Feelings of job dissatisfaction and job stress are problems shared by general practitioners (GPs) in many countries [1–5]. GPs report a lack of time and heavy workload as the main causes for these feelings of discontent and stress [6–9]. These negative feelings may in the long-term lead to burnout [10, 11].
Burnout is 'a syndrome of emotional exhaustion, depersonalisation, and reduced personal accomplishment that can occur among individuals who work with people in some capacity' . Emotional exhaustion is the key aspect of burnout, and refers to feelings of energy depletion. Emotional exhaustion can initiate the burnout syndrome: exhaustion may evoke depersonalisation and feelings of reduced accomplishment . Depersonalisation is expressed in a negative, cynical and distant attitude towards others. Reduced personal accomplishment is a negative attitude to oneself, in relation to one's job.
GPs' dissatisfaction and burnout do not only affect the GP's own well-being, but it may also have consequences for health policy and for patient care. Job dissatisfaction is a major cause of GP turnover [3, 9] and it may add to a negative image of the profession. This can lead to shortages of GPs, a main concern for health policy makers. Moreover, doctors' feelings of discontent can damage the quality of patient care [14, 15]. Other studies showed that exhaustion and burnout are associated with more self-reported medical errors [15, 16], although another study demonstrated that burnout is not associated with an objective measure of medical errors .
One of the perspectives to explain burnout is found in equity theory [18, 19]. This theory is already applied to general practitioners in earlier studies [10, 13].
According to equity theory, people evaluate their relationships with others in terms of input (investments, job demands) and output (outcomes, rewards), compared to others around them. This principle can also be applied to work situations. In work settings people compare their job demands and their investments with the rewards they receive. When job demands are high, or rewards are low, people may experience an inequity or imbalance. But 'equity is in the eye of the beholder' : the evaluation of the balance between job demands and rewards is dependent on personal factors.
According to equity theory, people who experience an imbalance are strongly motivated towards restoring this imbalance. People who experience an imbalance between their investments and rewards develop feelings of distress, and a long-lasting period of stress may eventually lead to burnout [10, 11]. Solutions to correct the imbalance can be found in decreasing the job demands, adjusting one's expectations, or increasing the rewards. Decreasing the job demands is the most obvious solution, as it is demonstrated that high job demands are more strongly related to burnout than a lack of rewards .
Although little specific information is available about how GPs' negative feelings are reflected in their patient interactions, it is possible to imagine what happens when a GP is troubled with feelings of burnout or dissatisfaction. According to the perspective of equity theory, GPs with high levels of burnout experience an imbalance between their job demands and rewards, and will try to restore this imbalance. One can hypothesise that GPs who are exhausted and cynical toward their patients, and suffer from feelings of worthlessness, will invest less in their patient contacts than other GPs. Their distant, cynical attitude that characterises burnout, will, in particular, reduce their openness and affect their attitude towards their patients. Also, GPs who are dissatisfied with their job and their available time are expected to invest less in their patients, and to shorten their consultations, in order to gain time and energy to restore the imbalance.
One of the aspects of a GP's job that demands extra time and energy, according to GPs themselves, are their patients' mental health problems [21, 22]. The GP has an important position in this, as they are often the first health professionals to be contacted by patients with mental health problems . GPs as generalists are the people assigned to provide integrated care for both patients' somatic and psychological problems. Early identification of patients' mental health problems is important, because it is the first step in finding adequate care for the patient.
Time is an important condition for discussing psychological problems in the consultation. It is known that consultations that include psychological problems take more time [24, 25], and doctors experience more frequently a lack of time . GPs mentioned this lack of time as an obstacle to detecting and treating patients with psychological problems in the consultation [26, 27]. Also, patients themselves mention lack of time as one of the reasons for not presenting psychological problems in the consultation . But time alone is not enough to provide adequate psychological care. Furthermore, specific communication tools are required to stimulate the patient to disclose their psychological problems [29, 30]. Aspects of GPs' communication that are associated with an increase of psychological aspects in the consultation are GPs' affective behaviour, that is being patient-centred [31, 32], asking questions about psychological or social issues [29, 32] and showing eye contact with their patients [33, 34].
Given the importance both of time and specific communication tools for discussing mental health problems, and given our presumption that burnout and dissatisfaction in particular affect GPs' available time and their affective approach in patient interactions, we expect the following:
GPs with burnout or dissatisfaction with the available time will, in order to restore the balance and gain time and energy, be less inclined to get involved in their patients' mental health problems, compared to GPs with low levels of burnout, or GPs who are satisfied with the available time. We expect that GPs with high burnout levels, or dissatisfaction with the available time, will adapt their communication to elicit less patient disclosure with respect to their mental health problems. There will be less encouragement for their patients to discuss their mental health problems, resulting in less involvement of psychological aspects in the consultation.
Therefore, we investigate in this paper:
Do GPs with high levels of burnout, and GPs who are dissatisfied with the available time
Have shorter consultations?
Show less affective communication in their consultations?
Talk less frequently about psychosocial issues?
Make less psychological evaluations?