At the start of this study, our aim was to elucidate the participants’ perceptions of their workload, and the potential explanations and consequences related to variations in workload. However, we noticed that the participants led the discussion into how their perceived workload had increased over the years. They further reflected on the mechanisms for this development. As this was a prominent feature throughout all of the interviews, we chose to let the participants elaborate on this, and integrated it in the further analyses of the material. We categorised the results into three main themes: (1) Heavy and increasing workload – more trend than fluctuation?; (2) Explanations for high workload; (3) Consequences of high workload.
Heavy and increasing workload – more trend than fluctuation?
Assuming fluctuations in workload, we asked the participants to identify what characterised periods of heavy workload. The participants all described variations in workload, both over weekdays and seasons. Both groups listed epidemics like influenza, with a higher inflow of patients, as resulting in increased workload. Particularly busy periods often occurred for GPs when they or their colleagues had a leave of absence or were preparing for or returning from one.
“It’s almost like you can’t be away for more than two days, because when you return, the pile of things to do almost feels impossible to handle.” I, female 1, GP
The co-workers, on the other hand, experienced higher workload when all the doctors at the office were present and thus there was a high turnover of patients. Furthermore, unplanned absence among the doctors was listed as a source of stress and increased workload for the co-workers, because they could not offer any appointments to the patients. The GPs reported now having longer working hours than before, and this despite many of them having reduced the number of patients on their lists. The participants were all experiencing heavy workload at the time of their interviews. GPs from both the focus groups and the individual interviews reported their current situation to be unsustainable.
“I think things can’t go on like this. I have reached a threshold of what I can fulfil; I think something drastic has to change. […] You get so tired, because you’re half an hour late all the time. It’s like a ‘rat race’ really.” I, female 9, GP
However, GPs from two of the focus groups experienced their current workload as sustainable, despite increasing. They reflected upon this sustainability as being associated with the way they were organised. One of these practices was managed by the municipality, and the other had recently been reorganised, leaving the managerial position to a medical secretary. The GPs suggested that this allowed them more time for patient contact, as they were relieved from handling some of the administrative tasks such as financial matters, and sick leave among their co-workers.
Explanations for high workload
The participants reflected upon many possible explanations for the high and increasing workload. Notably, the contributory factors suggested as being most important varied among GPs within the same focus groups and when interviewed individually. The GPs often pointed to “local challenges”, such as having many patients with complex issues, collaborating with the local hospital, and handling administrative and management duties. However, they hardly ever referred to how colleagues with similar challenges had handled these. The co-workers supported the GPs’ explanations, but they also shared more general views on how they perceived societal developments as affecting their working conditions. Below, we give an overview of the mechanisms suggested as creating higher workload, divided into three prominent themes.
Transfer of tasks
The participants experienced increasing transfer of medical tasks from secondary to primary care. Follow-ups for patients with cancer and chronic conditions were generally perceived as meaningful, but also challenging and time-consuming. Many participants expressed vexation towards the transferral of more administrative tasks such as writing sick-leave certificates or transport requisitions related to their patients’ hospital visits. The GPs experienced an increasing demand for new diagnostic investigations and tests, both prior to referral and after treatment in secondary care. They gave examples of discharge reports from secondary care instructing the GP to refer the patient to another specialist or radiological examination, thus causing extra workload. This was often perceived as a consequence of a more fragmented and subspecialised secondary care, focusing on shortening hospital stays, and it contributed to a feeling of impaired autonomy. Some GPs stated that they sometimes felt like they were working in “both primary and tertiary care”, being expected to help patients with problems that could not be solved in secondary care.
“For instance, if we send a patient because of a stomach-ache, they do a gastroscopy, and if they don’t find anything, they send him back, instead of taking care of the problem, like ‘can it be something else?’, and try to find out themselves, like they used to do before. Now they always bounce the ball back in our corner, and we have to do everything ourselves anyway!” I, female 10, GP
Nevertheless, the GPs acknowledged that secondary-care professionals also have a high workload and do not necessarily intend to be condescending. Communication between primary and secondary care was commonly identified as challenging and time-consuming. This was a well-known problem, but was now perceived to have a higher impact on the workload, as the time pressure was higher. Difficulties in reaching and conferring with secondary-care professionals were thought to result in potentially unnecessary referrals.
“So I think many referrals could have been avoided, if they had time, and you didn’t have to spend time in line on the phone.” G8, female 23, GP
Increased work per patient
The participants experienced an increasing amount of work per patient in recent years. Changes in legislation, developments in medicine, increasing investigation and treatment possibilities, a need for communication and cooperation with other parts of the healthcare system, and higher demand for documentation were all perceived as contributing factors.
“Something that has changed in very few years is that there is a lot more work to each patient. (…) Now there is a lot more we can do, (…), and then we had the Coordination Reform, with clearer commands in the discharge reports.” G8, female 21, GP
While some of the new tasks were regarded as important for patient care, others were perceived as meaningless and bureaucratic. An example frequently mentioned by GPs was writing health certificates.
“I don’t need a medical degree to document that someone had a cough three days ago (...) nor to write a health certificate for parking needs for someone who has no legs (…) as doctors we have to do something reasonable.” G2, male 5, GP
The sum of these statutory tasks and demands was seen as a threat to the GPs’ autonomy. The co-workers also reported that they were “writing and writing and writing” to document the work of their practice, although they did not believe this would improve patient health. There seemed to be a general consensus that administrative tasks and “paperwork” had increased considerably over the last decade:
“The workload comes mostly from the paperwork. I sit with paperwork until seven or eight o’clock every evening. I’m done with patients about four o’clock, so it’s the paperwork that makes it impossible to pick up the kids, or cook dinner…” I, female 1, GP
Changes in society
The participants reflected upon societal changes as explanations for the increasing workload. In general, both the GPs and co-workers experienced increasing patient expectations for healthcare services, treatment options, and their general health and well-being. The co-workers suggested that a lack of family support and limited social networks often resulted in an increased number of doctor visits. They gave examples of minor issues that previously could be solved by “asking grandmother”.
“People see their GP much more often nowadays. (…) Now you see the doctor at once – if you’ve been feeling ill for a few days (…) If a child gets a rash, then the parents go straight to the doctor to check it out. They didn’t do that before. Now they demand an answer – ‘What is this?’” I, female 10, GP
Some of the younger GPs suggested that the feeling of time pressure throughout the day resulted in many GPs preferring not to work as many hours as they had previously, similar to others in the society. On the other hand, some of the more experienced co-workers thought the doctors worked even more now and had higher competence in meeting patients’ expectations.
“Today’s GPs are different to those of 20 years ago. Before, they were mostly elderly, and men. Now, there are many women, and many young people with kids and completely different priorities. They want to go home at a decent time, pick up the kids, make dinner and drive to football practice.” G2, male 2, GP
The GPs reported that they experienced administrative and economic duties in the GPs’ offices to have become more advanced and complicated in the latest years. They perceived it as more demanding to handle employer responsibilities, such as dealing with pensions and sick leave for their staff. In addition, the expenses for running their offices had increased in recent years due to, e.g., increased requirements for electronic equipment and salaries for employees. As one experienced GP said:
“It has changed totally. And the capitation fee covers less and less of our real expenses. (…) I used to do my own accounting, but now I can’t possibly do it, because so much has changed. It’s more like running a company. That’s not what I intended to do (laughs). So considering this, it was much easier to be publicly employed.” I, female 10, GP
This caused economic worries for the GPs, and prevented them from reducing their patient lists and, hence, their workload, because parts of their financing are based on the size of their patient lists.
Consequences of high workload
Both the GPs and co-workers expressed that they now perceived busy days as the “new normal”. As a response to this, the GPs said they were forced to adjust their way of working by prioritising harder. They prioritised patient consultations, postponed documentation and administrative work to evenings and weekends, and were left with little time for personal rest and recuperation. System-level work, such as participating in meetings, forums and other arrangements at the municipal level, and preventive care were given less priority due to lack of time. Further, the GPs expressed worries about their professional development being negatively impacted through, for instance, postponing or skipping educational courses.
Consequences for patients and the healthcare system
Both GPs and co-workers described how high workload had general consequences for patients, such as longer waiting times for appointments, reduced continuity of care due to use of locums, and possibly reduced patient satisfaction. They also shared their thoughts regarding how high workload could lead to suboptimal handling of some patient groups, such as patients with chronic illnesses or complex problems, the elderly, patients with mental health problems and patients with a minority background.
“It does affect the patients, definitely – regarding waiting times, availability, phone calls and, to some extent, the treatment and the care they receive.” G2, male 3, GP
We found three different perspectives among the GPs regarding whether and how heavy workload influenced their own clinical decision-making, such as diagnostics, referrals, prescriptions and sick leave. All three perspectives were generally represented by different individuals within the focus groups. There did not seem to be any consistency regarding how these perspectives were related to GPs’ characteristics such as age, experience, gender, or geographical location.
The first perspective was that heavy workload definitely influenced clinical decisions. The GPs gave examples of a lower threshold for prescribing antibiotics to children, and for referring patients with conditions that could have been treated in general practice, such as excessive ear wax and potential deep vein thrombosis. As a female GP said:
“We try not to do it. We are all quite experienced here, but it’s hard to resist when there is so much to do.” G7, female 14, GP
The GPs reflected upon how this could have paradoxical effects, and in turn cause more work for the healthcare system and themselves. They were conscious of their gatekeeper function, and described increased referrals as an unfortunate trend they wished to avoid.
“The more time you have, and the better you’re feeling, both in private and at work, the more guts you have to keep calm and unaffected, which is the art of general practice. And then it’s the gatekeeper function – we have to make sure we don’t refer too many patients – both for the sake of the patients and for the community.” G8, female 21, GP
The second perspective we found was that heavy workload partially influenced clinical decisions. These GPs were worried that time pressure affected how they interacted with the patients and increased their tendency to take resource-demanding shortcuts in medical investigations. They proposed that stress throughout the work day could increase the risk of making mistakes, or prioritising incorrectly. However, they did not believe that decisions such as referring patients were affected.
“It’s about being present in the consultation. When in a hurry, you keep more distanced. Maybe you try to find some shortcuts to get things done in a shorter time.” G10, female 31, GP
The third perspective among the GPs was that heavy workload did not influence clinical decision-making at all, and that the patients were not affected directly.
“We have to state that the patient is our first priority, and that’s why our days look like they do.” G2, male 4, GP
All GPs expressed their belief that the trend of heavy and increasing workload had negative impacts on the healthcare system, especially through recruitment problems in general practice.
“I think it is a symptom that we can’t recruit enough GPs, and then there will be a huge problem in some years.” G2, male 5, GP
Personal consequences for GPs
GPs with children expressed problems regarding combining their job with family life. Many experienced difficulties in getting to kindergarten or school before closing time, finding time to eat dinner with their family, and taking part in their children’s recreational activities. These GPs underlined the importance of having a partner with flexible working hours, so that they could stay at the office for as long as required. GPs without family responsibilities said they felt this was an advantage when the workload was high, and that they could relieve their colleagues when needed.
The GPs described that the workload had consequences for their own health and well-being. At work, they often skipped coffee breaks, shortened their lunch break, and postponed toilet visits. At home, some said that they felt exhausted, easily irritated and stressed, and did not find time to exercise. Two of the younger female GPs worried about being burned out, and not being able to continue working as a GP in the future.
“Maybe I can stay another year or so, because I love my job. […] I just need some space to breathe in my working day; otherwise I think I will burn out.” I, female 9, GP
Similarly, the co-workers also felt stressed at work when the workload was high. However, in contrast to the GPs, they also highlighted how they did not have to bring this stress home with them, and they spoke positively of their regulated work hours. The GPs described their decreased motivation for continuing with their job, and a young male doctor said that, based on his experiences of the last year, he no longer wanted to be a GP. Several GPs had considered quitting or were looking for other jobs. Nevertheless, all of our participating GPs expressed a genuine love for their work, felt that their job was meaningful, and wished that conditions would improve so that they could continue.
“Yes, it’s a wonderful job where you meet all these incredibly nice people that you wouldn’t have met otherwise. It is varied, gives lots of challenges, both in medical and organisational terms. (…) In many ways, it is the best job in the world – you even have an illusion of autonomy (laughs).” G10, male 33, GP