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General practice under pressure

What possible connection could there be between theories of emotion and GPs’ working conditions? With 10 minutes to do a repeat script, check a chest, give an x-ray result, a flu vaccine and ask about the grandchildren, there isn’t much time for reflecting on threat and reward systems and how they might be relevant.

And yet, just as Christmas could not have happened without Santa Claus, humans cannot function without emotions. Understanding how emotions work is as interesting and relevant as knowing how to eat well.

Prof Paul Gilbert, a British psychologist, awarded an OBE for his contribution to mental healthcare, describes three emotional systems — a threat system, a drive system and a connection system. We are continually moving between these three systems. Each one is necessary for a balanced and flourishing life.

The threat system is necessary to warn of impending harm. This provokes a fight, flight or freeze response. Getting out of the way of an oncoming car, an angry boss, or simply working under time pressure all provoke a threat response with an increase in the hormones adrenaline and cortisol.

The drive system is necessary to achieve goals. After escaping a threat, we enter the drive system. Recovery from a heart attack can lead to healthy eating and an exercise plan. Frequently running late at work might lead to an audit of time management and the setting-up of new protocols to deal with interruptions such as phone calls or unnecessary requests. Operating in the drive system leads to short bursts of dopamine, experienced as a reward and a temporary feeling of wellbeing. You know the feeling, when you complete your to-do list, and before you start the next one.

The most beneficial system is the third, the connection system. Watch a mother with her newborn baby, a grandparent with their grandchild or remember the feeling of really being heard and understood. Connection is due to oxytocin. We feel at ease, connected, cared for and caring. Connection is a between-people system and is as likely to happen between doctor and patient as between mother and child, if the conditions are right. It is in this system that we do our best work and it is this system that helps us recover from the time spent in drive and threat. It cannot happen when drive or threat systems dominate. 

GPs have been operating in a threat system for so long that we have ceased to recognise it as such. Declining remuneration, increased tasks, worries about staff redundancy payments for those near retirement, locum payments for those who are ill and job opportunities for those newly-qualified are as big a threat as the lion in the forest was to our ancestors. A significant difference is that this threat is not short-lived, allowing a return to normality by fighting, fleeing or freezing. This threat is ongoing, with ongoing physical and mental consequences. 

Some deal with this by going into the drive system. They have become adept at doing everything the new contract has asked us to do. Registering those with asthma and diabetes, ticking the boxes that have been added by remote administrators who have no idea of the complexity of a GP consultation, submitting the necessary forms in order to receive payment. Completing these tasks and receiving payments provides short-term reward. Others find this demoralising. Completing tasks that have no personal meaning will not provide a reward, regardless of how much money it generates. In fact, feeling forced into performing meaningless tasks will drive some to find satisfaction and connection elsewhere.

We cannot force our body and mind into caring mode. We can only care from a position of safety. It is how we have evolved. We get out of the way of the lion first and when safe, see what we can do for others.

GPs have ever-present lions. Those responsible include everyone who had any part in designing the new under-sixes contract and equally, those who did nothing to prevent it. The main losers are the doctors and the people they care for. Until a new contract is drafted and GPs can act from a place of safety, the best they can do is realise that it is not their fault that providing compassionate care is difficult. They will do well to care for themselves, focus on what they need to create a place of safety from which they can provide the care and connection that patients need and have come to expect.

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