Editor—As an economist who has spent the past 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 and contribute to their unhappiness, as described by Smith in his editorial?1 This is aside from what I accept are genuine conflicts between levels of public funding and clinical aspirations to help patients. Looking at other professions, I note that people advance through their careers, their work changes, and 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 and travel as part of our work, and we manage teams on a diversity of projects. I have no idea what I will be doing in September this year, but I am confident that it will be interesting. Contrast these professional lives with those of doctors. General practitioners 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.

Might the calibre of people recruited to medicine be too high for the job, not necessarily for the technical elements but for the pattern of work once general practitioner or consultant status is reached? Is a degree of frustration inevitable given doctors' 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?

Editor—Smith in his editorial asks why doctors are so unhappy.1-1 He does not mention lack of leadership as a possible explanation. Within the NHS, doctors look for leadership from 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 postmortem examination at Alder Hey Hospital.1-2 Such was the haste to refer them that, apparently, at least one person 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 postmortem examination, whereas any doctor trained in the United Kingdom (and, we suspect, any doctor trained in the West) knows that some retention of tissue has been a routine aspect of postmortem examinations. This has exacerbated the public reaction to what has been an extreme variation on postmortem practice that 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 focused on delivery of good quality health care and less driven by political imperative.

Editor—I find myself surrounded by apparently unhappy doctors whose feelings on the whole I do not share.2-1 Sure, I'm worn out from working too hard (having four children at home does not help), but what's new about that?

As doctors we (especially in general practice) 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 comparatively 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 high status in society, though not as unquestioned as before. We have to recognise that we are providing a service, like any other, and that 90% of our patients are grateful for our dedication and caring. Patients do not like to see rude or arrogant doctors, of whom there are still a fair number (we can all name some, and so can our patients). Patients also do not need overcaring doctors 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, going without two foreign holidays a year, and maybe sending their children to the usually perfectly good local state school? What about taking a sabbatical? (The government will have to cope with any shortfall in doctors' hours.)

You can enjoy medicine if you focus on the things that really matter in your life. The government is indeed messing us about—but hasn't it always? Threatening to resign is not going to improve our standing in society or make us feel any better about ourselves.

Editor—Smith claims in his editorial that doctors are unhappy.3-1 He does not offer any significant evidence to support this. He then tries to work out why they are unhappy. It would seem unlikely that such an endeavour could prove fruitful, given the lack of time spent on defining the research question or hypotheses.

Is there any evidence that doctors are more unhappy than they were? If so, when did this slide start? If there is evidence that they are more unhappy, are they more unhappy than other public sector workers? Is the level of unhappiness global or is it different for different specialties, different age groups, and the two sexes? Is there any evidence that the levels of unhappiness are associated with policy changes, pay changes, media events, or more global societal changes? Are today's doctors really grappling with different sets of challenges than their predecessors, or have society, medical science, and medical teaching always been in a state of flux that pushes doctors to the limits? Is there really any significant difference in the challenge or does the difference lie in the expectations of doctors?

Surely these are the types of questions that need to be asked and answered with research before we start hypothesising about causal links and what needs to be done about it all?

A quantitative paradigm is implied from the above but qualitative methods may be initially more appropriate.

Of course, there are lots of ways of doing it, but the central point remains. We forget basic scientific principles at our peril. Politicians used to take a few soundings and call it policy. They were rightly criticised for this. The scientific method aims to improve on this. An opinion piece is what I expect to read in BMA News, or perhaps in the Education and debate section of the BMJ, but not as an editorial in a scientific journal. Am I the only one?

Editor—I feel privileged to be able to practise medicine.4-1 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 or comforting a family of a dying patient, or more exciting than rescuing a patient from the brink of death.

I have worked in the United Kingdom 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 without a word of all the successes. I guess it is something the profession has to go through until it becomes more open about its fallibility and the public realises that medicine does not have all the answers. The pace of change in the United Kingdom is daunting and unmanageable. A plethora of clinical guidelines, frameworks, and targets to meet is too much when doctors are expected to continue their day to day clinical work.

As much as I enjoy my work, I find myself utterly exhausted with the long hours, the extra management time, the lack of support from senior colleagues, and the battering by the press and politicians. The impact of my work on family life is too often unacceptable.

I concentrate on the positive aspects of my work, which keeps me going, but there is a lot of room for improvement.

Editor—In response to Smith's editorial about unhappy doctors I will describe how workload has increased.5-1

I have now been in my singlehanded general practice for some 14 years. I have roughly the same number of patients with the same range of acute problems, but the energy expended in servicing a practice of this size has increased dramatically. Why? I have no doubt that a little more intrusive administration may be a small factor, but I think that the main factor is an inevitable consequence of the advancement of scientific knowledge and the clinical applications arising therefrom.

Which of us knew much about cholesterol and triglycerides 30 years ago? Now we have a population who know their cholesterol number and television advertisements talking about the low density lipoprotein fraction.

What happened in 1970 when patients presented with angina? They were given glyceryl trinitrate tablets. A few years later they would probably have been given propanolol. A few years later still and atenolol had largely replaced propanolol together with a calcium antagonist. By 1985-90 selected patients would have been referred for an intervention procedure—now much more commonplace.

The result is more letters backwards and forwards to hospital, more blood checks to be done, more repeat prescriptions. This chronic and preventive management has added a second tier to the original job of responding to acute events.

Result—more person hours necessary to service a static population.

Solution—more doctors or more health workers to accomplish this.

Editor—The demands and stresses of our current way of working in general practice have now become intolerable for most doctors.6-1 I am aware from my roles in the local medical committee and the General Medical Council that exhaustion and poor morale are having a deleterious effect on the quality of care we give to our patients. To put it bluntly, the present situation is becoming increasingly unsafe for both doctors and patients alike.

We have mortgages, overdrafts, and offspring to finance so I appreciate many family doctors will experience income separation anxiety at the thought of resigning from the NHS. The reality is that the NHS is desperately short of family doctors, and becoming ever shorter as more and more of us retire early, work part time, or take extended stress related sick leave.

This puts us in a very strong position. We are needed, and the NHS cannot survive without us.

Dentists have successfully cut the umbilical cord between themselves and the NHS, but this has left much of the population without access to affordable dental care. Most doctors, I suspect, would not be happy with such an outcome of any action we might take.

Organising ourselves into geographically based units from which health authorities and primary care organisations could purchase our services would be eminently feasible. With the help of the BMA we could negotiate contracts which clearly define our workload and responsibilities and ensure appropriate remuneration. This would leave us self employed and masters of our own destinies. We have organised ourselves well to provide care outside working hours so why not during working hours as well?

Another possibility is that future changes to service provision outside working hours as a result of increased involvement of NHS Direct could mean that out of hours general practice cooperatives might consider redefining their role to include provision during working hours as well.

I hope that none of this will be necessary as the government will respond to our genuine and urgent concerns by speedily negotiating a new contract. If, however, the government is foolish enough not to recognise our united anger and determination on this issue, we need to have a plan in place to enable us to provide a safe and satisfactory level of care for the population while remaining in good health ourselves and paying off the mortgage.

We and our patients deserve nothing less.

Editor—Smith's editorial is timely.7-1 Many doctors in the United Kingdom must have moved from the happy to unhappy category of his survey over the past few years. Except we don't move: we are edged towards this state of poor morale.

I do not think that remuneration is the primary issue: the inadequate support for doctors is inexorably eroding their ability to provide an adequate service. There is a failure of will 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 medicine) we have seven consultants. Over the past six years we have lost one out of three registrars to another trust, as well as the equivalent of a senior house officer to the medical take rota. We have gained a staff grade doctor and a junior house officer, who 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 to the problem of providing a service. Without wishing to offend any staff grade doctors who might read this, I say it is not. A staff grade doctor cannot and should not be expected to carry the continuing medical, ethical, and legal responsibility for patients.

Lack of funding is an issue. The national service framework for older people does not seem to say much that is new. Also, note that unlike the national service framework for cardiology, there is no new money for the required improvements in stroke care.

Senior house officers have also commented on their concerns about career prospects, and I think that they are right to be concerned. At the moment, highly committed sixth formers still apply to read medicine. But for how long?

Editor—In his editorial on why doctors are so unhappy Smith makes the important point that public belief in the ability of medicine to address social problems fuels expectations which cannot be met.8-1 Ultimately this disillusions patients and increases the stress of doctors.

While agreeing, I suggest that it is not just doctors' inability to influence social factors that is stressful but their inability to control the deficiencies in their working environment and its impact on their relationships with medical colleagues.

One of the worst sequelae of this, not mentioned by Smith, is the way that this has set primary care against secondary care. I imagine there have always been scuffles along the primary-secondary care interface, but ever increasing demand in the face of inadequate resources has heightened this beyond measure.

How many general practitioners do not feel some resentment at their colleagues in secondary care for dumping work traditionally undertaken in hospitals on their doorstep without an accompanying shift in resources? How many hospital doctors feel that their colleagues in primary care set their threshold for referral too low? How often do we doctors 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 leaders within the profession will have to be 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.

Editor—Extending a process started by Margaret Thatcher in 1990, Milburn is developing an industrialised, consumer led NHS. Bureaucracy marches on: as a proportion of spending on health care, administrative costs have doubled from about 6% before the 1990 reform to about 12% now—still behind the United States at about 25%, but we're on course for that target.

Milburn is driven by a vision of the NHS as an industry producing clinical interventions as discrete commodities, episodically consumed by patients. Innovation will depend on subsidised corporate investors. Motives for this electorally unpopular strategy have been explained by Price et al.9-1 New Labour's devotion to creeping privatisation of the NHS starts from its apostasy to neoliberal economics and commitment to the general agreement on tariffs, trade, and services, opening all public services to global competition and investment.

The NHS is being parcelled into commodity units, dividing staff from patients and impeding effective care. No market will ever shift corporate investment from where it is most profitable to where it is most needed. Investors will take the profits while the NHS, staff, and patients will take the risks of downsizing and eventual system failure.

If the NHS did not have to provide the most difficult services for the most difficult people, we could just let them pile up in hospital emergency rooms. We could concentrate on high quality care for high quality people, with heroic salvage for the rest. But, according to opinion polls in the Guardian on 20 and 21 March, a substantial majority even of Conservative voters still believes in a socialised NHS based on neighbourhoods and devils they know, not on shopping around between competing providers. The industrial model violates continuity, solidarity, and locality, which make work satisfying, and promotes mistrust and £2.6bn of litigation. Like patients, most doctors are loyal to the founding principles of the NHS, but also like patients, their hopes diminish that these principles will be upheld by any party in office. Industrialisers depend on this shared hopelessness.9-2

Smith suggests an honest contract between doctors and patients as equal coproducers.9-3 This could indeed provide a material foundation for post-industrial production of socially useful values, beyond, outside, and eventually alternative to either commodity trade for profit, or state paternalism.9-4 Clinical medicine is potentially more effective than ever.9-5 Affordable delivery depends on continuity, social solidarity, and locality, impeding trade in care as a commodity, but meeting fundamental human needs.9-6 Health professionals could understand this better than career politicians, once they see who their real friends and enemies are. Over the past 50 years the BMJ has become an increasingly effective dissident press, seeing and saying that the emperors have no clothes. When we dare to accept the full social responsibilities that governments are seeking to evade, we shall gain the initiative and defeat our unhappiness.

Editor—Smith's analysis of why doctors are so unhappy is timely but too blinkered.10-1 Doctors' despair is not only rooted in an unrealistic relationship with patients and their inordinate demands. The causes lie within social factors that operate globally and have destroyed a contract of goodwill between doctors and the government. After the second world war a generation of doctors accepted the welfare settlement and felt a pride in a service that offered high class medical care to anyone regardless of social status. The comparatively lower salaries mattered less because doctors enjoyed autonomy and esteem. The deal was to accept relative professional failure but enjoy greater freedom from bureaucracy; now doctors are bound by auditors, controllers, and modernisers.

The single doctor dealing with all the problems of the patient, working with minimal equipment, and reliant on his or her personality for comfort has given way to a structure where doctors work in teams underpinned by massive investment in drugs, buildings, and investigative equipment of all sorts. When patients go to the doctor now, they expect their conditions to be investigated and to gain access to the full resources of scientific medicine. The doctor has changed from an authority into a gatekeeper, the patient from a dependant into a consumer. Every doctor who sees a patient commands thousands of pounds of expenditure 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. No longer are the doctor and the NHS perceived as a dependable and caring mother.10-2

These mutually frustrating interactions between patient, doctor, and manager have had more of a dramatic impact in the United Kingdom because the underfunding of the NHS has made dissatisfaction by all visible, newsworthy, and highly political. When the Blair government was driven to announce an increase in funding to bring expenditure up to levels of the European Union he blamed the shortfalls in medical care on the conservatism of the doctors alone. This message triggered a new slump in doctor morale because the need for appreciation was met by contempt and misunderstanding; it reinforced the feeling that doctors live under an occupying power where resistance and survival have become the prime preoccupation. It is time to get back to more honest and less patronising 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. More time and stability are essential now—just as patients need recovery time and support, so do their doctors. If doctors feel like hamsters in a ball, the time has come to let them out rather than increase the rate of spin.

Editor—We live in a world where the victim culture predominates. How you are today is seen as the result of someone else's actions. These actions are not intended to help you and probably are an attack on you. You may well be due compensation for your suffering. As part of this culture doctors also see themselves as victims.11-1

A macabre dance is going on in which doctors, patients, regulators, and politicians move round a triangle freely swapping between the roles of perpetrator, victim, and caretaker and often having all three roles at once. So, for example, a politician acting as caretaker for a victim patient may perpetrate an attack on a doctor by calling for the doctor to be struck off. The doctor who perpetrated negligence is now a victim. The politician may be surprised to find himself or herself a victim being attacked for his or her motives in caring for the patient. The victim patient may use the complaint to perpetrate an attack on the doctor and may find himself or herself having to act as caretaker for the politician's actions.

There is a way out of this triangle for doctors, patients, regulators, and politicians. All parties need to realise that their perceptions of the world are at best partial and that if they understood both themselves and each other more they would criticise each other less and accept each other more.

As doctors, we are at present victims of our misperception of the world. If we want enjoyable lives at work we will have to examine our assumptions and prejudices closely. This will be painful: it is so much easier to say our misery is someone else's fault.

Have we the courage to rediscover our own happiness?

Editor—Doctors are unhappy for a myriad of reasons, many of which have been highlighted by Smith.12-1 However, we doctors 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.

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 and both depression and disillusionment are our default mood states.

Editor—Some of the rapid responses to Smith's editorial are judgmental, righteous, and lacking in compassion.13-1–13-3 It is sad to read about the attitude of doctors towards their unhappy fellows—for example, if you're unhappy you must be a lousy doctor, a whiner, bored, so get out.

The lack of compassion so many doctors show towards one another, the competitiveness and paranoia many doctors feel towards one another, is part of the reason many doctors are unhappy. I have facilitated weekly or biweekly doctor support groups in New Hampshire for 18 years and worked with eight such groups over that time. One participant commented that when he came into medicine he expected no support from fellow doctors as he saw them as being aloof and cynical. Consequently, he was not proud to be a doctor and kept his distance. His experience in the support group showed him how to appreciate fellow doctors as compassionate and sensitive, and he consequently felt more pride and security in his role and enjoyed most of his colleagues.

Although these groups are termed physician support groups, the title is superficial since it could imply that the groups are for impaired doctors needing support. In fact, they are for doctors under normal stress, coping with normal family issues, difficult colleagues and patients, and a sick and impersonal medical system. Such a group provides profound emotional and spiritual support, but additionally could be called a consciousness raising group, an interpersonal skills group, or a physician empowerment group. It is not group therapy, but a successful group is very therapeutic.

Editor—I particularly like the final paragraph and box in Smith's editorial.14-1 In my specialty we had first to discover then to accept many of these points. Facing constantly changing reality within a system seems to be a necessary part of growing up—for doctors, nurses, and other professional colleagues, as well as patients, their carers, the government, and the media. I support Smith's view that honesty is the key to making all this less uncomfortable.

Whatever the circumstances, anxiety, bewilderment, doubt, and especially anger characterise resistance to change. They also form the emotional component of an immature response to the threat of some kind of loss. I mean no criticism in using the word immature here. It is simply that the natural process of psychological healing has not yet fully begun to ripen. When it does—with increasing acceptance of the new situation—sorrow is more likely, and this is the more common prelude to renewed happiness, calm, and contentment than those other painful feelings.

This is the essence of grieving, the purpose of which is not to hold on but to let go. The good news is that the process of emotional transition is the route not only to a new equilibrium but also to a more durable equanimity—that is, to permanent personal growth.

Many doctors know all this, but I think that it is something that bears almost endless repetition until the penny drops for everyone. In other words, it is a lesson for doctors not only to learn but to teach.

Editor—As both the results and the design of the survey attached to Smith's editorial clearly show, doctors are unhappy because they have come to believe that their unhappiness is caused by external and uncontrollable forces.15-1 In accepting this view doctors have lost the joy that comes 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 cardiopulmonary resuscitation to surgical residents. “Do we have to ask the patient's permission in order not to perform cardiopulmonary resuscitation?” they asked, seeming distressed at the possibility 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 areas of doctors' helplessness 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.

Editor—My intermittent unhappiness16-1 is grounded in my inability to come to terms with the fact that I make mistakes, a condition unfortunately shared by my patients, my administrators, and my family.

Editor—By 23 May 2001 we had received 65 rapid responses commenting on the BMJ 's survey on why doctors are unhappy, as well as 24 rapid responses and three letters commenting on the editor's editorial.17-1 17-2 The results of the survey have already been published and are available on bmj.com,17-3 17-4 but the debate has really only just begun. We have tried here to reflect the breadth of the debate so far, but why not read it in full on bmj.com and contribute to it yourself?