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GP Wellbeing
Combatting Burnout in
General Practice
GP Wellbeing
Combatting Burnout in
General Practice

Adam Staten
Euan Lawson
CRC Press
Taylor & Francis Group
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Boca Raton, FL 33487-2742

© 2018 by Taylor & Francis Group, LLC

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Library of Congress Cataloging‑in‑Publication Data

Names: Staten, Adam, author. | Lawson, Euan, author.

Title: GP wellbeing : combatting burnout in general practice / Adam Staten,
Euan Lawson.
Description: Boca Raton : CRC Press, [2018] | Includes bibliographical
references and index.
Identifiers: LCCN 2017034018 (print) | LCCN 2017034987 (ebook) | ISBN
9781315159218 (Master eBook) | ISBN 9781138066342 (hardback : alk. paper)
| ISBN 9781138066274 (paperback : alk. paper)
Subjects: | MESH: General Practitioners | Burnout, Professional--prevention &
control | Adaptation, Psychological | Job Satisfaction | General Practice
| United Kingdom
Classification: LCC R118 (ebook) | LCC R118 (print) | NLM WB 110 | DDC
610--dc23
LC record available at https://lccn.loc.gov/2017034018

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Contents

Preface ix
Dr. Adam Staten and Dr. Euan Lawson
Introduction xi
Dr. Clare Gerada

1 What is burnout? 1
Dr. Adam Staten
Key features of burnout 1
Impact on the individual 3
Effect on the GP workforce 4
Effect on the wider NHS 7
Conclusion 8
References 9
2 External pressures 11
Dr. Adam Staten
The Quality Outcomes Framework 12
The Care Quality Commission 12
Political mandate and continual structural reform 13
A negative media portrayal 14
A more litigious society 14
Conclusion 15
References 16
3 Pressures of the job 19
Dr. Adam Staten
Increasing workload 19
A population increasing in age and morbidity 20
Squeezed budgets 22
Time pressures 22
Increasing dependence of patients on doctors 23
Rising patient expectations 24
Poor coordination between primary and secondary care 24

v
vi Contents

Conclusion 25
References 26
4 Changing the system 29
Dr. Adam Staten
Corporate power of GPs 30
Value of the CCGs 31
GP federations 33
Harnessing social media 34
Conclusion 36
References 36
5 Changing the way we work 39
Dr. Adam Staten
Embracing technology 39
Interacting with the practice computer system 39
Communicating via new technologies 41
Telehealth 42
Increasing the skill mix in primary care 43
Physiotherapists 43
Pharmacist and medicines management 43
Physician associates 44
Mental health workers 45
Innovative models of seeing patients 45
Telephone triage 46
The Roundhouse Model 46
Shared medical appointments 47
The virtual ward and coordination of care 48
Conclusion 48
References 49
6 Finding the right career 53
Introduction 53
GP partner 54
Dr. Adam Staten and Dr. Peter Aird
What makes being a partner different? 54
Other aspects of the job 54
How to become a partner 54
The remote and rural GP 58
Dr. Kate Dawson
What makes rural general practice different? 58
Other aspects of the job 59
Career options in rural general practice 59
Community hospitals 60
The rural fellowship 61
Conclusions 62
 Contents vii

The overseas GP 64
Dr. Tim Senior
What makes overseas general practice different? 64
Other aspects of the job 65
Career options in overseas general practice 65
How to become an overseas GP 66
Conclusions 68
The military GP 69
Dr. Adam Staten
What makes military general practice different? 69
Other aspects of the job 70
Career options in the military 70
How to become a military GP 71
Conclusions 73
The entrepreneurial GP 74
Dr. Knut Schroeder
What makes entrepreneurial general practice different? 74
Other aspects of the job 75
Career options in entrepreneurial general practice 75
How to become an entrepreneurial GP 76
Conclusions 78
Useful further reading, links and resources 78
The humanitarian GP 79
Dr. Rebecca Farrington
What makes humanitarian general practice different? 79
Other aspects of the job 80
Career options in humanitarian general practice 81
How to become a humanitarian GP 82
Conclusions 84
The academic GP 85
Professor Alistair Hay
What makes academic general practice different? 85
Other aspects of the job 86
Career options in academic general practice 87
How to become an academic GP 87
Conclusions 89
The educational GP 91
Dr. Euan Lawson
What makes medical education different? 91
Other aspects of the job 92
Career options in medical education 92
How to get involved in medical education 92
Undergraduates opportunities 92
Postgraduate opportunities 93
viii Contents

Learners in practice 93
Working as an appraiser 93
How to become an educational GP 94
Conclusions 95
Resource 96
References 96
7 Resilience 97
Dr. Euan Lawson
Neurobiology of resilience 98
Acute stress response 98
Physician personality and resilience 98
Other features associated with resilience 100
‘Realistic’ optimism 100
Facing fear: An adaptive response 100
Ethics and altruism: Having a moral compass 100
Religion and spirituality 101
Social support 101
Having good role models 102
Being physically fit 102
Brain fitness: Making sure your brain is challenged 102
Having cognitive and emotional flexibility 103
Having ‘meaning, purpose and growth’ in life 103
The paradox 103
GP wellbeing: Lessons learned from a trainee-led initiative 105
Dr. Duncan Shrewsbury
References 106
8 Interventions for burnout 109
Dr. Adam Staten
Personal coping strategies 109
Organisational interventions 110
Reactive interventions for the individual 111
Proactive interventions for the individual 112
Mindfulness 114
Conclusions 115
References 115
9 Final thoughts 117
Dr. Adam Staten and Dr. Euan Lawson
The paradox of modern medical practice 117
Burnout and stigma 117
The science of happiness 118
Coming changes 119
Reference 119

Index 121
Preface

INTRODUCTION
The phenomenon of doctors becoming overwhelmed by the stresses of their job is
not new, but in recent years burnout has become an enormous issue in UK g­ eneral
practice. The many accumulated stresses of life as a general practitioner (GP) are
taking their toll and are causing nothing short of a workforce crisis.
A survey of more than 2000 National Health Service (NHS) GPs conducted by the
journal Pulse in 2015 found that 50% of them thought that they were at high risk of
burnout. This figure had risen from 46% just 2 years previously. A Commonwealth
Fund survey conducted in the same year found that 29% of UK GPs wanted to leave
the profession within 5 years, and yet more were unsure whether their long-term
future lay in general practice. At a time when the NHS needs more GPs than ever, it
is instead haemorrhaging doctors at an ever-­increasing rate.
The workload of general practice seems to be increasing inexorably, report-
edly increasing by 16% in the past 7 years. In 2013, GPs provided more than
340 ­million patient consultations, a rise of 40 million from 2008, and this
accounted for 90% of patient contacts within the NHS. The Conservative govern-
ment elected in 2015 made a commitment to provide 5000 more GPs by 2020 to
help relieve the pressure, but with falling recruitment, early retirement and many
doctors simply walking away from clinical practice in the middle of their careers,
this looks like an unachievable aim.
Worryingly, half of GP leavers are younger than 50 years old and 77% of those
planning on switching career are younger than 55 years old. It seems that GPs are
burning out quickly and burning out young.

CAN IT REALLY BE THAT BAD?

General practice remains the last bastion of medical generalism in a world of
increasing specialisation. Unlike our secondary care colleagues who work in ever-
narrowing fields, general practice is a cornucopia of physical and mental pathology,
and one of the few places in medicine where doctors come at symptomatology and
disease fresh while it is untainted by the investigations and treatments of others.
It is only in general practice that care can be truly holistic and where we have the

ix
x Preface

privilege of caring continuously for our patients over decades. It is a place where we
can make a real difference to our patients’ lives, not just to their illnesses.
More than this, there is enormous and exciting variety within general prac-
tice. No two GPs need work in the same way because GPs are in universal demand
in environments as diverse as isolated Scottish Islands, to inner city addiction
­clinics, from battlefields where they administer care to battlefield trauma, to
research institutions where they conduct cutting-edge research. With extended
roles, special interests, opportunities to be entrepreneurial or political, a career
in general practice can be what you want it to be. Broadly trained and adaptable,
GPs are also well placed to respond to the ever changing world of the NHS.
But something seems to be stopping GPs thriving in this world of possibilities.
Why can 29% of our colleagues not imagine themselves continuing to work in
general practice for another 5 years? How is it that 25% of GPs feel that the stress
of their job has made them unwell within the past 12 months?
This book is an attempt to understand why we are in this situation, what
­factors have brought us here and how we can change the system, our careers and,
perhaps, ourselves to cope with the stresses of our jobs.
This book explores the problems of NHS general practice, some of which are sys-
temic and some of which are individual. We discuss the administrative and political
burdens of general practice and the issues caused by the rising demands placed on
GPs by an enlarging, ageing and increasingly poly-morbid population. We explore
the possible solutions to these problems, some of which require the system to change,
and some that are based on changes that individuals can make for themselves.
In response to the pressures that they face, GPs around the country are
already working innovatively and collaboratively to overcome them, and this
book d ­ iscusses new proposals to change the way we consult, the way we structure
our primary health care teams, the way in which we use technology and the way
we interact with our secondary care colleagues.
Working GPs explain how diversifying their careers and finding niches for
themselves working within academia, or with refugees, or in remote locations,
has helped to keep their careers satisfying and fulfilling. And the nature of
burnout, the nature of resilience and what can be done to prevent burnout and
encourage resilience are discussed.
What we hope is demonstrated by the end of the final chapter is that in this
crisis there is a great deal of opportunity. There is the opportunity to improve our
working lives and to improve the way we deliver care to our patients.
Working independently and on a relatively small scale, the UK GP is uniquely
placed within the NHS to act dynamically and change things rapidly to suit both
doctors and patients. An increasing level of GP burnout is not inevitable, but it is
probable unless we seek out its root causes and act now to counter them.

Adam Staten
The Red House Surgery, Bletchley

Euan Lawson
Lancaster University
Introduction

The term ‘burnout’ was created in 1974 by the psychologist Herbert Freudenberger
who described job dissatisfaction precipitated by work-related stress.1 The most
common measure of burnout is the Maslach Burnout Inventory (MBI) used
for the past 25 years.2 This defines and measures burnout in three domains:
­emotional exhaustion (feelings of being emotionally overextended and exhausted
by one’s work), depersonalisation (an unfeeling and impersonal response to those
who receive the individual’s services, treatment or instruction) and personal
accomplishment (feelings of incompetence in one’s work). The World Health
Organization’s International Classification defines burnout as a ‘state of vital
exhaustion’.3
However, one defines burnout, it is recognised as a state of emotional, mental
and physical exhaustion caused by long-term involvement in emotionally demand-
ing situations and where the individual cannot, for whatever reason, meet the
constant demands placed upon them.4 Burnout is therefore best thought of as
a spectrum of symptoms ranging from tearfulness, depersonalisation, feelings
of hopelessness, depression and anxiety (in some cases indistinguishable from
depression). It might in fact be a more acceptable, less stigmatizing label for
health professionals to accept than depression.
Burnout is ubiquitous. In all health systems, age or length of practice,
approximately 50% of doctors meet the criteria for burnout at any one time.
In some ­populations, for example, younger doctors’ rates can reach as high as
70%. Surveys over the past 20 years have consistently shown that, on average,
around one-third of doctors are suffering from burnout at any one time, world-
wide, regardless of specialty. In a 2012 survey by the Physician’s Foundation,
60% of US physicians reported they would retire immediately if they could.
The 2014 Medscape Physician’s Lifestyle Survey showed a 46% prevalence of
at least one symptom of burnout in a responder group of 20,000 American
physicians. 5
Given the nature of medicine, its emotional demands and the need to put
patients first, it could be said that burnout is an occupational hazard of being
a doctor. However, burnout seems to be getting worse. For example, the 7th
National General Practitioner (GP) Work Life Survey found the lowest levels of

xi
xii Introduction

job satisfaction and the highest levels of stress since the beginning of the National
GP Worklife Survey. It also found the highest level of GPs expecting to quit –
­especially in those over 50 years old (54.1%).6

PRACTITIONER HEALTH
For about a decade I have been the medical director of the Practitioner Health
Programme (www.php.nhs.uk), a confidential service for doctors in London
with mental health and addiction problems. Since January 2017, the service
has been extended to all GPs in England (called GP Health Service, www.
gphealth.nhs.uk). Over the decade, the service has seen more than 3000 doc-
tors presenting (this around 10% of all doctors in London). Most have common
mental health problems – depression, anxiety and symptoms indistinguish-
able from post-traumatic stress disorder. All specialties have presented. GPs,
paediatricians and emergency care doctors are over-represented. Surgeons
are under-represented – more likely a hidden minority group within a hid-
den minority. Around one-third of the doctors have problems with addiction,
mostly alcohol.
Over the years, the age of the doctors presenting to the service has dropped
from a median age of 50 years (2009) to a median age of 29 years (2011). Of
course, not all mental health problems in doctors are related to their work; for
example, doctors are exposed to the same external life events as non-doctors
and are not immune to marital breakup, illness, loss and other common life
events. However, work plays an important part in a doctor’s life and for many
defines who they are. Given this, it is hardly surprising that doctors who attend
specialist sick-doctor services do so late in their illness, often in a crisis or after
a problem at work or drink-drive offence. They literally work to the bitter end.
Even when the signs of mental illness are obvious, doctors find it difficult to leave
work behind them and even harder to seek the help they so readily prescribe for
their patients. Doctors also have barriers in seeking help. These include practi-
cal difficulties, for example, taking time out to make an appointment, or where
they might live and work in the same area and have to see someone they know
professionally or personally. There are financial implications for self-employed
doctors taking time off sick, as even if insured most policies do not commence
until at least 1-month sickness absence and are unlikely to cover the full costs
of locum cover.
Stigma in accepting a mental health diagnosis is particularly common
amongst doctors, and high levels of self-stigmatisation represent a major obstacle
to accessing healthcare and, once unwell, returning to work. The ‘stiff upper lip’
is alive and well in the profession. When doctors do approach services, staff and
patients can treat them differently, adding to the isolation already felt by a men-
tally ill doctor. GPs might deny their vulnerability and not want to be seen as the
weak link in their teams – especially where they might be leading teams. Fears
that they might be referred to the General Medical Council if they admit to hav-
ing more serious mental health issues such as bipolar disorder or alcohol or drug
dependence also act as obvious barriers to seeking help.
 Introduction xiii

WORK AND MEANING AS A RISK

FACTOR FOR BURNOUT
Both mental illness and burnout are more common in those working in the
caring professions, especially where high degrees of altruism, self-sacrifice and
making others (namely patients) the main concern are required. Doctors are at
risk because their job defines them and gives a sense of meaning to life. Even
before arriving at medical school the embryonic doctor is embedded into a pro-
fession which (implicitly or explicitly) sees itself as ‘special’. From medical school
onward, students learn, play, work, live and even love together, creating a deep-
rooted ‘medical self’ or ‘vocation’, which incorporates the personal and the pro-
fessional selves into a single persona. The person becomes the doctor, the doctor
becomes the person. Inseparable. Goffman-esque as a total profession, doctors
spend most waking hours in the bounded space of their medical space, which
defines and contains them through their work; unable to leave behind at the end
of the day, as one doctor said, the hospital almost replaces your family.….being a
medic is not just a job that you go to, but something you are.
During training, doctors learn a unique scientific language and symbolically
the medical-self, contained within the medical world, is re-enforced through dress
(the white coat, albeit worn less and less), and especially through the acquisition
of a new name: ‘doctor’, institutionalising their sense of being special.7 Every suc-
cess and failure is personalised; as long as the involvement, commitment and hard
work are rewarded by continuous success (no matter how small), doctors gain a
sense of meaning from their work, and this becomes a virtuous circle.

CAUSES OF BURNOUT
Burnout occurs when it is impossible to achieve anymore; when inadequate
resources or lack of autonomy makes it impossible to accomplish work goals and
frustration erodes the spirit. Given the nature of medicine, doctors are always
going to fail (as they cannot cure all illness, alleviate all pain or stop death) and
hence burnout is inevitable.

Summary of causes of burnout

Work related Having little or no control over work
Lack of recognition or reward for good work
Unclear or overly demanding job expectations
Doing work that is monotonous or unchallenging
Working in a chaotic or high-pressure environment
Lifestyle Poor sleep
Working too much, without enough time for socialising
or relaxing
Lack of close, supportive relationships
Taking on too many responsibilities, without enough
help from others
Continued
xiv Introduction

Summary of causes of burnout

Personality traits Perfectionistic tendencies; nothing is ever good enough
Pessimism
Need to be in control; reluctance to delegate to others
High-achieving, competitive personality
Socio-political Societies’ unrealistic expectations of what doctors can
do with medicine, leading to doctors being the
container for fear, anxiety and disappointment
Funding pressures, unable to achieve the care promised
by governmental bodies

Burnout is not entirely due to pressures of the job or training. Doctors are
more at risk because they are chosen for those personality factors which foster the
antecedents of burnout, and these factors also attract them to a career in medi-
cine, for example, altruism, perfectionism and obsessiveness. A compulsive triad
of doubt, guilt and exaggerated sense of responsibility, again common amongst
doctors, adds to this vulnerability.8 Over the course of training and later work,
doctors develop defences to counter these characteristics.
In the 1950s the sociologist Menzies-Lyth described how it is necessary to
develop defences, such as depersonalisation and denial of feelings to work in prox-
imity to death, despair and disease.9 Her observations of student nurses showed
that the anxiety caused by close and intimate involvement with patients’ illnesses
and deaths could be avoided through the development of social defences – social
as they were created by the organisation, vicariously protecting the individuals
within the system. Defences such as discouraging attachment and engagement
with a patient by constantly moving nurses from ward to ward or breaking down
patient care into smaller and smaller ‘production line’ tasks undertaken by dif-
ferent individuals and finally defences such as encouraging depersonalisation by
referring to the patient in abstract ways such as ‘the liver in bed 10’.
Of course, health professionals must be able to detach themselves from their
patients, not to over-identify with them and to be able to drop their mask of
empathy at times. But the defences which protect from becoming over engaged
with patients also, and especially where there is no time to reflect on our failures
or meet with peers, can turn against the carer.

EFFECTS OF BURNOUT
For some doctors this results in disengagement and increasing aggression against
‘the other’, be this the patient, the employer or the NHS. They present with prob-
lems at work, a complaint from a patient or member of staff. Or doctors become
increasingly detached from their teams and become psychological isolates, unable
to give to anyone other than their patients. These doctors ignore the needs of their
families and friends or even ignore important professional or personal dead-
lines. These doctors may fail to pay bills or meet the requirements for appraisal
or revalidation, or they may experience boundary violations with patients.
 Introduction xv

For other doctors, they deal with their anxiety by working harder, staying longer
and longer at work and taking on an excessive sense of responsibility for things
beyond their control; ‘it must be my fault’ combined with the chronic feelings of
‘not doing enough’. These doctors present with anxiety or depression and guilt
for not caring enough and shame for not being able to meet the needs of their
patients. Unaddressed, and with added vulnerabilities, burnout for all doctors
can lead to substance misuse, depression, anxiety and suicide.

BURNOUT IN CONTEXT
Burnout is not new. A classic book in the history of general practice is John
Berger’s A Fortunate Man: The Story of a Country Doctor.10 This book describes
the real-life story of the heroic and caring GP, John Sassall. What is clear from
John Sassall is that he was far from a role model we should aspire to. Like many
of the doctors in modern practice, he gave his all to his patients, combined his
personal and professional selves and blurred the boundaries between his pro-
fessional and private lives. Far from being a celebration of a time lost, of an era
of general practice that we should aspire to, it should become compulsory read-
ing on how to prevent the balance tilting toward burnout. Sassall, too, was a
single-handed GP in the Forest of Dean. He had been a dual-handed practitio-
ner for many years, but when his long-term partner died, instead of acquiring
a new partner, he instead split the list and became single handed. Sassall was
a workaholic. He relished his work. It gave him meaning. The book describes
how he longed to be woken at night to do house calls. That he was incapable of
doing nothing, and just being. Sassall becomes deeply depressed, so much so
that his reactions were slowed and his concentration reduced – but so dedicated
or more likely lacking in insight, work he did. Sassall ended his own life.
The psychotherapist Carl Jung described the paradigm of the wounded healer
and the archetype of those who care for others, out of vocation or compulsion,
often masking the difficulties in caring for themselves. This characteristic is hinted
at in A Fortunate Man, when Berger wrote that Sassall cures others to cure him-
self… in essence denying his own vulnerability by creating dependence in his
patients and vicariously healing himself through them. Burnout, or as with
Sassal, depression, is therefore not new, and neither will it ever go away – it is an
inevitable consequence of working so close to patients. We are better served by
thinking of burnout as being at one end of a balance and mental wellbeing at the
other; we should aim over our professional life to shift the balance toward the lat-
ter through personal and organisational interventions. And between supporting
the individual and bringing about changes in the prevailing culture.

TOWARD A UNIFYING SOLUTION

There is a sense that the increase in burnout is due to the current generation of
doctors being less resilient than those of previous generations. However, it is
my view that all generations of doctors are remarkably resilient. Doctors, past
and present, are amongst the most resilient individuals in society – they can
xvi Introduction

go long hours without sleep, food and bathroom breaks (they even have resil-
ient bladders). Doctors survive and thrive and adapt in the face of adversity.
Resilience is about bending with pressure and bouncing back. But given the
right (or wrong) environmental factors, a storm, fire or undue pressure, every-
one will have their elastic limit and will break – some will develop burnout
and the more vulnerable will develop depression, anxiety, substance misuse or
other mental health problems. More regulation, less time to care, marketised
and industrialised health systems and increasing litigation all add to the envi-
ronmental or prevailing pressures.

DEALING WITH BURNOUT

Most doctor-directed interventions involve mindfulness, behavioural treatment,
mentoring, coaching or addressing personal coping strategies.11 On the whole,
direct time and attention to any doctor and this will help – and the evidence
shows this, irrespective of the modality the outcome is the same – improvement
with attention.12,13
Going forward, we must not fall into the trap of locating the disturbance just
in the individual or individual practice as this separates the individual from the
wider environmental stresses. Instead, we need a three-pronged approach.
The first approach is related to the individual: What can ‘I’ do: How can I
create a balance in my life between play and work? What can I do to reduce my
individual stressors or recharge my psychological batteries? Research shows that
simple interventions, such as taking holidays; having time with friends or family;
sport, music or simply just standing still, help reduce burnout. For each of us as
well, it is important to realise our limits and when things seem to be going wrong,
or when our mood dips or we feel that we are resorting to unhealthy coping strat-
egies, then think about seeking help.
The second approach is what can teams do: What can ‘we’ do? This is about
addressing our workplace and examining ways of reducing stressors where we can,
such as looking at rotas, adding in breaks between patients and looking at the spaces
where we can meet to learn or reflect together. Medicine is a relational activity – and
increasingly the spaces where doctors (and other health professionals) meet together
for formal and informal meetings are rapidly disappearing. Putting in spaces for
groups, either daily 15-min micro-meetings or weekly 60-min team meetings or
monthly 90-min reflective practice groups, has been shown to reduce the risk of
burnout. Organisational factors, including addressing work pressure, resources
(time, people and money) and spaces and opportunities for team working, are prob-
ably more important and evidence shows more likely to make a difference.
Finally, going forward it is important to address the macro-environmental and
external causes of distress: What can ‘they’ do? The ‘they’ being those who build
the regulatory, financial, organisational and investigation systems in which we
work. Addressing these massive structures involves policy makers, politicians
and senior leaders understanding that without structural change even the most
resilient individual will break. It means addressing factors, such as regulatory
requirements, political influences and media pressures.
 Introduction xvii

Balance work and play (between the machinery of caring and actual
­caring, declutter the space in the consulting room between us and
our patients)
Understand our limitations – we are not superheroes
Recognise, prevent and treat burnout in ourselves and our teams
Nurture the next generation – bring the fun back into work
Teamwork (working in groups, restore the times and spaces to work,
rest, play and reflect together)

Finally, burnout is common and a normal aspect of a doctor’s work. Going

forward, doctors have to learn to identify it and manage it throughout their
­professional lives.

Dr. Clare Gerada

Medical Director Practitioner Health: Principle General Practice
Former Chair of the Royal College of General Practitioners

REFERENCES
1. Freudenberger HJ. Staff burnout. J Soc Issues 1974;30(1):159–65.
2. Maslach C. Burnout: A multidimensional perspective. In Schaufeli WB,
Maslach C, Marek T, editors. Professional burnout: Recent developments
in theory and research. Washington, DC: Taylor & Francis; 1993.
3. World Health Organization. International Statistical Classification of
Diseases and Related Health Problems. 10th Rev. (ICD-10). Geneva:
World Health Organization; 2004.
4. Beck R, Buchele B. In the belly of the beast: Traumatic countertransfer-
ence. Int J Group Psychother 2005;55(1):31–44.
5. The Physicians Foundation a Survey of America’s Physicians. 2012.
http://www.physiciansfoundation.org/uploads/default/Physicians_
Foundation_2012_Biennial_Survey.pdf. Accessed on 19 July, 2017.
6. Hann M, McDonald J, Checkland K, Coleman A, Gravelle H, Sibbald B,
Sutton M. Seventh National GP Worklife Survey. http://www.­population-​
health.manchester.ac.uk/healtheconomics/research/reports/FinalReportof​
the7thNationalGPWorklifeSurvey.pdf. Accessed on 19 July, 2017.
7. Wessely A, Gerada C. When doctors need treatment: An ­anthropological
approach to why doctor make bad patients. http://careers.bmj.com/
careers/advice/view-article.html?id=20015402. Accessed on 19 July, 2017.
8. Gabbard O. The role of compulsiveness in the normal physician. JAMA
1985;254(20):2926–9. doi: 10.1001/jama.1985.03360200078031.
9. Menzies Lyth I. The functions of social systems as a defence against
anxiety: A report on a study of the nursing service of a general hospital.
Hum Relat 1959;13:95–121; reprinted in Containing Anxiety in Institutions:
Selected Essays, vol. 1. Free Association Books, 1988, pp. 43–88.
xviii Introduction

10. Berger J. A fortunate man: The story of a country doctor. London: RCGP;
2005.
11. West C, Durbye L, Erwin P, Shanafelt T. Interventions to prevent and
reduce physician burnout: A systematic review and meta-analysis.
Lancet 2016;388:2272–81.
12. Panagioti M, Panagopoulou E, Bower P, Lewith G, Kontopantelis E,
Chew-Graham C, Dawson S, van Marwijk H, Geraghty K, Esmail A.
Controlled interventions to reduce burnout in physicians. A systematic
review and meta-analysis. JAMA Intern Med 2017;177(2):195–205. doi:
10.1001/jamainternmed.2016.7674.
13. Nielsen H, Tulinius C. Preventing burnout among general practitioners:
Is there a possible route? Educ Primary Care 2009;20:353–9.
 1
What is burnout?

DR. ADAM STATEN

The Red House Surgery, Bletchley, UK

Burnout is more than feeling stressed. Burnout is a pervasive and debilitat-

ing state that results from an unsustainable period of overwhelming stress.
It is not a new phenomenon. The term was coined by the psychologist Herbert
Freudenberger in 1974 who recognised the condition in himself and colleagues
whilst working in drug addiction clinics in New York.1 Nor is burnout limited
to those working in health care.2 It is a familiar concept in many areas of life
from the financial services sector to professional sports.
Increasingly, burnout is recognised as a widespread issue in modern life, and
this pervasiveness is reflected by the deluge of new research that is being con-
ducted on burnout, not to mention the abundance of self-help literature that is
published every year to assist people in coping with stress and burnout, what-
ever the cause. Burnout seems to be especially common amongst those in caring
­professions such as health care, social work and teaching, with a prevalence of up
to 25% in these professions suggested by some research.3
In particular, burnout amongst general practitioners (GPs) working within
the National Health Service (NHS) seems to be on the rise, and this is causing
problems not just for the individuals concerned, but for a health care system that
is reliant on having a healthy, happy and functional primary care workforce.
Thus, it is essential that we as individuals, and the system as a whole, understand
what burnout is, what impact it has and how it can be stopped.

KEY FEATURES OF BURNOUT

Burnout is classically defined as an experience of physical, emotional and mental
exhaustion caused by long-term involvement with situations that are emotion-
ally demanding.3 It comprises three major components: emotional exhaustion,
depersonalisation and an absent sense of personal accomplishment.4 These three
major components were incorporated into a scoring system, the Maslach Burnout

1
2 What is burnout?

Inventory, which has been used to evaluate and study burnout in a variety of
­settings, and in a variety of guises, since its creation in 1981.5
Maslach and colleagues defined each of these three components. Emotional
exhaustion is described as the feeling of being emotionally overextended and
exhausted by one’s work. Exhaustion is seen by many as the key component of
the burnout syndrome, and some researchers have developed alternative scor-
ing systems to reflect this.6,7 Exhaustion has a pervasive effect on the ability of
a doctor to carry out his or her work safely and effectively. In addition, a sense
of exhaustion carries over into the personal life of a burnout sufferer, affecting
relationships and the ability to have a happy and fulfilling life outside of work.
The second major component, depersonalisation, is described as an unfeeling,
un-empathetic and impersonal response to the interaction with patients. In effect
the burnout sufferer dehumanises the person with whom they are interacting,
and this leads to cold, callous behaviour and cynicism. The result is unsatisfy-
ing patient–doctor interactions, both for the doctor and the patient, which con-
tribute to a diminished sense of personal accomplishment for the doctor, carry
the potential for further stress in the form of complaints against the doctor, and
result in poor health care provision for the patient.
Personal accomplishment relates to a sense of competence or achievement
in one’s work which results in job satisfaction or, if absent, dissatisfaction.
This absence is the third major component of burnout. A poor sense of personal
accomplishment has been found to be the leading feature of burnout amongst
some groups of medical professionals such as physicians working in pain man-
agement in the United States.8
The Maslach Burnout Inventory uses a questionnaire from which a score can
be given to each of these three features to identify those who are suffering from
burnout and those who are at risk of burnout. This sterile, statistical way of con-
sidering a human problem is particularly useful for research, but the real-life
interaction between these three components varies considerably, resulting in
­different degrees of distress and debilitation for sufferers.
Whilst the scope of this book is to consider the causes of burnout amongst
medical professionals and specifically amongst the general practice population
of the NHS, there are a number of general factors that contribute to occupational
burnout in all workplaces.
In general, people are at high risk of occupational burnout when they do
not feel in control of their work. It is not necessarily workload or the need
to make decisions that causes stress, rather it is the lack of authority to make
those decisions, otherwise known as a lack of decision latitude, which results
in an inability to deal effectively with the workload, leading to unsustainable
workplace stress and burnout.9 Related to this lack of control is dysfunctional
workplace dynamics, which may include workplace bullying and an unclear or
ill-defined job role.
Burnout can be the product of work that is monotonous or work that is cha-
otic, or work that combines elements of these two apparently conflicting fea-
tures.4 Work within health care is often capable of combing these two elements,
with mundane routine work frequently interspersed with complex, important
 Impact on the individual 3

and emotionally demanding tasks; perhaps this is why those working within
health care find themselves at such high risk of burnout.
Low income can be a factor in the burnout, as demonstrated in a study of
burnout among paediatric nurses.10 A poor work–life balance is another contrib-
uting factor to burnout, a common imbalance that is not limited to health care
professionals.²
Certain personality traits, such as perfectionism, competitiveness and the
need to feel in control, along with habitual high achievement, put people at
higher risk of burnout. These traits are common amongst medical professionals,
and in fact are often selected for in those applying to medical school.
These general factors, and a host of other factors that are specific to the role
of an NHS GP, can combine to create burnout which may manifest itself in a
multitude of ways.

IMPACT ON THE INDIVIDUAL

As with other mental health problems, burnout can cause a wide range of
­psychological and physical effects. Many of these problems are also features of
anxiety and depression, conditions with which burnout has an enormous degree
of overlap.
Burnout has often been described as occurring in three stages, each of which
may have both psychological and physical symptoms.11 The first of these stages
is known as stress arousal. This first stage is typified by difficulty concentrating,
memory lapses, irritability and anxiety. Physical symptoms, like those associated
with anxiety disorders, include teeth grinding, palpitations, headaches, poor
sleep and loss of libido.
The second stage is the period of energy conservation during which time some-
one beginning to suffer with burnout will attempt to compensate for the stress
they are experiencing. It is at this point that an individual’s usual mechanisms
for coping with stress may become overwhelmed, and so they begin to compen-
sate in maladaptive ways. This results in avoidance behaviours including lateness,
procrastination, social withdrawal and increased time off work. Avoidance behav-
iours can also manifest as difficulties in making decisions and problem solving
which bring with them a predictable deterioration in occupational functioning.
It is during this period that exhaustion can set in and psychological problems
increase which may lead to self-medication and substance misuse.
The final stage is exhaustion. At this point, chronic mental health problems
with anxiety and depression, including suicidality, may develop. Those experi-
encing this degree of burnout may increasingly rely on substance misuse as a
coping strategy, so addiction may be a concomitant problem. Feelings of apa-
thy are common and decision-making is poor, leading to poor patient care and,
possibly, unethical behaviour.12 Somatic symptoms which may also be present
include non-cardiac chest pain, dizziness and chronic headaches.
It is important to recognise the features that may be present in each stage of
this progression, both in ourselves and in our colleagues, but it is also impor-
tant to recognise that there need not be an inexorable decline through the stages.
4 What is burnout?

Occupational stress

Intervention

Effective coping Ineffective coping

Overwhelming stress

Ongoing
Poor functioning
occupational
and burnout
functioning

Figure 1.1 Cycle of stress and burnout.

Progression of stress and burnout can be halted and reversed if the problem is
recognised and tackled (Figure 1.1).
Unfortunately, if the problem is not recognised and is left untended, there can
be long-term physical and mental health consequences. Beyond chronic depres-
sive and anxiety states, occupational stress has been linked with an increased rate
of myocardial infarction, and a poor prognosis following an ischaemic event, the
metabolic syndrome, and even a postulated link with the formation of stones in
the urinary tract.13–15 Burnout is very bad for your health.
Substance misuse and addiction are also strongly associated with occupational
burnout. Between 10% and 15% of US physicians are thought to suffer with a sub-
stance misuse disorder, and in 1998 a British Medical Association working group
found that around 1 in 15 doctors in the United Kingdom had some form of depen-
dence on alcohol or drugs which equated to around 13,000 doctors n ­ ationally.16,17
This can have a huge impact on professional and social functioning, and it is often
a problem that is compounded by the reluctance of doctors to seek help.
Beyond the misuse of drugs and alcohol, there is also evidence that burnout
can result in the development of eating disorders, including overeating, leading
to overweight and obesity.18
The diverse symptoms of burnout can make it difficult to spot, but they
­ultimately combine to stop a doctor being able to function in the demanding
environment of general practice. As individuals cease to work effectively, or rec-
ognise that they have a problem and opt to stop working within the NHS entirely,
this has knock-on effects for the wider GP workforce who must take up the slack.

EFFECT ON THE GP WORKFORCE

In 2015 the US-based Commonwealth Fund conducted an international sur-
vey of primary care physicians based in 11 countries which included more than
 Effect on the GP workforce 5

1000 UK-based GPs. Amongst these NHS GPs, the survey found relatively low
levels of job satisfaction and high reported levels of stress, with 59% of GPs
reporting that their job was very or extremely stressful.19 This was higher than in
any other of the surveyed countries.
Levels of satisfaction were also shown to have fallen from 84% in 2012 to 67%
just 3 years later. This was the steepest decline in satisfaction of any of the coun-
tries surveyed; in fact, satisfaction levels had risen in 6 of the 10 countries that
were surveyed on both occasions.
In the United Kingdom, 29% of GPs reported that they intended to leave
general practice within 5 years, which broke down as 17% planning to retire,
8% planning to switch careers within medicine and 4% planning to leave medi-
cine altogether (Figure 1.2). There was a clear link between levels of perceived
stress and a desire to leave general practice, with 77% of those intending to leave
­medicine reporting that they find their job very or extremely stressful compared
to 49% of those intending to stay.20
On top of these worrying figures, a further 17% of GPs were unsure whether
they would still be working in general practice after 5 years. Therefore, nearly
half of the current workforce is either committed to leaving general practice or
considering doing so in the near future.
Not only will we lose GPs from the workforce in the next 5 years, but also
the Commonwealth Fund survey reported that 22% of GPs felt they had been
made ill from the stress of their work within the last year; so, even amongst those
GPs who intend to stay within general practice, workdays are potentially lost due
to illness.
Other than those GPs nearing retirement age who may be planning to retire
early, or retire as expected, a large number of GPs leaving the workforce are
young. Overall, 45.5% of GP leavers between 2009 and 2014 were younger than
50, with many in the early stages of their career.21 The loss of many of these doc-
tors to the NHS is the gain of other countries, with a significant number each
year choosing to work abroad in search of better working conditions.22
At a time when the government is trying to increase the overall numbers of
GPs, general practice is desperately struggling to retain its existing workforce.
For prospective GPs thinking of joining the specialty, this can be off-putting and
whilst GP numbers increased at an average rate of 2.3% in the 10 years leading
up to 2011, this rate of increase was only half that of other specialties.23 Despite
the Department of Health’s intention of increasing GP trainee numbers to 3250
each year, until 2014 training numbers had stuck stubbornly below 2700 and,
after the first round of recruitment for training places starting in August 2016,
30% of places remained unfilled nationally.24,25 Currently, only 20% of medical
graduates are choosing a career in general practice, well below the Department
of Health’s target of 50%.26
With recruitment suboptimal and workforce retention difficult, gaps are com-
mon in NHS general practice. For example, in 2014 the Wessex Local Medical
Committees conducted a survey which found that 67% of their practices had
needed to fill a vacancy in the preceding year and, of these practices, 28% had
failed to recruit.27 Numbers of GPs per 1000 head of population tend to be
6 What is burnout?

2012 2015

Norway 91

Netherlands 88 Australia 88
Norway 87 New Zealand 87
Switzerland 86
UK 84
Switzerland 84 Canada 84
Netherlands 84
New Zealand 82
Canada 82

Australia 80
% Satisfied or very satisfied

Sweden 75 Sweden 75

United States 68
UK 67

United States 65

Germany 63

Germany 54

Figure 1.2 Changes in satisfaction in practicing medicine, 2012–2015.

(From Davies, E., et al., Under Pressure: What the Commonwealth Fund’s 2015
International Survey of General Practitioners Means for UK General Practice,
The Health Foundation, 2016. With permission.)

lower in urban areas, in the north of England and the Midlands, which reflects
­particularly difficult problems with retention and recruitment in these areas.23
These gaps in the workforce increase the workload for other GPs which then
raises their risk of stress and burnout.
Despite these gloomy statistics, GPs in the United Kingdom are still pro-
viding a service that pleases their patients. In the 2015–2016 GP patient survey
 Effect on the wider NHS 7

conducted by NHS England, 85.2% of patients rated their experience as good or

very good.28 This was however a slight decrease from that of previous years which
perhaps shows how much the general practice workforce is feeling the strain and
that this is now beginning to impact upon the patient experience.
The NHS is dependent on general practice, and if general practice struggles, so
does the entire health care system.

EFFECT ON THE WIDER NHS

Since the creation of the NHS in 1948, general practice has been central to its
structure and function. The importance of general practice to the way the NHS
runs was re-iterated in 1997 when the Department of Health released ‘The New
NHS: Modern, Dependable’ and more recently in 2014’s ‘NHS Five Year Forward
View’ which outlined plans to move more services into the community, away
from secondary care.29,30
With GPs providing the vast bulk of patient contacts, and the vast bulk of
patient care, and with their role coordinating the care provided by increasingly
fragmented secondary care providers, the centrality of general practice to the
NHS is obvious to those who use it and to those who run it. It is for this reason
that as long as there is a will to have an NHS, general practice must ultimately be
supported and guided through each of its crises.
A GP workforce struggling with stress and burnout, working ineffectively
and providing poor patient care is self-evidently bad for the system, and the
system is already demonstrably beginning to suffer because of this. Tackling
GP stress and burnout should therefore be central to any strategy to improving
NHS services.
Poor primary care practice, or an overwhelmed primary care service, shifts
the burden of its work towards secondary care, either by higher rates of routine
referrals or by causing increased attendance to emergency departments.
Increased attendance at the accident & emergency department (A&E) creates
a rising number of breaches of the government’s 4-h A&E target and an increased
number of admissions to hospital beds (Figure 1.3).
In response to this problem, NHS England launched the ‘Avoiding Unplanned
Admissions’ enhanced service in 2015 as an attempt to reduce the number of
emergency admissions amongst people at high risk of hospital admission by
­asking GPs to create care plans for them. The intention was to ease the burden on
secondary care but, from the viewpoint of a beleaguered primary care workforce,
the strategy was backward, adding an extra burden to a general practice work-
force that was already struggling with its workload.
Furthermore, despite the enhanced service, the waiting time targets for A&E,
which is the government’s chosen metric for measuring A&E success, were not
met for any month except July in the year 2015–2016 and, in the quarter covering
October–December 2015, breaches of the 4-h wait were at their highest level in
more than a decade.31
Clearly, the causes for this were multifactorial and included problems of staff
retention and recruitment within emergency medicine, and difficulty discharging
8 What is burnout?

Emergency admissions for acute conditions that should not usually require
hospital admission – National timeseries
Admissions per 100,000 population 1200

1000

800

600

400

200

0
4

2
/0

/0

/0

/0

/0

/0

/1

/1

/1
03

04

05

06

07

08

09

10

10
20

20

20

20

20

20

20

20

20
Figure 1.3 Rise in emergency admissions. (Courtesy of NHS England
Analytical Service, Improving General Practice – A Call to Action,
Evidence Pack. 2014.)

patients at the end of their hospital admissions due to problems providing social
care, but difficulty accessing GP services were amongst the relevant issues.
A survey conducted by the Royal College of Emergency Medicine suggested
that 15% of A&E attenders could have been treated in the community. Moreover,
data from the GP Patient Survey show that the number of people able to get
timely appointments with their GPs had fallen from 88% in 2011 to 85% in 2016
and, of those unable to get a convenient GP appointment, around 4% attended
A&E instead.31
The pressures contributing to GP burnout, which will be discussed in detail
in Chapters 2 and 3, clearly impact the rest of the NHS. A system built around
primary care needs to have primary care providers who are supported to work at
their optimum.

CONCLUSION
Burnout is a common phenomenon that has an increasingly deleterious effect
on GPs, the wider NHS and, ultimately, patients. The problem leads to a vicious
cycle; burnt-out GPs leave practice which increases the pressures on the rest of
the workforce who are subsequently at higher risk of burning out.
This is already an urgent issue and, with nearly half the workforce considering
leaving general practice within the next 5 years, we may merely be at the edge
of the precipice with the possibility of things getting very much worse without
immediate action.
 References 9

REFERENCES
1. Freudenberger HJ. Staff burnout. J Soc Issues. 1974;30(1):159–65.
2. Hammig O, Bauer GF. Work, work-life conflict and health in an industrial
work environment. Occup Med (Lond). 2014;64(1):34–8. doi: 10.1093/
occmed/kqt127.
3. Mateen FJ, Dorji C. Health-care worker burnout and the mental health
imperative. Lancet. 2009;374(9690):595–7.
4. Tidy, C. Occupational Burnout. Patient.co.uk. 2015. http://patient.info/
doctor/occupational-burnout. Accessed on 19 July, 2017.
5. Maslach C, Jackson SE. MBI: Maslach Burnout Inventory. Manual
Research Edition. Palo Alto, CA: Consulting Psychologists Press; 1986.
6. Gómez-Urquiza JL, Monsalve-Reyes CS, San Luis-Costas C, Fernández-
Castillo R, Aguayo-Estremera R, Cañadas-de la Fuente GA. Risk
­factors and burnout levels in primary care nurses: A systematic review.
Aten Primaria. 2017;49(2):77–85.
7. Kristensen TS, Borritz M, Villadsen E, Christensen KB. The Copenhagen
Burnout Inventory: A new tool for the assessment of burnout.
Work Stress. 2005;19(3):192–207.
8. Kroll HR, Macaulay T, Jesse M. A preliminary survey examining
­predictors of burnout in pain medicine physicians in the United States.
Pain Physician. 2016;19(5):E689–96.
9. Wong CA, Spence Laschinger HK. The influence of frontline manager job
strain on burnout, commitment and turnover intention: A cross-sectional
study. Int J Nurs Stud. 2015;52(12):1824–33.
10. Akman O, Ozturk C, Bektas M, Ayar D, Armstrong MA. Job sat-
isfaction and burnout among paediatric nurses. J Nurs Manag.
2016;24(7):923–33.
11. Kumar, S. Burnout and Doctors: Prevalence, Prevention and Intervention.
Healthcare. 2016;4(3):37.
12. Everall R, Paulson, B. Burnout and Secondary Traumatic Stress: Impact on
Ethical Behaviour. Canadian Journal of Counselling. 2004;38(1):25–35.
13. Consoli SM. Occupational stress and myocardial infarction. Presse Med.
2015;44(7–8):745–51.
14. Almadi T, Cathers I, Chow CM. Associations among work-related stress,
cortisol, inflammation, and metabolic syndrome. Psychophysiology.
2013;50(9):821–30.
15. Arzoz-Fabregas M, Ibarz-Servio L, Edo-Izquierdo S, Doladé-Botías
M, Fernandez-Castro J, Roca-Antonio J. Chronic stress and calcium
­oxalate stone disease: Is it a potential recurrence risk factor? Urolithiasis.
2013;41(2):119–27.
16. Oreskovich MR, Kaups KL, Balch CM, et al. Prevalence of
­a lcohol use disorders among American surgeons. Arch Surg.
2012;147:168–74.
17. Sick Doctors Trust. Overview of Addiction. http://sick-doctors-trust.
co.uk/page/addiction. Accessed on 19 July, 2017.
10 What is burnout?

18. Nevanpera NJ, Hopsu L, Kuosma E, et al. Occupational burnout,

­eating behavior, and weight among working women. Am J Clin Nutr.
2012;95(4):934–43.
19. The Commonwealth Fund. 2015 Commonwealth Fund International Survey
of Primary Care Physicians in 10 Nations. http://www.­commonwealthfund.​
org/interactives-and-data/surveys/2015/2015-international-survey.
Accessed on 19 July, 2017.
20. Davies E, Martin S, Gershlick B. Under pressure: What the
Commonwealth Fund’s 2015 International Survey of General Practitioners
means for the UK. 2016. http://www.health.org.uk/publication/
underpressure#sthash.3qqLghqH.dpuf. Accessed on 19 July, 2017.
21. Health & Social Care Information Centre. General and Personal Medical
Services, England—2004–2014, as at 30 September. http://www.hscic.
gov.uk/catalogue/PUB16934. Accessed on 19 July, 2017.
22. Davies, M. GP Brain Drain is a ‘Signifcant Danger’ Says BMA. Pulse. 2016.
http://www.pulsetoday.co.uk/home/finance-and-practice-life-news/
gpbrain-drain-is-a-significant-danger-says-bma/20003804.fullarticle.
Accessed on 19 July, 2017.
23. NHS England Analytical Service. Improving General Practice – A Call to
Action. Evidence Pack. 2014. http://www.england.nhs.uk/wp-content/
uploads/2013/09/igp-cta-evid.pdf. Accessed on 19 July, 2017.
24. GP Taskforce. Securing the Future GP Workforce: Delivering the Mandate
on GP Expansion. GP Taskforce final report. Leeds: Health Education
England; 2014.
25. Kaffash, J. 30% of GP Training Places Remain Unfilled. Pulse. 2016. http://
www.pulsetoday.co.uk/your-practice/practice-topics/education/30-of-
gp-training-places-remain-unfilled/20031494.fullarticle. Accessed on
19 July, 2017.
26. Lambert T, Goldacre M. Trends in doctors’ early career choices for
general practice in the UK: Longitudinal questionnaire surveys. Br J Gen
Pract. 2011;61:e397–403.
27. Wessex, LMC. GP Recruitment Crisis. Press Release. 2014. https://www.
wessexlmcs.com/gprecruitmentcrisis. Accessed on 19 July, 2017.
28. NHS England. GP Patient Survey 2015–16. 2016. https://www.england.
nhs.uk/statistics/2016/07/07/gp-patient-survey-2015-16/. Accessed on
19 July, 2017.
29. Department of Health. The New NHS: Modern, Dependable. Department
of Health; 1997. www.gov.uk/government/uploads/system/uploads/
attachment_data/file/266003/newnhs.pdf. Accessed on 19 July, 2017.
30. NHS England. NHS Five Year Forward View. NHS England; 2014.
www.england.nhs.uk/ourwork/futurenhs/. Accessed on 19 July, 2017.
31. King’s Fund. What’s Going on in A&E? The Key Questions Answered.
http://www.kingsfund.org.uk/projects/urgent-emergency-care/urgent-
and-emergency-care-mythbusters. Accessed on 19 July, 2017.
Another random document with
no related content on Scribd:
the foundation is a very good one, but as I have generally allowed
people to call me what they have pleased, and as there is nothing
necessarily dishonorable in this, I have never taken the pains to
dispute its application and propriety; and yet I confess that I am never
so spoken of without feeling a trifle uncomfortable—about as much so
as when I am called, as I sometimes am, the Rev. Frederick Douglass.
My stay in this legislative body was of short duration. My vocation
abroad left me little time to study the many matters of local legislation;
hence my resignation, and the appointment of my son Lewis to fill out
my term.
I have thus far told my story without copious quotations from my
letters, speeches, or other writings, and shall not depart from this rule
in what remains to be told, except to insert here my speech, delivered
at Arlington, near the monument to the “Unknown Loyal Dead,” on
Decoration Day, 1871. It was delivered under impressive
circumstances, in presence of President Grant, his Cabinet, and a
great multitude of distinguished people, and expresses, as I think, the
true view which should be taken of the great conflict between slavery
and freedom to which it refers.

“Friends and Fellow Citizens: Tarry here for a moment. My

words shall be few and simple. The solemn rites of this hour and
place call for no lengthened speech. There is in the very air of this
resting ground of the unknown dead a silent, subtle, and an all-
pervading eloquence, far more touching, impressive, and thrilling
than living lips have ever uttered. Into the measureless depths of
every loyal soul it is now whispering lessons of all that is precious,
priceless, holiest, and most enduring in human existence.
“Dark and sad will be the hour to this nation when it forgets to
pay grateful homage to its greatest benefactors. The offering we
bring to-day is due alike to the patriot soldiers dead and their noble
comrades who still live; for whether living or dead, whether in time
or eternity, the loyal soldiers who imperiled all for country and
freedom are one and inseparable.
“Those unknown heroes whose whitened bones have been
piously gathered here, and whose green graves we now strew with
sweet and beautiful flowers, choice emblems alike of pure hearts
and brave spirits, reached in their glorious career that last highest
point of nobleness beyond which human power cannot go. They
died for their country.
“No loftier tribute can be paid to the most illustrious of all the
benefactors of mankind than we pay to these unrecognized
soldiers, when we write above their graves this shining epitaph.
“When the dark and vengeful spirit of slavery, always
ambitious, preferring to rule in hell than to serve in heaven, fired
the Southern heart and stirred all the malign elements of discord;
when our great Republic, the hope of freedom and self-
government throughout the world, had reached the point of
supreme peril; when the Union of these States was torn and rent
asunder at the center, and the armies of a gigantic rebellion came
forth with broad blades and bloody hands to destroy the very
foundation of American society, the unknown braves who flung
themselves into the yawning chasm, where cannon roared and
bullets whistled, fought and fell. They died for their country.
“We are sometimes asked, in the name of patriotism, to forget
the merits of this fearful struggle, and to remember with equal
admiration those who struck at the nation’s life and those who
struck to save it,—those who fought for slavery and those who
fought for liberty and justice.
“I am no minister of malice. I would not strike the fallen. I
would not repel the repentant, but may my “right hand forget her
cunning, and my tongue cleave to the roof of my mouth,” if I forget
the difference between the parties to that terrible, protracted, and
bloody conflict.
“If we ought to forget a war which has filled our land with
widows and orphans, which has made stumps of men of the very
flower of our youth; sent them on the journey of life armless,
legless, maimed and mutilated; which has piled up a debt heavier
than a mountain of gold—swept uncounted thousands of men into
bloody graves, and planted agony at a million hearthstones; I say
if this war is to be forgotten, I ask in the name of all things sacred
what shall men remember?
 “The essence and significance of our devotions here to-day
are not to be found in the fact that the men whose remains fill
these graves were brave in battle. If we met simply to show our
sense of bravery, we should find enough to kindle admiration on
both sides. In the raging storm of fire and blood, in the fierce
torrent of shot and shell, of sword and bayonet, whether on foot or
on horse, unflinching courage marked the rebel not less than the
loyal soldier.
“But we are not here to applaud manly courage, save as it has
been displayed in a noble cause. We must never forget that victory
to the rebellion meant death to the republic. We must never forget
that the loyal soldiers who rest beneath this sod flung themselves
between the nation and the nation’s destroyers. If to-day we have
a country not boiling in an agony of blood like France; if now we
have a united country, no longer cursed by the hell-black system
of human bondage; if the American name is no longer a by-word
and a hissing to a mocking earth; if the star spangled banner floats
only over free American citizens in every quarter of the land, and
our country has before it a long and glorious career of justice,
liberty, and civilization, we are indebted to the unselfish devotion of
the noble army who rest in these honored graves all around us.”

In the month of April, 1872, I had the honor to attend and preside
over a National Convention of colored citizens, held in New Orleans. It
was a critical period in the history of the Republican party, as well as in
that of the country. Eminent men who had hitherto been looked upon
as the pillars of Republicanism had become dissatisfied with President
Grant’s administration, and determined to defeat his nomination for a
second term. The leaders in this unfortunate revolt were Messrs.
Trumbull, Schurz, Greeley, and Sumner. Mr. Schurz had already
succeeded in destroying the Republican party in the State of Missouri,
and it seemed to be his ambition to be the founder of a new party, and
to him more than to any other man belongs the credit of what was
once known as the Liberal Republican party which made Horace
Greeley its standard bearer in the campaign of that year.
At the time of the Convention in New Orleans the elements of this
new combination were just coming together. The division in the
Republican ranks seemed to be growing deeper and broader every
day. The colored people of the country were much affected by the
threatened disruption, and their leaders were much divided as to the
side upon which they should give their voice and their votes. The
names of Greeley and Sumner, on account of their long and earnest
advocacy of justice and liberty to the blacks, had powerful attractions
for the newly enfranchised class; and there was in this Convention at
New Orleans naturally enough a strong disposition to fraternize with
the new party and follow the lead of their old friends. Against this policy
I exerted whatever influence I possessed, and, I think, succeeded in
holding back that Convention from what I felt sure then would have
been a fatal political blunder, and time has proved the correctness of
that position. My speech on taking the chair on that occasion was
telegraphed from New Orleans in full to the New York Herald, and the
key-note of it was that there was no path out of the Republican party
that did not lead directly into the Democratic party—away from our
friends and directly to our enemies. Happily this Convention pretty
largely agreed with me, and its members have not since regretted that
agreement.
From this Convention onward, until the nomination and election of
Grant and Wilson, I was actively engaged on the stump, a part of the
time in Virginia with Hon. Henry Wilson, in North Carolina with John M.
Longston and John H. Smyth, and in the State of Maine with Senator
Hamlin, Gen. B. F. Butler, Gen. Woodford, and Hon. James G. Blaine.
Since 1872 I have been regularly what my old friend Parker
Pillsbury would call a “field hand” in every important political campaign,
and at each National Convention have sided with what has been called
the stalwart element of the Republican party. It was in the Grant
Presidential campaign that New York took an advanced step in the
renunciation of a timid policy. The Republicans of that State not having
the fear of popular prejudice before their eyes placed my name as an
Elector at large at the head of their Presidential ticket. Considering the
deep-rooted sentiment of the masses against negroes, the noise and
tumult likely to be raised, especially among our adopted citizens of
Irish descent, this was a bold and manly proceeding, and one for which
the Republicans of the State of New York deserve the gratitude of
every colored citizen of the Republic, for it was a blow at popular
prejudice in a quarter where it was capable of making the strongest
resistance. The result proved not only the justice and generosity of the
measure, but its wisdom. The Republicans carried the State by a
majority of fifty thousand over the heads of the Liberal Republican and
the Democratic parties combined.
Equally significant of the turn now taken in the political sentiment of
the country, was the action of the Republican Electoral College at its
meeting in Albany, when it committed to my custody the sealed up
electoral vote of the great State of New York, and commissioned me to
bring that vote to the National Capital. Only a few years before, any
colored man was forbidden by law to carry a United States mail bag
from one post-office to another. He was not allowed to touch the
sacred leather, though locked in “triple steel,” but now, not a mail bag,
but a document which was to decide the Presidential question with all
its momentous interests, was committed to the hands of one of this
despised class; and around him, in the execution of his high trust, was
thrown all the safeguards provided by the Constitution and the laws of
the land. Though I worked hard and long to secure the nomination and
the election of Gen. Grant in 1872, I neither received nor sought office
under him. He was my choice upon grounds altogether free from
selfish or personal considerations. I supported him because he had
done all, and would do all, he could to save not only the country from
ruin, but the emancipated class from oppression and ultimate
destruction; and because Mr. Greeley, with the Democratic party
behind him, would not have the power, even if he had the disposition,
to afford us the needed protection which our peculiar condition
required. I could easily have secured the appointment as Minister to
Hayti, but preferred to urge the claims of my friend, Ebenezer Bassett,
a gentleman and a scholar, and a man well fitted by his good sense
and amiable qualities to fill the position with credit to himself and his
country. It is with a certain degree of pride that I am able to say that my
opinion of the wisdom of sending Mr. Bassett to Hayti has been fully
justified by the creditable manner in which, for eight years, he
discharged the difficult duties of that position; for I have the assurance
of Hon. Hamilton Fish, Secretary of State of the United States, that Mr.
Bassett was a good Minister. In so many words, the ex-Secretary told
me, that he “wished that one-half of his ministers abroad performed
their duties as well as Mr. Bassett.” To those who knew Hon. Hamilton
Fish, this compliment will not be deemed slight, for few men are less
given to exaggeration and are more scrupulously exact in the
observance of law, and in the use of language, than is that gentleman.
While speaking in this strain of complacency in reference to Mr.
Bassett, I take pleasure also in bearing my testimony based upon
knowledge obtained at the State Department, that Mr. John Mercer
Langston, the present Minister to Hayti, has acquitted himself with
equal wisdom and ability to that of Mr. Bassett in the same position.
Having known both these gentlemen in their youth, when the one was
at Yale, and the other at Oberlin College, and witnessed their efforts to
qualify themselves for positions of usefulness, it has afforded me no
limited satisfaction to see them rise in the world. Such men increase
the faith of all in the possibilities of their race, and make it easier for
those who are to come after them.
The unveiling of Lincoln Monument in Lincoln Park, Washington,
April 14th, 1876, and the part taken by me in the ceremonies of that
grand occasion, takes rank among the most interesting incidents of my
life, since it brought me into mental communication with a greater
number of the influential and distinguished men of the country than any
I had before known. There were present the President of the United
States and his Cabinet, Judges of the Supreme Court, the Senate and
House of Representatives, and many thousands of citizens to listen to
my address upon the illustrious man in whose memory the colored
people of the United States had, as a mark of their gratitude, erected
that impressive monument. Occasions like this have done wonders in
the removal of popular prejudice, and in lifting into consideration the
colored race; and I reckon it one of the high privileges of my life, that I
was permitted to have a share in this and several other like
celebrations.
The progress of a nation is sometimes indicated by small things.
When Henry Wilson, an honored Senator and Vice-President of the
United States, died in the capitol of the nation, it was a significant and
telling indication of national advance, when three colored citizens, Mr.
Robert Purvis, Mr. James Wormley, and myself, were selected with the
Senate committee, to accompany his honored remains from
Washington to the grand old commonwealth he loved so well, and
whom in turn she had so greatly loved and honored. It was meet and
right that we should be represented in the long procession that met
those remains in every State between here and Massachusetts, for
Henry Wilson was among the foremost friends of the colored race in
this country, and this was the first time in its history when a colored
man was made a pall-bearer at the funeral, as I was in this instance, of
a Vice-President of the United States.
An appointment to any important and lucrative office under the
United States government, usually brings its recipient a large measure
of praise and congratulation on the one hand, and much abuse and
disparagement on the other; and he may think himself singularly
fortunate if the censure does not exceed the praise. I need not dwell
upon the causes of this extravagance, but I may say there is no office
of any value in the country which is not desired and sought by many
persons equally meritorious and equally deserving. But as only one
person can be appointed to any one office, only one can be pleased,
while many are offended; unhappily, resentment follows
disappointment, and this resentment often finds expression in
disparagement and abuse of the successful man. As in most else I
have said, I borrow this reflection from my own experience.
My appointment as United States Marshal of the District of
Columbia, was in keeping with the rest of my life, as a freeman. It was
an innovation upon long established usage, and opposed to the
general current of sentiment in the community. It came upon the
people of the District as a gross surprise, and almost a punishment;
and provoked something like a scream—I will not say a yell—of
popular displeasure. As soon as I was named by President Hayes for
the place, efforts were made by members of the bar to defeat my
confirmation before the Senate. All sorts of reasons against my
appointment, but the true one, were given, and that was withheld more
from a sense of shame, than from a sense of justice. The
apprehension doubtless was, that if appointed marshal, I would
surround myself with colored deputies, colored bailiffs, colored
messengers, and pack the jury box with colored jurors; in a word,
Africanize the courts. But the most dreadful thing threatened, was a
colored man at the Executive Mansion in white kid gloves, sparrow-
tailed coat, patent leather boots, and alabaster cravat, performing the
ceremony—a very empty one—of introducing the aristocratic citizens
of the republic to the President of the United States. This was
something entirely too much to be borne; and men asked themselves
in view of it, to what is the world coming? and where will these things
stop? Dreadful! Dreadful!
It is creditable to the manliness of the American Senate, that it was
moved by none of these things, and that it lost no time in the matter of
my confirmation. I learn, and believe my information correct, that
foremost among those who supported my confirmation against the
objections made to it, was Hon. Roscoe Conkling of New York. His
speech in executive session is said by the senators who heard it, to
have been one of the most masterly and eloquent ever delivered on
the floor of the Senate; and this too I readily believe, for Mr. Conkling
possesses the ardor and fire of Henry Clay, the subtlety of Calhoun,
and the massive grandeur of Daniel Webster.
The effort to prevent my confirmation having failed, nothing could
be done but to wait for some overt act to justify my removal; and for
this my unfriends had not long to wait. In the course of one or two
months I was invited by a number of citizens of Baltimore to deliver a
lecture in that city in Douglass Hall—a building named in honor of
myself, and devoted to educational purposes. With this invitation I
complied, giving the same lecture which I had two years before
delivered in the city of Washington, and which was at the time
published in full in the newspapers, and very highly commended by
them. The subject of the lecture was, “Our National Capital,” and in it I
said many complimentary things of the city, which were as true as they
were complimentary. I spoke of what it had been in the past, what it
was at that time, and what I thought it destined to become in the future;
giving it all credit for its good points, and calling attention to some of its
ridiculous features. For this I got myself pretty roughly handled. The
newspapers worked themselves up to a frenzy of passion, and
committees were appointed to procure names to a petition to President
Hayes demanding my removal. The tide of popular feeling was so
violent, that I deemed it necessary to depart from my usual custom
when assailed, so far as to write the following explanatory letter, from
which the reader will be able to measure the extent and quality of my
offense:
“To the Editor of the Washington Evening Star:
“Sir:—You were mistaken in representing me as being off on a
lecturing tour, and, by implication, neglecting my duties as United
States Marshal of the District of Columbia. My absence from
Washington during two days was due to an invitation by the
managers to be present on the occasion of the inauguration of the
International Exhibition in Philadelphia.
“In complying with this invitation, I found myself in company
with other members of the government who went thither in
obedience to the call of patriotism and civilization. No one interest
of the Marshal’s office suffered by my temporary absence, as I had
seen to it that those upon whom the duties of the office devolved
were honest, capable, industrious, painstaking, and faithful. My
Deputy Marshal is a man every way qualified for his position, and
the citizens of Washington may rest assured that no unfaithful man
will be retained in any position under me. Of course I can have
nothing to say as to my own fitness for the position I hold. You
have a right to say what you please on that point; yet I think it
would be only fair and generous to wait for some dereliction of
duty on my part before I shall be adjudged as incompetent to fill
the place.
“You will allow me to say also that the attacks upon me on
account of the remarks alleged to have been made by me in
Baltimore, strike me as both malicious and silly. Washington is a
great city, not a village nor a hamlet, but the capital of a great
nation, and the manners and habits of its various classes are
proper subjects for presentation and criticism, and I very much
mistake if this great city can be thrown into a tempest of passion
by any humorous reflections I may take the liberty to utter. The city
is too great to be small, and I think it will laugh at the ridiculous
attempt to rouse it to a point of furious hostility to me for any thing
said in my Baltimore lecture.
“Had the reporters of that lecture been as careful to note what
I said in praise of Washington as what I said, if you please, in
disparagement of it, it would have been impossible to awaken any
feeling against me in this community for what I said. It is the
easiest thing in the world, as all editors know, to pervert the
meaning and give a one-sided impression of a whole speech by
simply giving isolated passages from the speech itself, without any
qualifying connections. It would hardly be imagined from anything
that has appeared here that I had said one word in that lecture in
honor of Washington, and yet the lecture itself, as a whole, was
decidedly in the interest of the national capital. I am not such a fool
as to decry a city in which I have invested my money and made
my permanent residence.
“After speaking of the power of the sentiment of patriotism I
held this language: ‘In the spirit of this noble sentiment I would
have the American people view the national capital. It is our
national center. It belongs to us; and whether it is mean or
majestic, whether arrayed in glory or covered with shame, we
cannot but share its character and its destiny. In the remotest
section of the republic, in the most distant parts of the globe, amid
the splendors of Europe or the wilds of Africa, we are still held and
firmly bound to this common center. Under the shadow of Bunker
Hill monument, in the peerless eloquence of his diction, I once
heard the great Daniel Webster give welcome to all American
citizens, assuring them that wherever else they might be
strangers, they were all at home there. The same boundless
welcome is given to all American citizens by Washington.
Elsewhere we may belong to individual States, but here we belong
to the whole United States. Elsewhere we may belong to a
section, but here we belong to a whole country, and the whole
country belongs to us. It is national territory, and the one place
where no American is an intruder or a carpet-bagger. The new
comer is not less at home than the old resident. Under its lofty
domes and stately pillars, as under the broad blue sky, all races
and colors of men stand upon a footing of common equality.
“‘The wealth and magnificence which elsewhere might oppress
the humble citizen has an opposite effect here. They are felt to be
a part of himself and serve to ennoble him in his own eyes. He is
an owner of the marble grandeur which he beholds about him,—as
much so as any of the forty millions of this great nation. Once in
his life every American who can should visit Washington: not as
the Mahometan to Mecca; not as the Catholic to Rome; not as the
Hebrew to Jerusalem, nor as the Chinaman to the Flowery
kingdom, but in the spirit of enlightened patriotism, knowing the
value of free institutions and how to perpetuate and maintain them.
“‘Washington should be contemplated not merely as an
assemblage of fine buildings; not merely as the chosen resort of
the wealth and fashion of the country; not merely as the honored
place where the statesmen of the nation assemble to shape the
policy and frame the laws; not merely as the point at which we are
most visibly touched by the outside world, and where the
diplomatic skill and talent of the old continent meet and match
themselves against those of the new, but as the national flag itself
—a glorious symbol of civil and religious liberty, leading the world
in the race of social science, civilization, and renown.’
“My lecture in Baltimore required more than an hour and a half
for its delivery, and every intelligent reader will see the difficulty of
doing justice to such a speech when it is abbreviated and
compressed into a half or three-quarters of a column. Such
abbreviation and condensation has been resorted to in this
instance. A few stray sentences, called out from their connections,
would be deprived of much of their harshness if presented in the
form and connection in which they were uttered; but I am taking up
too much space, and will close with the last paragraph of the
lecture, as delivered in Baltimore. ‘No city in the broad world has a
higher or more beneficent mission. Among all the great capitals of
the world it is preëminently the capital of free institutions. Its fall
would be a blow to freedom and progress throughout the world.
Let it stand then where it does now stand—where the father of his
country planted it, and where it has stood for more than half a
century; no longer sandwiched between two slave States; no
longer a contradiction to human progress; no longer the hot-bed of
slavery and the slave trade; no longer the home of the duelist, the
gambler, and the assassin; no longer the frantic partisan of one
section of the country against the other; no longer anchored to a
dark and semi-barbarous past, but a redeemed city, beautiful to
the eye and attractive to the heart, a bond of perpetual union, an
angel of peace on earth and good will to men, a common ground
 upon which Americans of all races and colors, all sections, North
and South, may meet and shake hands, not over a chasm of
blood, but over a free, united, and progressive republic.’”

I have already alluded to the fact that much of the opposition to my

appointment to the office of United States Marshal of the District of
Columbia was due to the possibility of my being called to attend
President Hayes at the Executive Mansion upon state occasions, and
having the honor to introduce the guests on such occasions. I now
wish to refer to reproaches liberally showered upon me for holding the
office of Marshal while denied this distinguished honor, and to show
that the complaint against me at this point is not a well founded
complaint.
1st. Because the office of United States Marshal is distinct and
separate and complete in itself, and must be accepted or refused upon
its own merits. If, when offered to any person, its duties are such as he
can properly fulfill, he may very properly accept it; or, if otherwise, he
may as properly refuse it.
2d. Because the duties of the office are clearly and strictly defined
in the law by which it was created; and because nowhere among these
duties is there any mention or intimation that the Marshal may or shall
attend upon the President of the United States at the Executive
Mansion on state occasions.
3d. Because the choice as to who shall have the honor and
privilege of such attendance upon the President belongs exclusively
and reasonably to the President himself, and that therefore no one,
however distinguished, or in whatever office, has any just cause to
complain of the exercise by the President of this right of choice, or
because he is not himself chosen.
In view of these propositions, which I hold to be indisputable, I
should have presented to the country a most foolish and ridiculous
figure had I, as absurdly counseled by some of my colored friends,
resigned the office of Marshal of the District of Columbia, because
President Rutherford B. Hayes, for reasons that must have been
satisfactory to his judgment, preferred some person other than myself
to attend upon him at the Executive Mansion and perform the
ceremony of introduction on state occasions. But it was said, that this
statement did not cover the whole ground; that it was customary for the
United States Marshal of the District of Columbia to perform this social
office; and that the usage had come to have almost the force of law. I
met this at the time, and I meet it now by denying the binding force of
this custom. No former President has any right or power to make his
example the rule for his successor. The custom of inviting the Marshal
to do this duty was made by a President, and could be as properly
unmade by a President. Besides, the usage is altogether a modern
one, and had its origin in peculiar circumstances, and was justified by
those circumstances. It was introduced in time of war by President
Lincoln when he made his old law partner and intimate acquaintance
Marshal of the District, and was continued by Gen. Grant when he
appointed a relative of his, Gen. Sharp, to the same office. But again it
was said that President Hayes only departed from this custom
because the Marshal in my case was a colored man. The answer I
made to this, and now make to it, is, that it is a gratuitous assumption
and entirely begs the question. It may or may not be true that my
complexion was the cause of this departure, but no man has any right
to assume that position in advance of a plain declaration to that effect
by President Hayes himself. Never have I heard from him any such
declaration or intimation. In so far as my intercourse with him is
concerned, I can say that I at no time discovered in him a feeling of
aversion to me on account of my complexion, or on any other account,
and, unless I am greatly deceived, I was ever a welcome visitor at the
Executive Mansion on state occasions and all others, while Rutherford
B. Hayes was President of the United States. I have further to say that
I have many times during his administration had the honor to introduce
distinguished strangers to him, both of native and foreign birth, and
never had reason to feel myself slighted by himself or his amiable wife;
and I think he would be a very unreasonable man who could desire for
himself, or for any other, a larger measure of respect and consideration
than this at the hands of a man and woman occupying the exalted
positions of Mr. and Mrs. Hayes.
I should not do entire justice to the Honorable ex-President if I did
not bear additional testimony to his noble and generous spirit. When all
Washington was in an uproar, and a wild clamor rent the air for my
removal from the office of Marshal on account of the lecture delivered
by me in Baltimore, when petitions were flowing in upon him
demanding my degradation, he nobly rebuked the mad spirit of
persecution by openly declaring his purpose to retain me in my place.
One other word. During the tumult raised against me in
consequence of this lecture on the “National Capital,” Mr. Columbus
Alexander, one of the old and wealthy citizens of Washington, who was
on my bond for twenty thousand dollars, was repeatedly besought to
withdraw his name, and thus leave me disqualified; but like the
President, both he and my other bondsman, Mr. George Hill, Jr., were
steadfast and immovable. I was not surprised that Mr. Hill stood
bravely by me, for he was a Republican; but I was surprised and
gratified that Mr. Alexander, a Democrat, and, I believe, once a
slaveholder, had not only the courage, but the magnanimity to give me
fair play in this fight. What I have said of these gentlemen, can be
extended to very few others in this community, during that period of
excitement, among either the white or colored citizens, for, with the
exception of Dr. Charles B. Purvis, no colored man in the city uttered
one public word in defence or extenuation of me or of my Baltimore
speech.
This violent hostility kindled against me was singularly evanescent.
It came like a whirlwind, and like a whirlwind departed. I soon saw
nothing of it, either in the courts among the lawyers, or on the streets
among the people; for it was discovered that there was really in my
speech at Baltimore nothing which made me “worthy of stripes or of
bonds.”
 Marshal at the Inauguration of Pres.
Garfield.
I can say from my experience in the office of United States Marshal
of the District of Columbia, it was every way agreeable. When it was
an open question whether I should take the office or not, it was
apprehended and predicted if I should accept it in face of the
opposition of the lawyers and judges of the courts, I should be
subjected to numberless suits for damages, and so vexed and worried
that the office would be rendered valueless to me; that it would not
only eat up my salary, but possibly endanger what little I might have
laid up for a rainy day. I have now to report that this apprehension was
in no sense realized. What might have happened had the members of
the District bar been half as malicious and spiteful as they had been
industriously represented as being, or if I had not secured as my
assistant a man so capable, industrious, vigilant, and careful as Mr.
L. P. Williams, of course I cannot know. But I am bound to praise the
bridge that carries me safely over it. I think it will ever stand as a
witness to my fitness for the position of Marshal, that I had the wisdom
to select for my assistant a gentleman so well instructed and
competent. I also take pleasure in bearing testimony to the generosity
of Mr. Phillips, the assistant Marshal who preceded Mr. Williams in that
office, in giving the new assistant valuable information as to the
various duties he would be called upon to perform. I have further to
say of my experience in the Marshal’s office, that while I have reason
to know that the eminent Chief Justice of the District of Columbia and
some of his associates were not well pleased with my appointment, I
was always treated by them, as well as by the chief clerk of the courts,
Hon. J. R. Meigs, and the subordinates of the latter (with a single
exception), with the respect and consideration due to my office. Among
the eminent lawyers of the District I believe I had many friends, and
there were those of them to whom I could always go with confidence in
an emergency for sound advice and direction, and this fact, after all the
hostility felt in consequence of my appointment, and revived by my
speech at Baltimore, is another proof of the vincibility of all feeling
arising out of popular prejudices.
In all my forty years of thought and labor to promote the freedom
and welfare of my race, I never found myself more widely and painfully
at variance with leading colored men of the country, than when I
opposed the effort to set in motion a wholesale exodus of colored
people of the South to the Northern States; and yet I never took a
position in which I felt myself better fortified by reason and necessity. It
was said of me, that I had deserted to the old master class, and that I
was a traitor to my race; that I had run away from slavery myself, and
yet I was opposing others in doing the same. When my opponents
condescended to argue, they took the ground that the colored people
of the South needed to be brought into contact with the freedom and
civilization of the North; that no emancipated and persecuted people
ever had or ever could rise in the presence of the people by whom
they had been enslaved, and that the true remedy for the ills which the
freedmen were suffering, was to initiate the Israelitish departure from
our modern Egypt to a land abounding, if not in “milk and honey,”
certainly in pork and hominy.
Influenced, no doubt, by the dazzling prospects held out to them
by the advocates of the exodus movement, thousands of poor, hungry,
naked, and destitute colored people were induced to quit the South
amid the frosts and snows of a dreadful winter in search of a better
country. I regret to say there was something sinister in this so-called
exodus, for it transpired that some of the agents most active in
promoting it had an understanding with certain railroad companies, by
which they were to receive one dollar per head upon all such
passengers. Thousands of these poor people, traveling only so far as
they had money to bear their expenses, were dropped on the levees of
St. Louis, in the extremest destitution; and their tales of woe were such
as to move a heart much less sensitive to human suffering than mine.
But while I felt for these poor deluded people, and did what I could to
put a stop to their ill-advised and ill-arranged stampede, I also did what
I could to assist such of them as were within my reach, who were on
their way to this land of promise. Hundreds of these people came to
Washington, and at one time there were from two to three hundred
lodged here, unable to get further for the want of money. I lost no time
in appealing to my friends for the means of assisting them.
Conspicuous among these friends was Mrs. Elizabeth Thompson of
New York city—the lady who, several years ago, made the nation a
present of Carpenter’s great historical picture of the “Signing of the
Emancipation Proclamation,” and who has expended large sums of her
money in investigating the causes of yellow-fever, and in endeavors to
discover means for preventing its ravages in New Orleans and
elsewhere. I found Mrs. Thompson consistently alive to the claims of
humanity in this, as in other instances, for she sent me, without delay,
a draft for two hundred and fifty dollars, and in doing so expressed the
wish that I would promptly inform her of any other opportunity of doing
good. How little justice was done me by those who accused me of
indifference to the welfare of the colored people of the South on
account of my opposition to the so-called exodus will be seen by the
following extracts from a paper on that subject laid before the Social
Science Congress at Saratoga, when that question was before the
country:

* * * * *

“Important as manual labor is everywhere, it is nowhere more

important and absolutely indispensable to the existence of society
than in the more southern of the United States. Machinery may
continue to do, as it has done, much of the work of the North, but
the work of the South requires bone, sinew, and muscle of the
strongest and most enduring kind for its performance. Labor in that
section must know no pause. Her soil is pregnant and prolific with
life and energy. All the forces of nature within her borders are
wonderfully vigorous, persistent, and active. Aided by an almost
perpetual summer abundantly supplied with heat and moisture,
her soil readily and rapidly covers itself with noxious weeds, dense
forests, and impenetrable jungles. Only a few years of non-tillage
would be needed to give the sunny and fruitful South to the bats
and owls of a desolate wilderness. From this condition, shocking
for a southern man to contemplate, it is now seen that nothing less
powerful than the naked iron arm of the negro, can save her. For
him as a Southern laborer, there is no competitor or substitute.
The thought of filling his place by any other variety of the human
family, will be found delusive and utterly impracticable. Neither
Chinaman, German, Norwegian, nor Swede can drive him from
the sugar and cotton fields of Louisiana and Mississippi. They
would certainly perish in the black bottoms of these states if they
could be induced, which they cannot, to try the experiment.
“Nature itself, in those States, comes to the rescue of the
negro, fights his battles, and enables him to exact conditions from
those who would unfairly treat and oppress him. Besides being
dependent upon the roughest and flintiest kind of labor, the climate
of the South makes such labor uninviting and harshly repulsive to
the white man. He dreads it, shrinks from it, and refuses it. He
shuns the burning sun of the fields and seeks the shade of the
verandas. On the contrary, the negro walks, labors, and sleeps in
the sunlight unharmed. The standing apology for slavery was
based upon a knowledge of this fact. It was said that the world
must have cotton and sugar, and that only the negro could supply
this want; and that he could be induced to do it only under the
“beneficent whip” of some bloodthirsty Legree. The last part of this
argument has been happily disproved by the large crops of these
productions since Emancipation; but the first part of it stands firm,
unassailed and unassailable.
“Even if climate and other natural causes did not protect the
negro from all competition in the labor-market of the South,
inevitable social causes would probably effect the same result.
The slave system of that section has left behind it, as in the nature
of the case it must, manners, customs, and conditions to which
free white laboring men will be in no haste to submit themselves
and their families. They do not emigrate from the free North, where
labor is respected, to a lately enslaved South, where labor has
been whipped, chained, and degraded for centuries. Naturally
enough such emigration follows the lines of latitude in which they
who compose it were born. Not from South to North, but from East
to West ‘the Star of Empire takes its way.’
“Hence it is seen that the dependence of the planters, land-
owners, and old master-class of the South upon the negro,
however galling and humiliating to Southern pride and power, is
nearly complete and perfect. There is only one mode of escape for
them, and that mode they will certainly not adopt. It is to take off
their own coats, cease to whittle sticks and talk politics at cross-
roads, and go themselves to work in their broad and sunny fields
of cotton and sugar. An invitation to do this is about as harsh and
distasteful to all their inclinations as would be an invitation to step
down into their graves. With the negro, all this is different. Neither
natural, artificial, or traditional causes stand in the way of the
freedman to labor in the South. Neither the heat nor the fever-
demon which lurks in her tangled and oozy swamps affright him,
and he stands to-day the admitted author of whatever prosperity,
beauty, and civilization are now possessed by the South, and the
admitted arbiter of her destiny.
 “This then, is the high vantage ground of the negro; he has
labor; the South wants it, and must have it or perish. Since he is
free he can now give it or withhold it, use it where he is, or take it
elsewhere as he pleases. His labor made him a slave, and his
labor can, if he will, make him free, comfortable, and independent.
It is more to him than fire, swords, ballot-boxes, or bayonets. It
touches the heart of the South through its pocket. This power
served him well years ago, when in the bitterest extremity of
destitution. But for it, he would have perished when he dropped
out of slavery. It saved him then, and it will save him again.
Emancipation came to him, surrounded by extremely unfriendly
circumstances. It was not the choice or consent of the people
among whom he lived, but against their will, and a death struggle
on their part to prevent it. His chains were broken in the tempest
and whirlwind of civil war. Without food, without shelter, without
land, without money, and without friends, he with his children, his
sick, his aged and helpless ones, were turned loose and naked to
the open sky. The announcement of his freedom was instantly
followed by an order from his master to quit his old quarters, and
to seek bread thereafter from the hands of those who had given
him his freedom. A desperate extremity was thus forced upon him
at the outset of his freedom, and the world watched with humane
anxiety, to see what would become of him. His peril was imminent.
Starvation and death stared him in the face and marked him for
their victim.
“It will not soon be forgotten that at the close of a five hours’
speech by the late Senator Sumner, in which he advocated with
unequaled learning and eloquence the enfranchisement of the
freedmen, the best argument with which he was met in the
Senate, was that legislation at that point would be utterly
superfluous; that the negro was rapidly dying out, and must
inevitably and speedily disappear and become extinct.
“Inhuman and shocking as was this consignment of millions of
human beings to extinction, the extremity of the negro, at that
date, did not contradict, but favored, the prophecy. The policy of
the old master-class dictated by passion, pride, and revenge, was
then to make the freedom of the negro, a greater calamity to him,