Doctors` Health and Wellbeing

Doctors’ Health and Wellbeing
PROFESSOR AMANDA HOWE, MD FRCHP
Keynote lecture
26 June 2013
Wonca World Conference Prague
Acknowledgements
 This lecture was based on academic literature and
contributions submitted by Wonca members. Not all
references appear in these slides, which are a
synthesis of many aspects – these are designed for
readers to get an overview and summary of ideas.
Quotes are anonymised.
 The lecturer acknowledged the hard work done by
doctors everywhere, and expressed gratitude to the
conference organisers for inviting a keynote on this
important topic. Amanda hopes it will be useful to
you and your students and colleagues. Stay well!
 “It’s an incredible job – I love it – it’s my children that keep me
awake at night not my job!”
 “We’ve gone through a really challenging time, but we’ve held
each other together. And I think we’re moving on ..”
 “It was when he said – we’ve got to do this, you’re not well – I
just couldn’t bear it, being a doctor was the only thing I was any
good at…..”
 “It was a relief when I finally ‘fessed up, but it took me two years
to get back to work and I’m still being monitored..”
 “You hear about the high rate of suicide in doctors … but I never
thought about him taking that way out ….”
Doctors’ health and wellbeing
 Why does it matter?
 What affects it?
 What can be done to maximise it
 Personally
 Organisationally
 Professionally
 Next steps
DOCTORS’ HEALTH AND WELLBEING
Key influences
- WHO WE ARE
- THE JOB WE DO
- WHERE WE WORK
- WHO WE WORK WITH
- AND HOW WE PROTECT
OURSELVES AND OTHERS
Why does it matter?
 Doctors are a social investment
 Loss to service
 Harm can occur
 It could be you (and often is….)
 So if ill health can be prevented or impacts minimised
- LET’S DO IT!
Risks – a brief summary of a big picture
1. Doctors are at risk of same things as their patients – this
includes being victims of aggression, being exposed to infective
conditions, and suffering any acute /chronic condition
2. Also risk of aggression as frontline of ‘failures of system’
3. Nature of medical work inherently stressful – uncertainty,
high personal responsibility, negative outcomes happen …
4. Some health systems are less stressful than others
5. Impacts of risk vary – particularly with system stressors,
stage of career, and gender
Risk factors for doctors
Personal factors
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•Personality, gender,childhood stressors, adverse
events
Context
•Work patterns, workload (nature and level of risk),
adverse events, team stressors, access to drugs
Organisational
• Competitive status of doctors: work design,
culture, societal expectations, support (or not)
It could be you / me….
 27%+ UK doctors show significant stress
 7% substance misuse lifetime prevalence
 Doctors have a higher suicide rate than the general
population
 Sickness absence costs the NHS £1.7 billion a year
 High rates of addiction and non-psychotic mental
health problems compared to other professions e.g.
law / teaching
 Different patterns in men and women
Revalidation Support Team & NCAS
Concerns coming forward
Behaviour/misconduct – 57%
Clinical concerns including
governance/safety 64%
24%
22%
30%
4%
7%
6%
Health concerns 24%
7%
Data: n= 1472 cases NCAS 2007 - 2009
Personal contributions
 Being off with depression cost me my job, my marriage and my self esteem
 Another talked at length about the aftermath of an avoidable patient death
and the huge personal guilt and shame this had caused to all involved, as
well as the psychological and reputational impacts of the legal case and
settlement which ensued.
 Another expressed the common experience that services did not work as
well for them as for ‘ordinary’ patients’ – I was crying all the time, couldn’t
get out of bed most of the time when I wasn’t working, but when I went to see
the psychiatrist she hardly asked me anything and certainly didn’t really find
out how I was functioning ….
 A GP whose child had been disabled by an accident said –‘my practice were
really great but eventually it all came down to money and cover, and that’s
when I went really downhill’ – this resulted in long term loss from the
workforce
Personal risks
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Predictors of poor mental health
Prior characteristics:
Selfcritical / introvert
Previous mental health problems
‘Wishful thinking’
Reactive patterns – not coping with stress and
workload, stressed about personal life as well as
work
Gender and doctors’ health
 Women internalise and men externalise
 Men more likely to present with addictions and
evidence of underperformance: women with stress /
depression and burnout
 Violence and aggression against doctors takes
different forms and has different effects
 For women doctors, lower status, lower wages, less
control over work options, and dual burdens of care at
home and at work take additional toll.
Early career years more vulnerable
 South Africa - 76 % residents surveyed experienced burnout,
27% doctors moderate depression, 3 % were identified with
severe depression. Work-load, working conditions and
system-related frustrations were ranked as the most
important contributing factors to burnout
 Nigeria - 50% residency doctors reported their life was
stressful: some residents resorted to the use of alcohol,
cigarette, drugs and medications to handle stress; 61.4%
would pursue another career. Many residents reported
experiencing intimidation and harassment. 31% admitted
emotional or mental health problems during the program.
 Australia - More than two-thirds of the junior doctors
surveyed reported that they had experienced high levels of
stress at work. 54% of respondents were at risk of
secondary trauma or compassion fatigue and 69% were at
risk of job burn-out.
The effects of the system
 Low wages in some countries for doctors
 WHO notes ‘inverse workforce law’ with a shortfall
est. 4.3 million HPs needed to support health care in
developing world
 Rural to urban drift
 Country and system more predictive than speciality
in terms of risks to health
 NB NOTHING in WHO specifically about doctors’
health and wellbeing
Key constructs
RESILIENCE
PROFESSIONALISM
LEADERSHIP
Resilience
1.
‘The ability to succeed, to live, and to develop in a
positive way ... despite stress or adversity that
would normally involve the real possibility of a
negative outcome’.
2. ‘the ability to maintain a healthy trajectory in spite of
adverse events and conditions’
A.k.a. – the bounce back factor!
RESILIENCE
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Construct
– ‘5Cs and an M’!
Confidence (self-efficacy)
Co-ordination (planning)
Control
Composure (low anxiety)
Commitment (persistence)
Make adversity meaningful
Individual characteristics
 Ability to engage with and
utilise others for own
support and development
 Manages negative emotions
 Asserts influence but accepts
external controls
 Learns from past experience
 Seeks and uses supportive
environmental factors
 Practises the use of
protective factors
Developing resilience in training
 Enhance self – efficacy – teach and
 practise coping
with stress, give students meaningful tasks and
feedback, show them that persistence pays off
 Mentoring / tutoring – focus on planning, managing
anxiety, longer term goals and feedback on the 5Cs
 Reflective practice – useful to discuss resilience
 Design graded challenges – building resilience over
time through increasing complexity of curriculum
 Student choice – allow some control and autonomy
 Role models – choose resilient individuals and show
how it isn’t easy!
Resilience, professionalism and leadership
WHAT your learners learn – e.g. ethical dilemmas, risks
to doctors’ health, causes of error
HOW they learn – building up exposure to difficulties,
simulations, leading teams, increasing autonomy
WHO they learn from – role models, diverse patients,
each other, specific reflection on leadership qualities
WHERE they learn – in work settings, in communities
WHY – explicit professionalism & leadership outcomes
WHEN – all through
Organisational interventions
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Recognition and acknowledgement of stressors
Coping strategies
Mindfulness
Work/life balance
Registration with GP, and uptake of services
Supervision / support
Workplace culture
Working time limits
Moderate professional expectations
Recognition of doctors
with problems
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Presentation
Behavioural changes
Absenteeism / less
reliability
Third party concerns
Self presentation
Police / legal concern
Medical intervention –
’signed off sick’
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Barriers to presentation
Fear of / culture of stigma
Ability to deny / minimise
extent
Access to drugs – self or
colleagues
Lack of / loss of insight
Lack of access to services
Loss of confidentiality
Good practice in care of sick doctors
 Explicit acceptance that this
will happen to some
 Particular compassion –
major threat to identity
 Clear policies of support
 Additional confidentiality
 Higher index of suspicion
 More proactive followup
 Clear agreements, including
limits of confidentiality
Specialist services (e.g.PHP)
 Option to self - refer
 Rapid confidential
assessment and plan
 Multi-disciplinary team
 Occupational health
expertise
 Knowledge of HR and
regulatory / legal side
 Context of public safety
And what about the ‘system’?
 Should work with these principles not against
 Additional protective factors at organisational level >
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alertness to risks in the system
regular managed timeouts to discuss problems
shared responsibility to act on stressors and risks
acceptance of responsibility for acting on difficulties
culture of support , safety and confidentiality
external networks, partnerships and strategies
Relevant team CPD ; ‘hardy training’ …’team resilience’
Tests of resilience – family medicine
approaches work for difficult situations
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Need for support which is
• Person focussed
• Available over time
• Can address multiple needs
• Co‐ordinates / plans for risk mitigation
• Uses a team and supports that team
• Connects with others and shares pain
• Uses existing systems but builds more
Is Wonca a resource for resilience?
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Meets criteria
Support networks
External status
Shares innovations
Persistent / committed
Makes FM more
meaningful
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May need to consider
Infrastructure
Sustainability
Inclusivity
= ? Re. efficacy and
planned approaches
Risk assessment and
management
External alliances
More research!
Eight principles for being a resilient doctor
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Make home a sanctuary
Value strong relationships *with the right kind of people!
Control stress not people
Recognise conflict (and distress /upset) as an opportunity
– work out what’s wrong and try to change it
Manage bullying and violence assertively
Have an annual preventive health assessment
Get our medical organisations to work for us
Create a legacy
Rowe L, Kidd M. First do no harm. https://ama.com.au /doctorshealth