. Medicine is often regarded as a career with "great expectations" but for many of us it has become a career of failed expectations. The core reasons why we decided to become doctors probably include, to a lesser or greater extent, academic challenge, financial reward,"status" and altruism. Traditionally, the NHS has happily provided slots into which, depending on our particular bent, doctors have slipped into for a lifelong career. However, these margins of these slots have become blurred and doctors find themselves ill-fitting, like round pegs in square holes. GPs find themselves compelled to embrace evidence based practice, traditionally the preserve of their academic colleagues. Status has been eroded by the publics failed expectations of doctors ability to cure all "in this day and age" ,fuelled by the medias insistence that the public both understands the NHS and their rights within it. Doctors find that their financial wellbeing has now fallen badly behind their traditional peers. And finally, altruism is regarded as the sourge of our "performance managed" but sadly underfunded NHS. So for many doctors their original points of reference have moved.Doctors know they are unhappy with their current lot but I wait, with bated breath, for someone to tell me where I can find my "great expectations" again!
can you make the correct diagnosis? 5 May 2001
Gary Gorlick, assistant clinical prof. of pediatrics, UCLA los angeles, california Send response to journal: Re: can you make the correct diagnosis?	Can you make the correct diagnosis as to why many doctors are unhappy? The dignosis, in large part , can be found in the mail (letter) section of the Western Journal of Medicine May 2001 edition by this author. I wonder over this conundrum: services are rendered by the following and they are allowed to charge for them as they see fit and as the market allows: accountants, lawyers, dentists, veterinarians, roofers, carpenters, gardeners, markets, crafstmen, shoe-repairmen, etc etc. But doctors are not allowed to do this!...This is the crux of being denied satisfaction in good work and labor...IT IS WRONG; IT NEEDS TO END.
Happiness is a State of Mind 5 May 2001
Andrew Burd, Chief of Plastic Surgery Chinese University of Hong Kong Send response to journal: Re: Happiness is a State of Mind	I have worked in the NHS for almost twenty years and experienced the long hours, sleep deprivation, awkward patients, endless clinics etc. etc. I loved it, its part of the turf; and the joy and satisfaction of bringing a smile to the face of child ravaged by burns is a priceless privilage. What finally caught me out in the UK was the ethical ambiguity of those who implement morally unjustifiable policy for the sake of political expediance and call it rationalisation. The degree of civilisation of a nation will be judged by the way it treats its children. You do not need to look far to find 'los olvidados' in the British NHS. Public voicing of such concerns is not welcomed and I have left the UK. That makes me sad as a person. But being a doctor? I love it still and would do nothing else and feel greatly blessed to be able to do some little good in this complex world.
Why are doctors so happy? 5 May 2001
Joseph Watine, Eur Clin Chem Hôpital de Rodez, France Send response to journal: Re: Why are doctors so happy?	Most doctors have many reasons to be happy: they have a very stimulating profession that can bring them a lot of intellectual and moral satisfactions, they have one of the best social status one could dream of, most of their patients love and respect them, they enjoy salaries and other material advantages that are much higher than average, etc.
Our own worst enemies 6 May 2001
P K Morrish Send response to journal: Re: Our own worst enemies	Richard Smith should be applauded for his brave attempt to summarise an extraordinarily complicated phenomenon. It would be nice to pin the new contract in a prominent place in the waiting room. We are, of course, our own worst enemies. We are selected on our academic abilities, then educated in a fiercely competitive environment. We end up programmed to fight our colleagues rather than support them and scared to admit our own fallibility and weakness, either to colleagues or patients. When one does show weakness (though I think the prefered term is sensitivity!)one's colleagues divide between those who simply don't understand, and those who do understand and will, in private only, tell of their own difficulties. You can't turn the former into the latter, and the profession is probably better for the presence of both. It is important however that both sides acknowledge the existence and value of the other, and are prepared to negotiate with Government, with PCT's, with Trust boards for better working conditions (and salary if that is what makes us happy) for all of us.
Who wants to be an SHO? 6 May 2001
Andrew Williams, A&E SHO Barts & The London Send response to journal: Re: Who wants to be an SHO?	Dear Editor, The problems that we are all too aware of with the current state of health care in this country are compounded at junior grades with the lack of job opportunites available. Many people are finishing house jobs and then locuming for several months whilst applying for appointments or going abroad. We are constantly told that we need more doctors and that x numbers of new posts are being created in politically emotive areas, such as cardiology, but this does not filter down to ground level. You only have to look at the hundreds of applications medical recruitment departments are receiving for limited jobs on rotations and stand alone posts to see how widespread the problem is. In the ever disconcerting working environment that the NHS provides, a lack of career opportunites and bottle necking at senior grades just makes us even more unhappy. No competing interests.
doctors need more training opportunities 6 May 2001
Victor Mendes, cardiothoracic surgery germany Send response to journal: Re: doctors need more training opportunities	all doctors should be trained adequately, individually, regularly, and should be supported to make steady progress and to find the adequate job.
Postgraduate Exams 6 May 2001
J Bryant, SHO London Send response to journal: Re: Postgraduate Exams	Postgraduate exams. Firstly it needs to be established if the current standards are beyond that which is required for safe practice under supervision, and entry into SpR training (they are after all only entry exams to a training programme, not an assessment to be a consultant). As a junior it appears the standards are ridiculously high (for instance MRCP Part one, 60% fail rate, -does that mean that 60% of candidates are too unsafe to be considered for a second exam, which only if they pass would allow them to then be considered for entrance to a prolonged supervised training programme?). A panel of senior doctors would be better placed to answer this question. If it is felt that current standards need to be maintained, then current study leave is clearly inadequate to cover nessecary reading and course work. A minimum of two days home study leave per week would be required (16 hours reading per week, this is what most candidates currently do as a minimum for 6-18 months per exam). It is inapropriate to expect juniors to just give up more of their free time, and stress their relationships and partners, for several further years (we've already been unpaid at college for 5 years, and we currently do our fair share of overtime). If the NHS wants these high standards they'll have to grant adequate study leave. The rest of the planet is moving toward a 40 hour week, and so should we. Compulsory exams and therefore the relevant study should be part of that time. Possible Conflict of Interest: As a 'junior'(i.e. only 10 years experince in studying medicine) I am involved in sitting further post graduate exams, this may be construed as a CoI, but I think the relevant facts speak for themselves.
IF THIS HAPPENS IN UK IMAGINE THE PLIGHT OF FULL TIME PRACTIONERS CATERING RURAL POPULATION 6 May 2001
K V Arulalan, primary care pediatrician vellore south india Send response to journal: Re: IF THIS HAPPENS IN UK IMAGINE THE PLIGHT OF FULL TIME PRACTIONERS CATERING RURAL POPULATION	I'm a full time practising pedatrician catering mainly to rural population of Vellore district,Tamil Nadu,South India. I finished MD 11 years ago.I Served the indian railways for 2 years and then due to family commitments started full time pediatric general practice.I have a peculiar problem.I have finished my DCH,MD,and also cleared the national board exam which is equivalent to MD.So DOCTORS, not patients,think that I can handle all cases.They try their medicine And when it fails refer the case to me.In the primary care setting many times I'm not able to do much and refer them to a tertiary care centre.Unfortunately there is only one teritiary care centre in our area catering for nearly 4 million People think that I did not respect the referring doctor.My argument,which I don't express openly,every doctor irrespective of the training should able to say whether child can be recovered in a primary care setting.If the answer is NO they should not refer the case to another primay care pediatrician but should refer to higher center directly.WHEN DOCTORS THEMSELVES CANNOT UNDERSTAND THE LIMITATION OF ANOTHER DOCTOR HOW CAN YOU EXPECT POLIITICAN TO UNDERSTAND? THIS IS THE CAUSE OF MY UNHAPPINESS WHILE CATERING RURAL POPULATION IN SOUTH INDIA.
Medical profession should be more united in addressing problems 6 May 2001
Simon Smith, Consultant Psychiatrist South Shropshire CMHT, 25 Corve Street, Ludlow, Shropshire SY8 1ET Send response to journal: Re: Medical profession should be more united in addressing problems	Richard Smith's editorial on "Why are doctors unhappy?" (1) makes the important point that public belief in the ability of medicine to address their social problems fuels expectation which cannot be met. Ultimately this disillusions patients and increases the stress of the medical profession. Whilst agreeing, I would suggest that it is not just our inability to influence social factors that is stressful but our inability to control the deficiencies in our working environment and the impact this has on our relationship with medical colleagues. One of the worst sequelae of this, unmentioned in Smith's editorial, is the way that this has set primary care against secondary care. Whilst I imagine there have always been scuffles along the primary-secondary care interface ever increasing demand in the face of inadequate resources has heightened this beyond measure. How many GPs do not feel some resentment at their colleagues in secondary care for "dumping" work traditionally undertaken in hospitals at their doorstep without an accompanying shift in resources? How many hospital doctors feel that primary care colleagues set their threshold for referral too low? How often do we end up fighting against each other in the battle for those limited additional resources that the government sends our way? If these internecine difficulties are largely symptomatic of inadequate resources, and the effectivenes of successive governments' divide and rule policies, perhaps we should now accept that resources will never be enough, and decide as a profession how to manage within these inadequacies. This will require the profession to become more united than it currently is and will need leaders within the profession conciliatory to the needs of colleagues who work on the other side of the primary- secondary care divide. Unless this can be achieved I do not believe that the question of doctors' happiness at work will ever be resolved. 1. R Smith. Why are doctors so unhappy? BMJ 2001;322:1073-1074 ( 5 May )
Ample reason to be unhappy 6 May 2001
Mark Berelowitz, Consultant Child and Adolescent Psychiatrist Royal Free Hospital Send response to journal: Re: Ample reason to be unhappy	Richard Smith is correct to point out that doctors are unhappy. So are nurses, psychotherapists, managers, and indeed everyone else who works in the NHS. He is also correct that we are not unhappy all the time. Our pleasure lies in the fact that most of us are already working to the new contract he espouses, in partnership with our patients, as members of excellent multi-disciplinary teams. That gives us great satisfaction, and helps many of our patients. Using our own personal resources, and with the help of our local management, we are constantly developing news ways of working, and new ways of developing the colleagues within our teams. But on a bad day that feels like a finger-in-the-dyke approach. Our clinical and management teams cannot solve the other pressing problems, which are listed below. 1. The NHS and the medical schools are still grossly underfunded. This has several consequences. a. The physical environment is crumbling. b. The NHS as a whole has not yet entered the information technology age. At the same time, we are all swamped with paperwork. c Without competitive salaries, a decent environment, good recreation facilities or decent morale, recruitment will be an increasing problem. I wonder if Mr Milburn knows how many consultants top up their secretaries' salaries from their own pockets, to provide them with a decent living, and so as not to lose them to the commercial world. d. Patients are right to make demands. But we cannot provide evening clinics, outreach nursing or facilities for patient support groups without more money. Annual cost improvements have already sucked us dry. e. All the new money that does come in is hypothecated, and goes to specific projects and programmes. Those services and problems which are not part of this year's targets are left to beg for scraps. 2. We are in a constant state of management reorganisation (upheaval). My own service is part of three separate such reorganisations. This makes it impossible for the health authorities or ourselves to plan beyond next week, as no-one knows who will be working with whom, and who will make the key decisions. 3. The social contract has changed. People want lots of nurses on the wards, but they object to the building of new nurses accomodation in their communities. Just about everywhere, the NHS is a major local employer, but local government does little to make it easier for people to get to work without using their cars. I cannot make go my mind whether our leaders know what is going on in the NHS, or they do not. Which of those alternatives should give us most cause for concern? Either way, it seems that the government is hell-bent on undermining the three major groups in the country which still have a sense of service, namely those in education, healthcare and social care.
We are picking up pieces of society's meltdown 6 May 2001
S P Prabhu, Specialist Registrar in Clinical Radiology Bristol Royal Infirmary, United Kingdom Send response to journal: Re: We are picking up pieces of society's meltdown	Today society has accepted that drinking alcohol,smoking, divorce and work related stress are part of normal day living.This has lead to increase in ill-health and problems like coronary artery disease, cancer of the lung and GIT, psychiatric disorders and poor parenting, to name only a few.Criminals are glamourised in national newspapers instead of being punished or their crimes. Society seems to have changed its values and priorities over the last few years. There is no dearth of money when it comes to paying footballers, buying rock concert tickets, junk food or cigarettes.However, when it comes to paying for hospital care or care for the elderly, people seem to have no money. This had lead to a demand on the NHS in the UK which is unsustainable. Doctors and nurses are overworked and underpaid.But there is no support for this lot of public servants like there is when a football player complains of the same problems. We get no national headlines inspite of working under enormous pressure.There is a decline in the number of talented young students applying for medicine due to the lowering of status of doctors in society today. Politicians give money to managers to improve hospitals and the first thing that happens is that the money is used to a new building to house more management staff and shiny new computers!!The need for more beds is forgotten till the kitty is nearly empty.That problem is likely to be more apparent to the ward manager and the junior doctor who spend half their night shift on the phones looking for a bed.This leads to the a delay in the patients waiting to see the doctor and the whole atmosphere turns stressful for everyone. There is too much stress in the media about so-called errors committed by the medical profession, but why does no one mention the heroic acts performed daily in operation theatres and wards all over the country where a new life is brought into this world and another life saved from the jaws of death.No one mentions that screening programmes and prompt treatment have saved people whose smoking habits led to coronary artery disease and lung cancer. The reason for all this is that society has become obsessed with pessimism and the blame culture and is clutching at straws to explain its decline.
Tackle the cause 6 May 2001
I Gulamali, GP Basildon Send response to journal: Re: Tackle the cause	Untill the politicians and our own leaders(academics as well as elected ) ones start leaving in the real world and stop raising the patients expectations this situation is unlikely to improve. There is this notion that medicine can cure everything and we on the front line know how untrue this is from the reality. Our academics should stop jumping on every piece of evidence based conclusion drawn from the trials, as quite often the results are not reproduced, and makes one wonder.It is not uncommon that the observation in day to day practice do not always mirror the findings in trials and the rigid approach being encouraged by some of the academics especially those who pass more of their time in meetings and churning up papers rather than seing real patients should come to an end. Finally i think the govt and our leaders should preach by action rather than by words. ( for example stop thrusting changes on us which are not tried and tested like PCG/PCT, walking centres, PMS just to mention some).
Judgemental doctors in error 6 May 2001
Norman E Crumpton, retired psychiatrist Send response to journal: Re: Judgemental doctors in error	One of the major difficulties that practising doctors have to face in these days of instant litigation, is the 'Holier than thou' colleague. This person is often an academic who's clinical commitment is minimal .He will pontificate learnedly in court or in print totally ignoring the difficulties of the clinical setting. His wisdom after the event is convincing, but his ignorance of the realities of practice in a deprived clinical environment abysmal. He is beloved by the lawyers and politicians, because his authoritative certainties are so convincing, and almost impossible to refute. Every one who practices, with high levels of commitment in the hurley burley of the demanding Health service, will make at least one mistake per year, and probably at least one serious mistakes during 35 years of high endeavour. Emotive words such as 'Scandal' are beloved by journalists and even the Editor of the BMJ , has used such terms to describe normal clinical incompetence. (The rate of error and similar judgmental incompetence in the editorials of national newspapers is about one a week). I applaud "The new contract" in the Blue box. The public should be taught the realities of normal medical practice; they should expect that a number of babies will be handicapped at birth, that relatives will die as a result of normal medical error, and that these events are part of normal life. The ignorant pontificating of non or partial practitioners, such as Donaldson and some 'Important' members of the GMC, should always be challenged, and doctors should never give evidence against a colleague in a court of law, unless they are certain that if practising in exactly the same circumstance, that they would never ever make the error which they are judging. If doctors followed these honest principals most litigation would rightly fail.
Stop whinging and move 6 May 2001
Andrew Haig, Emergency Medicine Specialist Send response to journal: Re: Stop whinging and move	The answer is simple, don't vote in the BMJ, vote with your feet and leave. I did 10 years ago after completing my housejobs and a year as an SHO. Come to the 'Land Down Under' and you'll never want to return to Dear Old Blighty, not even for a holiday. We don't have miserable weather, mad cow disease, foot & mouth, or suicidal doctors. It's good enough for Barry Sheen and 'Aussie' Joe Bugner, I'm sure you'll find it good enough for you. If you value your health, your family, you sanity pick up the phone and ring Australia House
It's a nurse thing. 6 May 2001
Sohail Muzammil, Trainee orthopaedics St. Mary's Hospital Send response to journal: Re: It's a nurse thing.	I feel there is one very glaring albeit politically sensitive reason that most doctors privately acknowledge but will not come out with. It is the stranglehold the nursing community has gradually obtained on healthcare in the NHS here in the UK. All this nonsense about their being the patient's advocate has had the effect of the nurse now assuming the mantle of the protector of the patient. Who from..? Well "those doctors" of course. This has brought about an almost adversarial relationship between doctors and nurses treating patients. Nurses questioning treatment plans in front of patients, ignoring orders, and generally flexing their political muscle in the wards are quite familiar to most of us. And now we have talk of nurse consultants in political appeasement gone mad. The doctor holds all responsibility for his/her patient, but has now been relegated to a second rate role in this NHS. It is the doctor who is the ultimate patient's advocate but in this wierd democracy of numbers he/she will get sued if there is a slip up but the box of chocolates will go to the nurses counter when all is well. To salvage the NHS and to restore morale among doctors healthcare management has to return to them. Regards Muzammil
Re: Stop whinging and move 7 May 2001
Joseph Watine, Eur Clin Chem Hôpital de Rodez, France Send response to journal: Re: Re: Stop whinging and move	Andrew Haig’s view sounds quite sane: doctors should not participate in this vote. Why should they be unhappy? They have a very stimulating profession that can bring them a lot of intellectual and moral satisfactions, they have one of the best social status one could dream of, most of their patients love and respect them, they enjoy salaries and many other material advantages that are much higher than average, etc.
Re: Ample reason to be unhappy 7 May 2001
Ian Nesbitt, spr Anaesthesia newcastle Send response to journal: Re: Re: Ample reason to be unhappy	i second your concern about politcians: do they know, do they care, and which is most worrying? As an example, I wrote to Nigel Crisp (chief exec) a few months ago. After one reminder and a six week delay, he replied (in a relevant manner). I also wrote to Mr Milburn. After a reminder at one month, I received a standard "brush off" reply (which utterly failed to address any issue I had raised). My response to this (by return of post) has been ignored (despite a further two reminders). This is the quality of person who is supposedly in control of the NHS, supposed to be setting examples. Should we despair, orbe incandescent?
Restoring the soul of medicine 7 May 2001
Brian McMullen, Locum GP / Associate Lecturer OU Send response to journal: Re: Restoring the soul of medicine	I believe that Richard Smith answered his own question in his editorial on 20th January "Restoring the Soul of Medicine". Education for medicine is mainly an intellectual exercise. There has been a neglect of the affective realm and of the meaning and spiritual aspects of health. Personal experience has been devalued. Doctors are still being trained to defeat illness and fight death at great personal cost. We are expected to relieve suffering that is an essential part of life and growth along with happiness. In the UK most work in a system that is based on an outdated concept. Increasingly diagnosis and management are managed by protocols and evidence that leaves little room for creativity or a meaningful relationship with another. However scientific reductionism has passed it's peak and a holistic model represents the hope for the future. There is a thirst for emotional and spiritual healing. The public has found it in alternative medicine and I am confident that doctors will return to the holistic roots of Western medicine.
Its not all doom and gloom 7 May 2001
Nicola Jakeman, Medical Officer Special Scale Bay-of-Islands Hospital, New Zealand Send response to journal: Re: Its not all doom and gloom	I feel privalaged to have the opportunity to practice medicine. I enjoy my work, which is more than can be said for a large proportion of the population. Through my training I have acquired experience and skills which have enabled me to travel and help those in need. There is nothing more rewarding than treating a sick baby, comforting a family of a dieing patient, or more exciting than rescuing a patient from the brink of death! I have worked in the UK and New zealand and the press is equally ruthless towards the medical profession in both countries. It can be disheartening to have every mistake blazed across the newspapers, but no word of all the successes. I guess its something the profession has to go through until we become more open about our falibility and the public realise that medicine does not have all the answers. The pace of change in the UK is daunting and unmaneagable. A plethora of clinical guidelines, frameworks and targets to meet, is all too much when we are expected to continue our day to day clinical work. As much as I enjoy my work, with the long hours, the extra management time and the lack of support from senior colleagues and battering by the press and politicians I find myself utterly exhausted.The impact of my work on family life is all too often unacceptable. I concentrate on the positive aspects of my work and this certainly keeps me going, but there is a lot of room for improvement.
not happy or unhappy but concerned... 7 May 2001
David Seddon, consultant physician queens medical centre, nottingham Send response to journal: Re: not happy or unhappy but concerned...	Richard Smith's article is timely. Many doctors in the UK must have moved from the 'happy' to 'unhappy' category of his survey over the lsat few years. Except we dont 'move': we are 'edged' towards this state of poor morale. I certainly dont see remuneration as the primary issue. Rather it is the inadequate support for doctors that is inexorably eroding their ability to provide an adequate service. There is a failure of will to on the part of the Department of Health to support the establishment of a Consultant based service. The pressure is on Consultants to deliver all aspects of the service as never before. A pressure not discussed in Smith's article is the impact on Consultants of the reduction in junior doctors' hours and the Calman reforms on higher medical training. In my department (geriatric medcine) we have 7 consultants. Over the last 6 years we have 'lost' 1 of 3 registrars to another Trust and have 'lost' the equivalent of an SHO to the medical take rota. We have gained a Staff Grade and a JHO, the latter of course needs supervision. Our Trust and indeed many Trusts seem to take the view that the appointment of numerous Staff Grade doctors is an adequate solution the problem of providing a service. Without wishing to offend any Staff Grade doctors who might read this, it is not! A Staff Grade doctor cannot and should not be expected to carry the continuing medical, ethical, and legal responsibility for patients. The National Service Framework for older people is a document that to my mind does not seem to say much that is new... and note readers that unlike the NSF for cardiology, there is no new money for the required improvemnets in stroke care. SHOs have commented on their concerns on career prospects and I think they are right to be concerned. At the moment we do still have very committed Sixth Formers applying for medicine. But for how long? I would disagree with one contributor to this discussion. Patients and relatives have a right to expect informed discussion as to the risks and benefits of treatment. I think they do also have the right to expect that the error rate in medical care is a lot lower than it currently is. This applies to the private sector as well as to the NHS. Death in a healthy patient related to general anaesthesia is now very rare... patients have the right to expect that errors such as intrathecal injection of intravenous vincristine should not happen at all, not just be very rare. Finally, I find Dr Mazammil's contribution worrying. It is precisely such an attitude that leads to bad practice, errors and complaints. And as a very last word, I would appeal to as many doctors as possible to contribute to this very important debate.
Pull together with patients and staff 7 May 2001
Robert J MacFadyen, Consultant Cardiologist Raigmore Hospital Inverness Send response to journal: Re: Pull together with patients and staff	The current swathe of early retirements by medical practitioners is understandable due to community pressure felt largely because the medical profession is now far more open with patients than previously. This commendable approach undermines the ability of a patient to opt out of ones own illness and a detailed knowledge of risk/benefit of treatment. The truth hurts everyone and patients in their disappointment turn on their health professionals individually or collectively looking for someone to blame. This is not helped by groups who blame each other! Secondary care doctors blaming primary care, nurses blaming doctors and doctors blaming politicians and vice versa. In fact things are getting much much better (at least in the UK), more open and better funded, albeit happening very slowly and surely. The future is bright for the patient in that they will understand that their isn't always someone to blame nor a cure for every problem in life. To be more informed is to be a better person not a reason to question the rationale, motive or practice of a doctor, surgeon, pharmacist, nurse or physiotherapist. The only residual problem is that if society maintains the current weight of prurient interest in distress supplemented by overwhelmingly negative commentary and criticism (I always thought critisism was meant to be an exercise in balanced assessment) even the best and most experienced doctors and other staff will look elsewhere for employment. They already go overseas where the financial rewards are greater, in alternative non patient related work (such as in legal representation!) or in early retirement for those lucky enough to have that option. The future is bright but perhaps we can be forgiven for not seeing it through the haze of media manipulation of opinion.
Re: Surprise, surprise - we're pathetic! 7 May 2001
Fauzi , M.O.incharge rural health centre Send response to journal: Re: Re: Surprise, surprise - we're pathetic!	because i can not bring happiness to public nor staff for ihave nothing to give except a few tablets.
I haven't Toxol. 8 May 2001
Alexandr Spitsky, gynecologic oncologist Rostov state oncological dispensery /Russia/ Send response to journal: Re: I haven't Toxol.	1.I can't treat patients with modern preparations such as Toxol. 2.I would like to study in Europe and to receive the European certificate of doctor. 3.I would not like, that in Russia people die because of the illiteracy of their doctors and the absence of medicines.
The Buck Stops Here 8 May 2001
John Powell, GP Rotherham Send response to journal: Re: The Buck Stops Here	Demands on healthcare providers will always continue to grow. The one and only thing we need is a clause in our contract that says effectively that a human being (doctor) can only do what is physically possible in the time given, and using the resources available. We need a "lid" The law of supply and demand will then dictate further "reform"
Belief in ourselves 8 May 2001
David Simpson, Consultant Psychiatrist Tavistock Clinic London Send response to journal: Re: Belief in ourselves	I welcome Richard Smith's editorial which brings to our attention the serious current problem of a very high level of dissatisfaction and unhappiness amongst the medical profession. I believe that his diagnosis of a bogus contract and mismatch of expectations between doctors and patients is correct. However I think the nature and implications of this require further exploration and I do not share his optimism that we are moving to a more real relationship between doctors and patients. I agree that there is a mismatch between the expressed aims of modern technological medicine and the reality of disease and the inevitability of death. The effect of this on many doctors is a sense of failure in not being able to deliver the impossible. I believe that as doctors we are particularly vulnerable in this respect; the desire to help people who suffer and to be appreciated for it being a key psychological factor in our motivation. As a consequence of doctor's increasing despair in the current climate of criticism what we see is a tendency for us not to overvalue but to undervalue ourselves and the contribution we make. In my view this has lead to serious difficulty amongst us in the medical profession in believing in and standing up for ourselves and our expertise. Of course there is hostility and opposition to the importance of doctors, not least from doctors themselves, some of whom wish to believe that they have nothing different to offer from other professions or patients themselves. However, what is lost is not only the value of our extensive training but our authority which is derived essentially from our clinical experience and which is the fundamental basis of our contribution to patient care. Unless we in the medical profession grasp this nettle I do not believe that the real contract with patients which Richard Smith describes is possible. David Simpson.
Why are doctors so unhappy? 8 May 2001
Huma Khurram, Postgraduate Student Jinnah Govt.Hospital Send response to journal: Re: Why are doctors so unhappy?	I agree with all doctors who told the various reasons of becoming unhappy. I agree with most of the suggested answers, that doctors are unhappy because they are overworked, underpaid, undersupported, unrealistic expectations from relatives and government etc etc all this is true .........but there is a need to overcome this unhappiness. There must be suggestions for that.....and what can be those? There is a lack of proper training for junior doctors. Junior doctors have to do their post graduation training unpaid, which is quite lengthy and desperate for them. No other good chances for everyone, and not everyone can get a chance to go abroad for a higher degree. Salaries are not enough to make ends meet nowadays.
Economic liberalism: Human disaster all over the world 9 May 2001
R Blamey, Internal Medicine San Borja Arriarán Hospital Send response to journal: Re: Economic liberalism: Human disaster all over the world	If we like it or not, the operational economic system is determining human beings... and their unhappiness, for patients who can't pay for health care or drugs, for physicians who can't satisfy all the needs -most of them artificially created. Furthermore, if your needs are met and you have time for a home life, would you be happy knowing that millions of people are dying in Africa, Asia or outside your city, because they were born in the wrong place, wrong time and wrong world? The world has the answer, but nobody (in the "civilized" world) wants to make it real... the human misery is greater. World is what we are.
De-politicise the NHS! 9 May 2001
Nicola Cooper, SpR gen int med / elderly Pontefract General Infirmary Send response to journal: Re: De-politicise the NHS!	The NHS was created for a purpose outside of itself. 50 years on, like many institutions, it now has a life and a purpose of its own. This is how organisations work. Politicians at the top of the bureaucratic pyramid change health policy as quickly as they change themselves. It's time to de-politicise the NHS - to create an independent NHS supported by national standards and a department of public health which concentrates on prevention; hospitals which are free to run their own affairs and employ the doctors they need and a realistic expectation about what the NHS can and cannot provide. Too radical? MAKE THE NHS INDEPENDENT! Can't the BMA run a campaign on this issue?
What happened 9 May 2001
Rakesh Bhargava, Professor of Othopaedics SMS Medical College & Hospital,Jaipur,India Send response to journal: Re: What happened	My father was a doctor too.As a child I remember the adulation and respect he drew from the people he treated, one reason why I chose this profession.Forty years later I see a changed scenario.There is a sea change in the patients attitude.Not all of it is my doing. Doctors are overworked,no doubt.People view it as a pyramid where the top have reached their level of inertia.Well, which discipline is different.I had my house robbed four times.Not once did the chief of local police come to investigate.Its not expected of him.Yet every patient wants the Professor to be at his bedside till he is symptomfree. Doctors are underpaid,Name adiscipline whose top brass get more pay then our senior cadre specialists.The bureaucracy will quote your private practice.Fine, then count that when deciding on the perks, at least the amount declared in the tax returns. My father's patients regarded him as a God.Now the patients treat you as one and demand miracles.You know it all (or ought to), and you cannot let a patient die no matter what.Giving life is not in your hands they agree for sure but in the same breath are equally sure that preventing death is.The politicians are stoking these beliefs."We have made every endeavour to give them the best medical education and training and now if they fail or are not able to give what you want, they are either incompetent or malingering and shirking work and responsibility" seems to be their dictum.The media adds fuel to the fire by highlighting the medical errors.Doctors are human beings capable of errors is completely eclipsed by the facade of "superhumans" and "demi- Gods".Other technocrats make mistakes too but their "substrates" are not humans. Sounds crude, but call them what you will, our objects of work are human beings, and this nothwithstanding,errors do occur and will continue to do so.I am not suggesting that there should be a leeway for errors but that they can, do and will occur should not be lost sight of.The media should remember that even the "Editor regrets".
doctors picture should change 9 May 2001
G O Ahmed, S.H.O. Send response to journal: Re: doctors picture should change	___ simply young doctors are shocked by the work enviroment after graduation. very long hours of working,very little money & the worst non-respect by people. the people are ready all time to complain aginst you. any mistake happens from any member of the team is the doctor 's responsibility, the doctor's fault. if the patient is cured no one says thankyou. it is your job. how can any one respect you &doctors are appearing in the court daily (for mistakes). i think doctors should press hard so that media show the real picture, that doctors are dedicated & caring people & not anything else.
Re: Why are doctors so unhappy? 9 May 2001
David Kernick, General Practitioner St Thomas Health Centre, Cowick Street, Exeter Send response to journal: Re: Re: Why are doctors so unhappy?	Dear Sir In his analysis of the causes of doctors’ distress, Richard Smith (Why are doctors are so unhappy? Smith R. Editorial. BMJ 2001;222:1073- 4.) identifies a number of problems but overlooks the fundamental cause – the exposure of a paradox, which has been previously accommodated by the implicit nature of medical practice. Until recently, practitioners were able to accommodate two mutually exclusive directives. The linear principals based on the principals of science view biological and organisational life as a machine that can be engineered towards defined objectives. The non-linear directive arises from the experience of doctors in the complex environment of the real world where life is directed by the interaction of many parts in a manner that is uncertain, contingent and where there is only limited room for manoeuvre. Here change proceeds incrementally on the basis of experience, intuition and reflection. With healthcare decisions driven almost exclusively by the evidence based medicine movement, a demand for explicit rationing frameworks and quantitative performance management measurements, the paradox is exposed. Unable to accommodate this dilemma, practitioners demonstrate high levels of distress. But there are more fundamental concerns. Doctors may not be the only victims of this development. Despite increasing resources being directed into healthcare, the population feels its health is actually getting worse (Office for National Statistics. Living in Britain: Results From The 1996 General Household Survey. The Stationary Office London, 1998.) There may be a more universal dis-utility associated with the exposure of this paradox. Yours faithfully David Kernick
Try reducing your hours 9 May 2001
Mike Laurence, GP Bacon Road Medical Centre, Norwich NR2 3QX Send response to journal: Re: Try reducing your hours	I find myself surrounded by apparently unhappy doctors whose feelings on the whole I do not share. Sure, I'm worn out from working too hard [having 4 kids at home doesnt help] but whats new about that? We [especially in general practice] actually have far more control over our working lives than nearly every other occupation I can think of. We have a job for life, [an increasingly rare commodity these days] and can switch jobs within the profession relatively easily from or into clinical practice, with a bit of extra training. The constant flow between general practice and public health illustrates this well. Despite Shipman, butcher gynaecologists and Alder Hey, we still enjoy very high status in society, though not as unquestioned as before. Doctors have to recognise that we are providing a service, like any other, and that 90% of our patients are grateful for doctors dedication and caring. Patients do not like to see rude or arrogant doctors, of whom there is still a fair number [we can all name some, and so can our patients]. Patients also don't need over-caring doctors either, who burn out after 10 years complaining about how their talents are unrecognised and their patients ungrateful. Doctors need to be balanced, open and adaptable to change. These traits can be acquired. Perhaps the unhappiest doctors should consider reducing their hours a bit, go without 2 foreign holidays a year, and maybe send their kids to the usually perfectly good local state school? Or take a sabbatical? [The government will have to cope with any shortfall in doctors hours] It is possible to enjoy medicine if you focus on the things that really matter in your life. Sure, the government is messing us about - but haven't they always? Threatening to resign is not going to improve our standing in society or make us feel any better about ourselves. Dr Mike Laurence MSc MRCGP
Juniors and Safe Care 10 May 2001
Jeremy Newman, PRHO Medicine Frenchay Hospital Send response to journal: Re: Juniors and Safe Care	Why is is that the most junior of doctors are left in the middle of the night, alone with the sickest patients? How can one houseman and an SHO provide safe care for so many desperately unwell people and see all the admissions as well? Does no-one care about these people outside the hours of 9 to 5? I can’t answer any of these questions. Can somebody help
WHY ARE DOCTORS UNHAPPY? 10 May 2001
Fauzi , M.O.incharge rural health centre Send response to journal: Re: WHY ARE DOCTORS UNHAPPY?	I love my profession but as Dr. Frank Breman said we are controlled by others. Also important are the comments by DR.LIPLEE that opportunities are not the same for all. Also that judgemental doctors are in error. Moreover, we are picking up the pieces of society's meltdown. ALL OF THIS HAS BEEN VERY WELL EXPLAINED IN: Ample reasons to be unhappy. Dr.J.BRYANT has brought forward an important point too. Finally, all doctors must be supported to make steady progress.
Give me a number! 10 May 2001
Clare Rogers, SpR (LAT) General Surgery Rotherham General Hospital Send response to journal: Re: Give me a number!	I have studied all my life and I am now 30. I sailed through SHO jobs and postgrad exams and therefore thought I had a reasonable chance of a training number. There were none so I was forced into research that I didn't enjoy and didn't pay. My supervisor left half way through so I have no published papers. I haven't finished my thesis because registrar jobs are so busy and I spend all my time applying for numbered posts. There are 200 people like me and some weeks no numbered posts are advertised. The government is going to import Spanish Surgeons. I could have my CCST in 4 years if I could get a number! It doesn't make sense.
Civic Society makes happy or unhappy people 10 May 2001
Paras K Pokharel, Ast .Professor BP Koirala Institute of Health Sciences,Dharan,Nepal Send response to journal: Re: Civic Society makes happy or unhappy people	Why I am neither happy or unhappy shows my indifferent attitude, which is even more dangerous than having one idea of happy or unhappy. Having completed an MD in General Medicine and joined government health services to serve the population, I realized science is not enough to understand people. I moved to a Community Medicine residency for three years in AIIMS. After completion I have spent the last 5 years working as a primary care physician and Asst. Professor of a non- practising Health Sciences University. I am gradually starting to compare with my contemporary friends the importance and position in society that they have earned in the same period. My encounters with them reminded me why someone is so what he is. All norms and rules are made by certain perceptions. If I am caring for rural populations, I may not be not competent to practice in good places. If I am not charging a high fee I may not be a saleable doctor. When bureaucrats and politician take some health related decision it is never on the basis of facts, but always inspired by their connection with a line of favouritism to their people. Most Senior Doctors are well trained in UK and do not try to promote a junior if he is not from his own family. Nepotism is a well-accepted norm. Why blame the profession: it is basically people around you who make happy or unhappy. No matter what you are? Paras K Pokharel Asst. Professor Department of Community Medicine, BP Koirala Institute Of Health Sciences, Dharan, Nepal.
PROFESSIONAL SATISFACTION IS A MYTH! 10 May 2001
S C Pradhan, Director Mental Health Mount Isa, QUEENSLAND Send response to journal: Re: PROFESSIONAL SATISFACTION IS A MYTH!	I don't believe doctors are more happy or unhappy than they should be. It is difficult to comment whether a doctor is more happy than a police officer or less happy than a school teacher. Probably they are as happy or unhappy as any one else in the society or in other professions. As Abraham Linclon had said happiness is not a mater of externals and a man is as happy or unhappy as they make up their minds to be. Although some external events may disrupt the balance of a perfectly sane individual it does not do so for all the poeple for all the time. If social changes brings existential crisis it does not do so exclusively for the doctors! Hence the secrect of unhappiness or misery as Bernard Shaw puts it, is to ask in your leisure hours if you are happy or not, as was done by the honourable editor of the editorial (no puns intended).
How not to be unhappy? 10 May 2001
B Venugopalan, Epidemiologist Selangor, Malaysia Send response to journal: Re: How not to be unhappy?	I believe all of us were happy when we initially graduated as doctors. The disillusionment set in later due to the various reasons already mentioned in the survey. So the challenge now is how not to be unhappy with our current situation. Some of my suggestions are: 1) Separate and allocate sufficient time both for professional/ family life/ personal health - readily said but rarely implemented. 2)Discuss with the management on scheduling tasks to meet your capabilities instead of allowing circumstances to dictate your work routine. 3) Attempt to cultivate an emphathetic attitude as this will be extremely useful in relationships with the individual patient or communities. 4)Separate your professional role from your family life- in other words don't bring work (and attendant problems)home! 5)Maintain an honest approach to problems/ people and know your limitations- and when to ask for help. 6) Support junior staff in their career advancement- the positive feedback received may the spark you might be looking for in your career. 7)If all these steps do not seem to help, maybe it is time for a short break (few weeks at least) to reassess the health of your career and family life. I acknowlege that some of the suggestions mentioned above may not be practical for some, but the important thing is for us to realize the various options available.
more happy less unhappy 11 May 2001
Mohan Devegowda, GP individual pracitice Send response to journal: Re: more happy less unhappy	Dear Editor, I never expected to become a doctor in the first place. When i became I told myself to be a GP. I enjoy my working with the community. I swim with their sorrows and pleasures. i have realised my limitiations as a GP.I stick to it, so I enjoy. I am always recognised and given preference most of the time in the community.. I am thrilled when my diagnosis is right because i did it myself. unhappy because financially not rewarding. Community thinks we make quite a lot of money which is untrue.As a GP i have to spend most of time with patients not with my family.And also I have to update continuously on everything.And i have tobe a thorough gentleman all the time. I just cannot falter.
Could someone please educate Richard Smith? 11 May 2001
Declan Fox, Locum Family Physician O'Leary, Prince Edward Island Send response to journal: Re: Could someone please educate Richard Smith?	Richard Smith is dangerously ill-informed in his musings on unhappy doctors. Just two points--first, the evidence I have seen on consultation times shows that they have gone down since 1990, not up as he suggests. Second, how in the name of God can he put such faith in Alan Milburn's promises of handing more power to frontline staff? We have seen this over and over since 1990---purchaser/provider split, GP fundholding, trusts, PCGs. NONE OF IT WORKS. It does not work because each New Thing brings with it increasing bureaucracy and decreasing trust in frontline staff. Ministers and senior civil servants are congenitally incapable of allowing clinical staff in the NHS to manage themselves. I left NHS GP in 1998, early retirement following two bouts of depression, a spell in a mental hospital and extensive treatment with drugs and cognitive therapy. I now work several months per year in a rural community in Canada. The work is harder in some ways, it is certainly riskier, involving hospital in-patient cover and emergency room work. Yet not only can I do this but I do it well and I enjoy doing it. Two big reasons spring to mind for that---there is virtually zero bureaucracy/paperwork and there is zero management interference with our work. Out here, self-employment means precisely what it says. Our only point of contact with the Department of Health is when we bill them fortnightly. Consequently we hold ourselves responsible to our professional consciences, to our colleagues, to our patients. I submit that this level of accountability far exceeds, in practical and useful terms, any paper system in the NHS. Health statistics for the Canadian population would tend to support that too. Sincerely Declan Fox MRCGP
Ask and you can't recieve 11 May 2001
Prashanth Gupta, Medical Student St. John's Medical College Send response to journal: Re: Ask and you can't recieve	In India,as in many other parts of the world doctors are underpaid and overworked,the risks if you make a mistake are too great and the rewards if you are right are minimal,that i feel is'nt fair. This is the main reason that upsets many medical students when they see their peers in other professions doing extremly well and unhappy medical students make unhappy(and ineffective) doctors.
Re: Re: Stop whinging and move 12 May 2001
Alastair D Short, General Practitioner Glasgow Send response to journal: Re: Re: Re: Stop whinging and move	Quite right. It is easy to forget job security and NHS monopoly mean we are free of many of the stresses of our patients.
A reply to Richard Smith 13 May 2001
Marion Newman , Gerhard Wilke Send response to journal: Re: A reply to Richard Smith	We would like to submit a joint reply to Dr Smith's editorial. Richard Smith's analysis of why doctors are so unhappy is timely but too academic; the causes of doctors’ despair is not an unrealistic relationship with patients and their inordinate demands or even the inadequacy of medical training. The causes lie within social factors that operate globally but have a specific impact within the UK and the NHS. We think that there was a contract, or a series of interlocking contracts, between the medical profession and the NHS and over the years they have turned out to be as illusory as Richard Smith’s bogus patient contract. Young people went into medicine because the work was useful, interesting, helped people, and offered status, money and autonomy. Growing up in the decades after the World War II, they accepted the post war settlement and the Welfare State and felt a pride in a service that offered high class medical care to any one regardless of social status and wealth. The corollary of relatively lower salaries mattered less because the social wage was greater and doctors still enjoyed autonomy and esteem. There was a shadow side to this system of good will and vocation because other and implied contracts or sub-contracts operated within the system – sweat your guts as a junior doc doing one in two and you too can reach the sunny uplands of life as a consultant or become the senior partner who can take an afternoon off and engage in politics or other rejuvenating pursuits. The deal was to become a GP and accept relative professional failure but enjoy greater autonomy and freedom from bureaucracy; now general practitioners are ground under the heel of managerialism and target setting of all kinds. Trust has been replaced by control. All over the world the liberal nineteenth century model of the doctor (usually male) dealing heroically with all the problems that his patients brought him, working with minimal equipment and few drugs and reliant on his charisma to comfort his patients has given way to a modern structure where doctors work in teams underpinned by massive investment in drugs, buildings and investigative equipment of all sorts, some of which is very expensive. When patients go the doctor now, they expect their conditions to be investigated and they go to the doctor partly to gain access to the real gains that science has brought medicine. Every doctor who sees a patient, orders a test or a prescribes a drug ultimately commands thousands of pounds of expenditure, often quite unthinkingly, and every system of medical care has taken steps to regulate costs and bring doctors to heel, a process facilitated by the ease and relative cheapness of modern computers. This process, which is international and inescapable, has been sharpened in the UK by the peculiarities of the NHS. As a recent table in the BMJ shows, funding of the NHS was similar to comparable European Union countries until the late 70s and it was possible to argue that any shortfall was made up by increased efficiency and reduced administrative costs. The decline in funding, relative to European Union countries, began under the last Labour government, accelerated under the 18 years of Conservative rule and continued for two years under New Labour. When the Blair government was finally driven to announce an increase in funding to bring expenditure up to levels in the rest of the European Union the message was not of gratitude to people who had worked under difficult circumstances but rather that the blame for the shortfalls in medical care lay in the conservatism of the doctors. The way this message was heard on the ground was that the life of the struggling professionals wasn't going to be made any easier. The slump in morale then accelerated because many of those who had an inner hope of the Labour cavalry coming in to rescue them from two decades of Tory attacks realised the truth. There would be no rescue. The profession had seen what had been done to the teachers, the university lecturers and the social workers. It was looking a degree of proletarianisation in the face. The choices have become stark: dropping out, inner emigration, evangelical conversion, compliance, relying on the fact that doctors are still needed when the politicians have moved on or the managers have been restructured out. In organisational terms, it is striking how unmodern the thinking of the modernisers is. What is being imposed in the NHS is a version of management thinking that applied in organisations up to the eighties. These organisations had clear core tasks, comprehensible organisational hierarchies and roles and a reliable and fairly stable leadership. Such organisations could still believe that control, planning and prediction of outcomes were possible. The trouble is we are in an age of the post-modern organisations where events are more chaotic than controllable and where managers, in private and global companies, work with emerging patterns of risk, success and behaviour. In this sense the modernising agenda of New Labour is old fashioned in management terms. Of course, as practicing doctors know daily life in the NHS is more in tune with the chaos metaphor of an organisation than with the control one. The NHS is too large to be controlled and too complex for individual players to feel that they can make sense of it, have their voice heard in it and influence outcomes. Perhaps the agenda needs to be turned upside down, it is the politicians who should be reigned in and see their role as providing sufficient resources and facilitating the work of doctors and managers. At a time when doctors are urged to become more open with and accountable to their patients, they ask the same of the politicians who cast doctors in the role of the patriarchal conservatives whilst it is noticeable how secretive the politicians are about their own plans and how little they divulge to the people whose entire working lives are bound up with the NHS. The contracts for the Private Finance Initiative, for example, remain secret on grounds of commercial confidentiality even though cheap technology in the form of the Internet exists to make them easily available. Sometimes it feels like living under an occupying power where resistance and survival have become the prime pre-occupation. Without direct knowledge of their feelings, it seems as if the politicians in charge of the NHS are acting and thinking as if they had to tame an unruly colony of naughty children. It is time to get back to more grown up and honest forms of exchange. It is time to get away from the myth that yet another restructuring will usher in the dawn of the perfect NHS. Two restructuring exercises a decade have given doctors change indigestion. Almost any structure will do, provided there are enough resources within the system. Time and stability are now essential, the focus must shift away from macro strategies and organisational arrangements and to giving clinicians and local managers protected time and space to review and re- engineer their work in the light of their experience and assessment of local needs. If doctors, as a recent editorial in the Lancet suggested, feel like hamsters in a ball, the time has come to let them out rather increase the rate of spin. Dr Marion Newman Gerhard Wilke Mill Lane Medical Centre, 112 Mill Lane, London NW6 1XQ Group Analyst and Org. Consultant marion@newmanhome
A Desert perspective 15 May 2001
Richard Knight, Consultant Riyadh Send response to journal: Re: A Desert perspective	I resigned an NHS post and came to Riyadh. In my Trust there was minimal direction from management yet ever increasing demands from patients/consumer groups/media. The never ending string of UK locums coming to Riyadh to pay for schools fees and BUPA cover all tell the same story. Doctors are portrayed in the media as lazy and incompetent and only interested in private patients. After 30 years in medicine I have seen my standing in the community descend from one of respect to one of derision. I see no reason to begin to believe that this will change before I retire--just as soon as I can.
Have a heart, not a swinging brick! 15 May 2001
Chrystal D Frost, Researcher in Primary Care University of Huddersfield Send response to journal: Re: Have a heart, not a swinging brick!	Your article interests me greatly. As a researching Psychologist I am not expecting any surprising results from your 'survey'. Everyone in the world will tell you that they are overworked, underpaid and unsupported. That's why, when we all get together our conversations turn to misery. Moaning can be an effective coping mechanism. It allows the opportunity to discover that others are a/ in similar states ,which is empathic and supportive, or b/ worse off than you, which brings relief and confidence; either way it can make you feel better. This out-pouring is a good release for those who tend to work on their own, as so often found in the heathcare professions (self reliance is a double-edged sword). If you listen to a group of healthcare professionals moan for long enough the mood changes, as they start to recount why they are still doing the job. Small positive incidents can keep the doctor in the job, despite hundreds of neutral or negative encounters; Things like patient courage; a patient who actually says 'thank-you'; knowing you made a difference/ saved a life despite obstacles placed in your way. For a more meaningful survey, perhaps it would be better relating financial remuneration to the duration, volume and nature of responsibilities associated with the work. As it is, the responses from your readers say far more than your survey ever could, and highlights that one factor which seems to have been neglected for some time; Relative Isolation. I am currently researching the workplace generated emotions of General Practitioners and the impacts they have upon the individual. This whole area is far more complex than first suggests but I must point out that adding to low morale with negatively skewed surveys and further demoralising feedback will not improve how the profession is viewed, either from within, or from outside. The main focus of my study is on developing an intervention to reduce the effects of working in isolation, and this has been enthusiastically received by working practitioners. It has the potential to improve morale and provide opportunities for GPs to learn effective coping strategies and beneficial practices from each other. I think it necessary to point out here that there is no hidden agenda in my research as it has no organisational or governmental funding. It would be naive and unrealistic for any of us to expect a quick fix to this problem. Anyone who promises such a thing can have put but little thought behind it, but there are others like me, trying to improve things. What is it about our society and media that constantly looks for doom and gloom? If we join in and do nothing but moan, people will stop wanting to listen to us. Surely we should be celebrating the successes of our healthcare professionals and their amazing abilities to cope in the face of great odds. Perhaps if there was more of that, others would be more supportive too.
Are doctors the scapegoats??? 15 May 2001
Annapoorani , M.O,Primary Health Centre,Tamilnadu,India Chennai Send response to journal: Re: Are doctors the scapegoats???	It was with the noble intention of saving lives that many enter the medical profession.It's been a long and arduous journey for this noble profession from the demi-god status to the present scanario where even the most noblest of thoughts and actions done with the only intention of saving a life is sued in the court of law. I'd like to narrate an incident here. A doctor on a holiday, walking along the road in rural Kerala in South India found a person who was choking on eating fish.The man was very dyspnoeic,and the doctor realised that nothing except an immediate tracheostomy would help. Medical care was far away,and hence the doctor with the sole intention of saving the life performed tracheostomy with a shaving blade and knife.The man was saved,later taken to a hospital in a faraway town and became alright except for an extended period of stay in the hospital for wound infection . The doctor was later sued in a court of law,for not following aseptic measures and for the wound infection thereof.Though the doctor was later acquitted by the Supreme court after a long period of trial,by the time the verdict was given his name was spoilt ,his practice took a downturn and nothing need be told about the mental torture he and his family must have undergone during the period of trial. THIS IS WHAT PRACTISING IN A COUNTRY LIKE INDIA MEANS. With little regard for the humanitarian nature,new found consumer activism ,commercialisation and vested interests of a some lawyers pressurise the young medicos and medical profession at large leading to discontentment ,in addition to overwork,low pay and poor work environment Yours faithfully Dr.Annapoorani
What precisely are you doing? 16 May 2001
L Reinecke, Radiation Oncologist Rand Clinic, Berea, Johannesburg, South Africa Send response to journal: Re: What precisely are you doing?	I would like to teach and do research - being 57 years old and having had more than 30 years of experience - that is where I should be. But, circumstances beyond my control keep me in the one on one patient situation - the value of which I realise for the patient - But, I believe once a physician is over 50 it is time for them to put their experience to better use - at least 50% of the time should be spent in teaching and research
Doctor unhappiness in the NHS 16 May 2001
Jonathan Rhodes, Professor of Medicine Royal Liverpool University Hospital Send response to journal: Re: Doctor unhappiness in the NHS	Dear Sir, Doctor unhappiness in the NHS You ask (Editorial BMJ 5 May 2001) why doctors are so unhappy. You do not mention lack of leadership as a possible explanation. Within the NHS doctors look for leadership by the Chief Medical Officer working in conjunction with the Chief Executive under the overall lead of the Secretary of State for Health. Perhaps particularly in Liverpool - but we suspect elsewhere as well - there is a widespread feeling of dismay that our apparent leaders have allowed themselves to be carried along on a tide of emotional criticism of the profession. Sixteen Liverpool doctors have been referred to the General Medical Council by the Secretary of State himself as a result of the Redfern report into retention of organs removed at post mortem examination at Alder Hey Hospital (1). Such was the haste to refer them that, apparently, at least one individual who is not on the medical register was included. Our NHS leaders have also expressed shock that any tissue is retained as part of a post mortem examination whereas any UK-trained doctor (and, we suspect, any Western-trained doctor) knows that some retention of tissue has been a routine aspect of post-mortem examinations. This has exacerbated the public reaction to what has been an extreme variation on post mortem practice which we do not condone. Any successful organisation, from a multinational company to an army, needs leadership that is capable of inspiring its staff. That is not achieved by public pillory of highly respected clinicians. To many in the medical profession the NHS seems currently to be drifting rudderless and is in urgent need of inspirational leadership focussed on delivery of good quality health care and less driven by political imperative. 1. Stationery Office. The Royal Liverpool children's inquiry report. London: Stationery Office, 2001 Yours faithfully, Keith Parsons, Consultant Surgeon, Royal Liverpool Hospital and President, Liverpool Medical Institution Susan Evans, Past President, Liverpool Medical Institution Alasdair Breckenridge CBE, Professor of Clinical Pharmacology, University of Liverpool Peter Calverley, Professor of Pulmonary and Rehabilitation Medicine, University of Liverpool Christopher Evans, Consultant Physician, Royal Liverpool University Hospital Ian Gilmore, Professor of Medicine, University of Liverpool Anthony Hart, Professor of Medical Microbiology, University of Liverpool George Hart, Price Evans Professor of Medicine, University of Liverpool John Neoptolemos, Professor of Surgery, University of Liverpool Jonathan Rhodes, Professor of Medicine, University of Liverpool Robert Sells, Consultant Surgeon, Royal Liverpool Hospital and Professor of Immunology, University of Liverpool Alan Shenkin, Professor of Clinical Chemistry, University of Liverpool Robin Walker, Consultant Physician, University Hospital, Aintree Tom Walley, Professor of Clinical Pharmacology, University of Liverpool Alastair Watson, Professor of Medicine, University of Liverpool Gareth Williams, Professor of Medicine, University of Liverpool Peter Winstanley, Professor of Clinical Pharmacology, University of Liverpool ps Enquiries may be addressed to Prof Rhodes or to Mr Keith Parsons at: parsons_keith@hotmail.com No conflicts of interest (and in particular, none of the authors are amongst the 16 referred to the GMC)
An outsider's view 16 May 2001
P A West, Director, YHEC University of York Send response to journal: Re: An outsider's view	As an economist who has spent the last 30 years looking at health care all round the world, may I suggest that frustration and perhaps boredom play a part in the anger of doctors? This is aside from what I accept are genuine conflicts between levels of public funding and clinical aspirations to help patients. Looking at other professionals, they advance through their careers, their work changes, they build teams and grow their businesses. Some stay in single practice but many move into management with changes periodically in their working life. Similarly, economists like me have a wide range of research, travel as part of our work and manage teams on a diversity of projects. I have no idea what I will be doing in September this year but I am confident it will be interesting. Contrast these professional lives with that of doctors. GPs may have opportunities to develop their management skills but in an environment where the management structures and self-employed status of colleagues make this far from easy. And someone has to see the patients each week. Consultants have more of the variety and team building mentioned but again, their work plans look very much the same, year-in, year-out to the outsider. This leads me to my conclusion. Is it possible that the calibre of people recruited to medicine is too high for the job - not necessarily for the technical elements but for the pattern of work once GP or consultant status is reached? Is a degree of frustration inevitable given their abilities and the relative consistency of the job beyond the age of 30 or 35? Are many years of clinical practice consistent with the job enrichment that able people may want as their career develops?
Are They Unhappy Because they are depressed? 17 May 2001
A Karim Jasim Al-Sheikhli, Associate Professor of Psychiatry. Jordan University Hospital,Amman,Jordan. Send response to journal: Re: Are They Unhappy Because they are depressed?	Dear Editor, It was very interesting to take a look at the response of the doctors to the questionnaire of the unhappy doctor. What attracted my attention was the following: 1.More than 50% were from Britain. 2.More than 50% were either very unhappy or unhappy. 3.More than 50% came from secondary care, whether as senior or Junior. It is well known that certain psychiatric disorders are high among doctors. Among those are depressive illness,suicide,drug misuse,& alcoholism.I think we ought to look into the results of this survey seriously for many reasons, among them: 1.Doctors are caring for other people,they treat other people and have the responsbility of giving high standard medical practice as suggested by the GMC. 2.The problem with doctors is that when they get really depressed--some of those who responded to the questionnaire and rated themselves as very unhappy/unhappy might possibly need treatment--get suicidal..etc, no one pays attention to that, whether their families or their employers. 3.I suggest that in order to overcome the problem of stigmatisation,all doctors ought to be informed that if they feel very unhappy to the extent which might affect their performance in treating patients or have a bad effect on them (suicide?) or have a deleterious effect on their families,there ought to be a certain office for e.g within the GMC,Royal college of Psychiatrists for UK doctors,or within area health authorities which can deal with the problem of the doctor concerned confidentially. With my best regards, Yours Sincerely, Dr.A.Karim.Al-Sheikhli,MRCPsych,DPM.
Papering over the cracks is never going to be easy 18 May 2001
Mark Oliver, GP Stafford Send response to journal: Re: Papering over the cracks is never going to be easy	I am a GP in a fairly prosperous market town. We have ample evidence of conspicuous wealth all around us with new superstores opening, hugely expensive new houses being built and lots of expensive foreign made cars on our roads. However our local NHS seems in permanent deficit, our newly opened hospice may not be able to afford to stay open, waiting times remain unacceptable and my surgery provides GP care to patients for the price of £1.20 a week per patient. Trying to provide a first rate service in these circumstances is difficult, and not made easier by politicians who pretend you can have 'owt for nowt. The challenge is to find a way of persuading the people to finance a decent health service that is politically acceptable. Until then dealing with dissatisfied people who struggle to access first rate health care is always going to be a losing battle, stressful and depressing for those who undertake it especially when we are caring people trained to always do our best for patients. Perhaps we need to accept that the UK is a difficult and stressful place to work and learn to cope better wuth the stresses this imposes until the penny finally drops.
Change System of Medical Education 18 May 2001
Parth Gokhale, Medical Student J.N.M.C, Belgaum, India Send response to journal: Re: Change System of Medical Education	I am a Post-Graduate student in Internal Medicine. I am of the opinion that the current plight of Doctors is more a consequence of education imparted to them. As the profession continues to specialise and superspecialise we have forgotten the role of a Family Doctor. We have failed to understand that in these days the need for a Family doctor is more acute than ever.Morever the medical education is no way near in helping the Doctor. In the third world countries like India the M.B.B.S course is of four and half years out of which only 15-30 days are given to subjects like Psychiatry and there is no formal course on Behavioural Science. This despite the fact that during General Practice or during specialist consultant practice about 30-40% patients come with some Psychological or Psyco-somatic complaint. There is no course on communication skills or in health management aspects. On the other hand precious time is devoted to teaching intricate details of the pathogenesis of disease or in memorising the sub-branches of nerves. If the education which is required to impart skills is itself defective and outdated how can the Doctor who is the product of such an Education system be perfect. The solution lies in introducing social education in the Medical Education. There is a subject called Preventive and Social Medicine in the curriculum of Indian Medical schools. However this subject does not encompass the various social problems encountered in Medical Practice. Inclusion of such social subjects will go a long way in improving the sinking morale of the practitioners and the declining status of the profession.
Desires and the reality of being Doctor 20 May 2001
Suely Grosseman, medical professor of paediatrics Paediatric Department of the Federal University of Santa Catarina -Brazil Send response to journal: Re: Desires and the reality of being Doctor	Dear Sirs, I was very happy to read your survey because I am just finishing my thesis named "Work Satisfaction: From the desire to the reality of being doctor". So, I am sending you the abstract to collaborate with some data. Taking into account that human being's satisfaction with his work includes a symbolic dimension regarding his subjectivity, the general objective of this thesis was to understand, close to medical professionals, the meanings of the desire of being doctor and work satisfaction, guided by the identification, in medical professionals, of the construction process of the desire of being doctor, the meanings of this desire and the relationship among the expression of those meanings and their work satisfaction. The research was carried out by the qualitative approach with principles of the Holistic-Ecologial Referencial. The type of study was the multicases and the technique of data collection was the in depth semi-structured interview. Twenty five doctors, that act in Santa Catarina (Brazil), in several work places, in the paediatrics, medical and surgical clinics, ginecology/obstetrics and public health areas, of both sexes, with more than fiftheen year of having formed were the subjects of this study. The desire of being doctor usually emerged in childhood or in the beginning of adolescence and had as meanings, in most of the subjects, the altruism. The subjects imagined that by being good doctors they would be happy and they idealized that, as consequence, they would have social and financial recognition as well as good quality of life. The desire was influenced by medical professionals' models, family beliefs, sickness circunstances and/or collective desires of the family or of "other significant ones". The concrete reality of the medical work, in rule, was not known by the subjects. In the academic formation, it happened the first break of the meanings of the desire of being doctor. In the concrete reality of medical work, among the factors for the "satisfaction of being doctor" the subjects mentioned the feeling of technical competence and adequacy in the area of performance, the good interpersonal relationship, the possibility of studying or to express the creativity, the social, financial and intellectual recognition, the balance between work dimension and other life dimensions as well as the political and/or social involvement; many of these factors fulfil the subjects desires, from the past. Among the limiting factors of work satisfaction, there emerged the psychological difficulty to deal with the patient (with the excess of responsibility and the suffering and death of the patient), the disillusion with the meanings of recognition and good quality of life. This disillusion is due to professional depreciation - confirmed by the health systems and the society - and to technology which together cause physical and mental overload. The improvement of the doctor -patient relationship through the medical "care" approach was one of the strategies carried out to deal with psychological suffering. The desire of being a good doctor was rendered but the desire to invest in the professional improvement contiues. The desires of recognition and good quality of life persist and they are longed for by many subjects. The emerging themes are discussed and interventions and investigations are suggested in ergonomics, medicine and other areas of knowledge that deal with the human being, with the intentioo of collaborating for the promotion of the professionals'satisfaction with their work on behalf of their work and life quality.
FIND OUT CAUSE OF HAPPINESS TOO 20 May 2001
K R Sethuraman, Professor of Medicine Jawaharlal Institute of PG medical education & research, Pondicherry, India. Send response to journal: Re: FIND OUT CAUSE OF HAPPINESS TOO	Your responders are a biased lot of "unhappy" doctors. You should balance it with another survey on "Why are you happy in your profession?" That will reveal the other side of the coin. We have heard the "whiners." Let us hear the others.
It's Nice to be Employed, it Makes Some People Very Happy! 22 May 2001
T Carol, Not got one Isn't work a perception? Send response to journal: Re: It's Nice to be Employed, it Makes Some People Very Happy!	Dear Editor and readers, As a patient/member of the public I had thought that I would complete your survey, but after considering it I couldn’t. I hope that no one is supposed to take the survey seriously. If so, how can you justify a result led survey in a high status professional publication? Its design is appalling and if it had come from any other discipline it would have been scoffed at. If you are going to do such surveys, shouldn’t it be impossible to view the results and comments until 'after' all the votes are cast. You are also inviting ‘non-professionals’ to vote on your own perception of why doctors ought to feel unhappy, by asking them to respond to 3-4 closed questions. This is inappropriate, as the questions are designed to support a biased view and it would be impossible to answer even 3 of them without lending support to that view. Does its purpose have a covert agenda perhaps; to perpetuate a feeling of unhappiness amongst medical professionals, or designed to incite bad feeling? As a patient reading the survey it certainly seems that way. You must be fully aware that national newspapers will manipulate and cite the results in their editorials. Somehow I don't think it will enhance the doctor/patient relationship a great deal. My husband, a Police Officer, has recently spent a considerable amount of time amongst thousands of swollen, rotting and burning sheep carcases, which were dug up because the waste was seeping into the water system. At other times he has stood in temperatures below freezing for hours on end, stood in the sweltering sun unable to take off his uniform and has often been in the presence of dangerous chemicals. Added to that he’s suffered more than a few bruises over the years and many an endless night shift. Like all other Police Officers, he frequently misses family milestones, constantly works short-handed and is drowned in paperwork. Should all these things effect his interaction with the next distressed person who reaches out for his help? Apart from odd occasions, he's generally a happy man and grateful he has employment, as it puts food on our table and pays the bills. I on the other hand, despite trying, am not happy a good percentage of the time. In the scummy jobs I've had to endure in the past, because ill health had robbed me of education and a carer, I've kept smiling and focused on my work. I beg of all of you, if you feel so unhappy that it affects your work to give it up altogether, not to move on elsewhere. The patient, regardless of where they live, who they are, what ails them or their status in life, deserve true dedication and 100% commitment, 100% of the time. This is because your work is unique and has the potential to devastate the lives of whole families if it's delivered inappropriately. It would be nice to think that patients like me, who need to have good doctors, can relax in the full knowledge that they aren't going to encompass the full wrath of dissatisfaction, along with its unpleasant consequences. Unfortunately that doesn't happen and I, like many other people who have medical conditions through no fault of our own are made to feel worse by the added anxiety of what we will meet next, and we can go away feeling ashamed of ever needing a doctor. Is this morally right from a profession, which by its nature leaves patients with no alternative routes? Be happy, it costs you nothing. However, not being happy costs your patients dearly. Carol T
Keep politics out of medicine 24 May 2001
Indranil Kundu, GP Langley, Berkshire Send response to journal: Re: Keep politics out of medicine	The problem is all down to the basic fact that the government does not like the idea of doctors having autonomy in their profession. They have done a very good job in doctor bashing and the morale is an all time low. We are grounded with tons of paperwork, work long hours, never get appreciated for the work we put in, human errors get blown out of proportion in the media and we are not left with a chance to prove our side of the story. the media has made their money by selling shocking headlines.But you will not come across equally screaming headlines declaring the doctor's side of the story. Keep people like Tony Blair, Alan Milburn, William Hague and his shadow deputy out of the NHS and let nurses and doctors be managers of the system, they know it best. Politicians, Health secretaries and managers come and go. But you are a doctor forever hopefully.There is still time to make a change, before we all plan to move into, maybe management or politics.
The next 6 years - Do I Go On? 28 May 2001
Roonio Baskaradarcchi, 1st Year Medical Student University of London Send response to journal: Re: The next 6 years - Do I Go On?	No one said being a doctor was going to be easy but surely there is some satisfaction in the job? I started studying medicine believing that the ability to save lives and make a difference to others was a very special thing. Everything that I have ever believed about medicine seems to be crumbling down and most of the respondents here have painted a very gloomy picture of life as a doctor. Even as a student, the smiles I get from patients after spending time with them is heartwarming but is there anyone out there that believes that there is hope and that it is worth continuing with my education? A very confused medical student.
Re: The next 6 years - Do I Go On? 29 May 2001
C K, IT professional Investment Bank Send response to journal: Re: Re: The next 6 years - Do I Go On?	After finishing medicine proper, I immediately changed my career plans and have now been working in IT for the past 3 years. I have other friends from med who also changed career paths right after graduating. Mostly we were pressured by our parents to become doctors. But I also know others who are in residency training right now and they seem to be enjoying themselves. So my advice to you is: leave if your heart isn't in it. =)
Beating round the bush! 29 May 2001
A N Ghanem, Consultant Urologist King Khalid Hospital Nagran, Saudi Arabia Send response to journal: Re: Beating round the bush!	Sir, Having read with interest Richard Smith’s editorial based on the BMJ survey and the lively debates on “Why are doctors so unhappy?” [1], one wonders if the roots of the problem and its solution remain overlooked while all are just beating round the bush. What has been said so far may have just succeeded in identifying the ill effects and manifestations of the problem: unhappy sick profession and discontented public with a falling apart MOH that was once one of the prides of the British system. I believe all doctors owe it to a single man who has identified and addressed the real problem. So I am asking all: “Hats off, please, and bow to this man” Professor J E Fischer who has the courage to tell the bitter truth about the current status of medicine in USA [2]. He has not only given a personal perspective but also an inside witness’s account that audit the system of “Phase 1 managed care”, marking the historical demise of such a failure system that succeeded in nothing but making such unhappy profession and discontented public worldwide. Should the Editor of this Journal kindly approve publication of only these lines I should be most content and grateful, having expressed my support and admiration to the author and brought the fact to the attention of those concerned. However, there are further comments one wishes to make, if allowed. I do not just give verbal vote of support to Professor Fischer but also believe one took a stand similar to that of “Dick” on smoking without daring to use a word he once introduced and twice used. Soon after implementing the system in UK and realizing what it aimed at, in 1988, I did not only leave MOH but also opted for elective removal from the full registration records of the General Medical Council. It was with sadness to learn, a few years later, that most of the best consultants, who taught me most medicine and surgery I know, had also opted for early retirement at the age of 55 years. This was just to avoid the hassle of the failure system. What a waste. Of most concern is Professor Fischer’s estimation that it may take decades in USA for the old system to be, if ever, restored. I pray for the countries that faithfully followed USA, wondering how long it may take to realize that the system has been proved a failure. I decline to estimate how long it may take some other countries to restore the old health care system or install a better one. The only foreseen optimism for a rapid change may come from a rather an unexpected paradox: the self-appointed economists who implemented and managed the failure system may wish, instead of persisting, to run for cover before impending law suits catches them in USA, and is sure to follow elsewhere. No doubt they all will try to justify their errors by governments’ policies but this may not work. The discontented public and unhappy doctors [2] have already realized that providing a quality healthcare (and education) are Nation’s best investments, in which every professional has a job to do: the medical professionals to provide the health care, managers to sort out the public’s and workers’ problems, economists to insure adequacy of supplies and raise funds necessary for it. Should the economic measures mentioned by Professor Fischer prove insufficient, one can think of one or two obvious sources for increasing the required funds- without increasing taxes. Yours sincerely Dr, A. N. Ghanem, MD (Urol) FRCS Ed. References 1. Smith R. Editorial. Why are doctors so unhappy? BMJ 2001; BMJ 2001; 322: 1073-1074 2. Fischer JE. Matter for Debate; Current status of medicine in the USA: a personal perspective. J.R. Coll. Surg. Edin. 2001; 46 (2): 71-75
Re: The next 6 years - Do I Go On? 30 May 2001
Andy Evans, Clinical Lecturer King's, London Send response to journal: Re: Re: The next 6 years - Do I Go On?	Dear Roonio Baskaradarcchi Of course you should carry on. There is no better job than being a doctor. You may never save a life (although it's thrilling when you do) but whatever career pathway you choose, you will be making a difference. If you read the correspondence carefully, nobody questions that looking after people is incredibly satisfying-it is the obstacles that prevent us giving our patients the best possible treatment that cause us to complain. It is because we want to help our patients, that it pains us when we don't have all the answers. We don't like complaints, but these are usually outnumbered by the quieter voices of gratitude. We are unlikely to be rich, but (in the UK) we're all likely to be comfortably off with excellent job security. We won't all become exactly the type of doctor we wanted to be, but that is true of any job-not everyone will get the promotions they feel they deserve. (I've been rejected at interview for jobs I've wanted, but things have always worked out for the best). We don't like being so tired that we can't do our job effectively, but things are improving all the time. What is important is that you always recognise that what you are doing is important and is essential to make your patients better. As a student, take careful histories, you may pick up the important clue that the busy doctors have missed. As a PRHO run things efficiently, check your results meticulously and relish the opportunities you have to treat patients in the emergency situation (with senior help if you need it). Further up the career ladder your responsibilities will increase and so will your satisfaction, whether from an inspired diagnosis, a skilfully executed procedure/operation or offering a caring explanation to a patient of their illness. When gathered together doctors often talk shop- this isn't just that we have no spare time to pursue other interests- its also because medicine is fascinating. And whatever the newspapers may say about the medical profession, your parents will always be proud of you.
doctors you too have a spine and brain 30 May 2001
Prahladhan , registrar in radiodiagnosis sr medical college, tamilnadu, india Send response to journal: Re: doctors you too have a spine and brain	Sir, The article has at last brought the truth to the open.We, the "intelligent, hardworking who spend life in service of suffering humanity" are unhappy, depressed. But instead of whining have we ever thought what is the solution? My humble suggestions: problem 1: poor pay? work as hard as you are paid for: stop work at 5pm and leave. not a joke. if we do it together it will not become a joke. be bold we have nothing to lose: we dont have patient respect as things stand. problem 2: media publicity of medical errors: give wide publicity that our treatments are not 100% safe. use pamphlets explaining the pros and cons to every patient and relative. problem 3: overwork hold meetings in the hospital and decide how much work you can reasonably put up with. if more work ask for extra personel. if management disagrees dont do the surplus work. may be there are more problems and more solutions. but first stop whining and ask for your rights....like a man ...or woman.
Re: unhappy GPs 1 June 2001
Andrew Falloon, GP Locum, New Zealand General Practice, Christchurch, New Zealand Send response to journal: Re: Re: unhappy GPs	It appears, from the table of unhappy doctors, that GPs seem to be mostly "unhappy" with their work. I would suggest that it's time for them to actually DO something about it for once. Their previous attempts to change their lot really are nothing more than pathetic bleatings, which have been calmly and nonchalantly repelled by the UK government's spindoctors. If GPs in the UK stopped being so passive and formed a collective, robust protest to conditions in NHS general practice they would achieve much better conditions for both themselves and, more importantly, their patients.
People make fun of medical students these days 2 June 2001
Ravindra Arya, Intern NSCB medical college hospital(s)-Jabalpur, MP, India Send response to journal: Re: People make fun of medical students these days	I must begin my reasons of unhappiness from the time i took biosciences froup in high school. i was excellent in mathematics and perhaps if i would have joined indian institutes of technology, i wud have been a software consultant in united states with an exhorbitant salary and great working conditions, as those people are, for whom i used to solve physics assignments. forced by my parents i joined medicine as a proffession, worked hard, been a topper, rank #1 through out, bagging every institutional award and medal for academics, which my university had to offer. yet courtsey of govt. policies (of reservation to somewhat so-called under -priviledged communities, note the paradox) i am left without a specialist residency which is very essential to survive further in a community like indian one. even if i do get a specialist residency it is highly unlikely i will get the same in the discipline of my choice (orthopedic surgery, and even after that my career wont be as stable as those classmates of mine who had choosen soft ware as a proffession, they are already drawing salaries like $70,000 to $200,000 per annum and will rise more. (i get around $500 per annum as an intern) whereas i have been academically superior to them through out my career. i alos observe that social status what doctors enjoyed abt 2 decades back has already detiriorated and doctors are not recognized as intelligent or successful people any more in the society. this career is looked down upon by career councellors and speaking personally people make fn of medical students these days.
Unhappy, or war-weary? 5 June 2001
Andrew Bamji, Consultant rheumatologist Queen Mary's Hospital Sidcup Send response to journal: Re: Unhappy, or war-weary?	Most doctors are not unhappy in their work as doctors, but they are weary of constant battle against politicians who will not listen. The NHS has always been underfunded for what doctors can perceive could be done - the Hospital Management Committee report for Sidcup in 1952 sounds strangely familiar today. I have written letters to every government in existence since 1973, criticising some decision, some failure to fund, some re-organisation. I am sure I am not alone. This constant personal snipe, conducted with intermittent rushes of blood to the head, has been largely successful if only because the letting off of steam is a Good Thing. It sometimes produced results, but no longer. Until the advent of this government politicians may have chosen to disagree with doctors and the confrontations have often been bitter, but they have been honest because politicians have respected medical education and experience. What is different about this government is that it no longer treats the medical profession with any respect at all. Other correspondents have alluded to this; explicitly it takes the form of backbiting, expressing opinions before the facts are known and refusal to enter any dialogue. Contract negotiations drag on, personal letters go unanswered and this is on a scale hitherto unseen. We are not, of course, alone. The teachers have had the same problem. Further the constant propaganda about increased funding grates with those of us who know that all the extra billions are eaten by inflation, working time directives and litigation, not to mention funding interest payments on Private Finance Initiatives. Deceit does not help; the £5000 announced for every ward is actually £2500 from the centre and the rest to be found internally. We know the limits; we know that the extra funds announced (often more than once) never reach the shop floor. The open deceit (to our eyes) indicates the contempt this government has for us. So I do not believe that doctors are unhappy - merely weary of fighting constant battles that they seem unable to win. In my opinion the greatest boost to doctors' morale would be if a government simply stood up and told us that there was not enough money, they had no intention of giving us more money and that we should shut up and get on with it. At least we would then know where we stood, and would not have to spend precious minutes, hours even, explaining to our patients that what the government says is not what the doctors get. As no government will ever do this our duty to our patients is to tell them the truth that the government will not.
Workload - a social construct 5 June 2001
C Gunstone, GP Pricipal Gordon Street Surgery Burton Send response to journal: Re: Workload - a social construct	Workload is rising - but is it? Consultation rates are pretty static and visiting rates are dropping steadily. The environment of General Practice is improving - certainly in Burton almost all practices have had substantial premesis improvement in the past 15 years. Workload is a personal impression, in the same way as stress is. Some of the major changes of the past 20 years are social. More families where both partners work. More marital break up. More demands that both parents share equally in child care. More belief in the necessity for a social life, or life outside medicine. (How many practicing GPs could have said, as a VTS SHO recently said to me, "I have a very active social life"?) So workload perception is not just a result of what is happening within medicine, but of our own perception of how our life should be.
The NHS should be politically independant 7 June 2001
Mark Norman, Cardiology London Send response to journal: Re: The NHS should be politically independant	Dear Sirs and Madams, I have worked in the NHS since 1994. Over the last 7 years workload has increased substantially, but with political statements saying we will improve the NHS. What is not clear is will this happen in our lifetimes. Change of government leads to change of policy, swinging from one political dogma to another. The fact that the NHS is under goverment control is the issue in the UK. Politicians who in some cases have no professional qualifications are making judgements on short-term political decisions and do not have anything but their own interests at heart. The NHS has been around longer than many of them have been alive, soon they will have killed the NHS. Initially the dogma of the NHS in the 1945-1950 period was based upon the political issues of the day. Things have dramatically changes since then, well.. in terms of politics. The NHS has not moved with the times. With the ever increasing business ethos of the UK, privatisation and autonomy of the railways etc. why is the NHS still under the direction of politicians? A service to succeed should be independant of politics and should be there to provide a service. Chronic underfunding has made the UK Health Service second rate. Who wants to work for second best? Morale has reached an all time low as we are all aware that buildings are second rate, equipment is second rate, funding is second rate; 6% of GDP in the UK spent on Health in comparison to 9% in Europe and 14% in the US. If you want to keep an old banger on the road while the neighbours can afford a new car every year, who will be happier? Make the NHS politically independant or the old banger will eventually conk-out. What do the BMA propose to do, actions speak louder than words, inertia from going out and doing is the only way to make these politicans see that we are fed up. They will keep hammering us all as they have a unified voice while we are in disarray. I look to the BMA to direct the political debate, and not tomorrow, today. Get a move on before we all move to the USA, Europe where there is less political influence. How many replies have there been from the USA, when I looked through the replies....none.
Re: The NHS being politically independant, is there a better system? 12 June 2001
Peter Bradley, GP Springwood, Qld, Australia Send response to journal: Re: Re: The NHS being politically independant, is there a better system?	In reply to Tim Burrough's response to, "Enough is enough", and to Mark Norman, re "The NHS must be politically independent". (Rapid responses to survey, “Who are the unhappiest doctors of all?” - BMJ May 2001) I could not agree more. It appears health is far too often used as a political football and should ideally be de-politicised. This happens all over the world. The other point implied but left unsaid is that we are still a long way from devising the elusive 'perfect system'. Certainly this is unlikely to ever happen unless, (surprise, surprise), politicians adopt a bipartisan approach, and truly seek it. Something absolutely fundamental to the subject, is the question of the manner of remuneration of the provider, and the question of having some control over one’s commitment. Having considered this issue for longer than I care to remember, and practised in two countries, I would like to advance a suggestion perhaps worthy of debate; How about a system which capitalises on the strengths of both public and private? The major themes appearing in response to this survey were; (a) general demoralization resulting from the feeling of over-work and lack of control over one's commitment, (b) general feeling the system is losing the battle to provide good quality care, and…… (c) last, but not least…..underpay. I am convinced, having worked in both 'free' and 'private' systems, that a happy medium is possible. One of the major causes of over-use and abuse of any system is if it is free at point of entry. This makes it hard to control demand as it is too open-ended. I am sure this is one of the major causes of the stress in the UK and Canadian systems for example. That is, trying to be all things to all people, and under-funded for the task. Alternatively, the US system, the other extreme end of the spectrum, if you like, excludes too many from good care because it is just too expensive, or, under the HMOs, often too controlled in terms of choice both in care and care provider, as evidenced by the call for ‘a return to humanism in medical practice’ at the recent annual conference of the Society of American Teachers of Family Medicine. On the other hand, should we really have to bear the responsibility of running a mini means test on every patient that comes through the door? I think not! From the consumers (patients) point of view, they want good affordable care, when they need it, preferably free once into a secondary (hospital) care situation. I doubt many would argue with that. So how to meet all this? Answer,…by a mix of both approaches. That is, a salaried service, set by an independent apolitical Salaries Commission, financed from taxation, but not free. Rather the consumer (patient) still pays a modest up-front user fee, which goes towards defraying the cost of providing the service. That is, a small share of residual costs after government grants like computerisation and staff subsidies, etc have been factored in, but where this fee does not go directly towards the doctor's salary. This would seem to incorporate the better elements of the two main alternatives. Any views on this? Peter Bradley MB ChB, Dip RA&NZCOG, MRNZCGP, FRACGP peterb@uq.net.au
My 2pence worth.. 17 June 2001
Richard Middleton, Private Anaesthetist Melbourne Send response to journal: Re: My 2pence worth..	Although I believe that the topic has been comprehensively covered by now, perhaps I could make an attempt to sum up my feelings about why Doctors are unhappy.. The following is based on personal experience and observations in both UK and Australia.. We are.. 1)...by the very nature of the work involved, a "self selected" group of highly motivated, high achievers. 1a)..Possibly MORE likely to suffer from significant clinical depression.. 2)...told from the very first moment in Medical School that we are the "elite" of our generation. 3)...subject to significant social and financial privation in our early under and postgraduate years, with the implicit promise of future "golden rewards". 3a)..often mistreated by those senior to us in our chosen speciality or hospital, for any of many reasons.. 4)...by and large justifiably proud of our achievements and expecting some reasonable recognition for same. 5)...usurped/undermined in our chosen role by any number of semi/poorly/un-trained peripheral persons, all eager to assume some of the kudos that they despise us for achieving. 5a)..occassionaly usurped/undermined in our chosen role by fellow medical practitioners, for various reasons.. 6)...impeded in the discharge of our duties by the devious and doubtful behaviour of legions of "bean counters" and others who act in any thing BUT the best interests of our patient. 7)...working as "biological" (i.e Frail and Fallible) organisms, for the benefit of other "biological" (i.e Frail and Fallible) organisms, under the conditions outlined in (5), (5a) and (6) 8)...expected to be more than mortal in our abilities to cope with the many and varied pressures of (7) above.. For these efforts we are rewarded at a level that is usually considerably less than other "equivalent" professionals. 9)...judged (for financial and status purposes) by those who should know better, for those actions (or inactions) that are inevitable, given the truth of (8) above.. 10)..put under extraordinary pressures by the predatory behaviour of some members of the "legal profession" and the "public" should we be unfortunate enough to fail as in (8) above.. 11)..reviled and discredited should we try to improve the system, point out its problems, redress the mistakes, etc, etc. Not only by "management" and other peripheral personages, but often by members of our own profession who should of course, know better.. Furthermore we are 12)..singularly disorganised when it comes to improving our current standing and conditions. Not withstanding the very real rewards and joys that our work can bring us, the above can so easily contribute to feelings of desperate hopelessness and unhappiness, which can only increase as time passes and no improvement is apparent. Should we be unfortunate enough to suffer from genuine depressive illness as (1a) above, these factors will make our lives increasingly difficult and intolerable. When it all gets too much, we are particularly effective at killing ourselves, because we have the knowledge and the means, readily to hand. The Answer?? Stand together as a body, united with a common goal and ethic, to support each other in our support of our patients. Sounds too idealistic doesn't it?? Unfortunately we are still far too fragmented. Many who should know better are still too immersed in their own interests.. The truth is that unless we do address these problems together, things will only get worse.. Medical School intakes will drop and the number and quality of Medical Practitioners WORLDWIDE will decline inexorably. Any comments??
If the UK's so bad why not come to Australia? 8 January 2002
Cassandra E Sharrock, Workforce Officer Mallee Division of General Practice Send response to journal: Re: If the UK's so bad why not come to Australia?	I know that the article is quite dated but several doctors have complained about the current medical system and working conditions in the UK whilst others cannot speak highly enough of the above in Australia. If you are dissatisfied in your current position why not see if the grass is greener on the other side and make a move to Australia, I have several positions vacant (that come guaranteed with a lifestyle!) in the Mallee district of Victoria, Australia. Don't dream it, do it!
Rediscover human values everyone! 7 April 2002
Narayanan Muthuswamy, Physician Internist Chennai 600012. India Send response to journal: Re: Rediscover human values everyone!	Doctors are as unhappy or as happy as everyone else. Worldwide economic recession, political adventurism and busybody attitides, refusal to communicate properly from person to person, superiority complexes, all contribute to the problem. Only solution to the problem seems to be that everyone involved- the Government, the doctor, the patient and the media should introspect, analyse deeply, communicate properly and attach utmost importance to human values and uphold standards.After all, maintaining human values seems to be the highest benchmark available. M.Narayanan
Reasons why Doctors are unhappy 16 January 2003
Jayaram M Nambiar, consultant Dr TMA Pai Rotary Hospital Karkala Send response to journal: Re: Reasons why Doctors are unhappy	There are many reasons why doctors are unhappy. 1) Lack adequate facilities at working place 2) The lack of appreciation from your superiors 3) The attitude of pateints towards fast cure -they are not ready to wait dr jatyaram Competing interests:   None declared