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Myth of the superhumans

At a recent Medical Council event, President Prof Freddie Wood provided a jarring insight into attitudes to doctor health within the profession.

Recounting how he called for greater pastoral support for doctors after becoming Council President in 2013, he revealed that this message was not initially well-received by fellow doctors. It seemed the myth of the superhuman was still alive and well.

 “I got a lot of criticism from my professional colleagues for it – ‘oh we don’t need it’ – when in fact we do,” said Prof Wood, a pioneering cardiothoracic surgeon during his medical career.

Until recent years, doctors were expected to have a “stiff upper lip” and not speak to anybody about their problems. This was “probably because the profession was predominantly male orientated”, said the Council President.

The Council believes it is important for the profession to provide care and treatment access for doctors, said Prof Wood, who referred to recent positive developments in this regard. These include the establishment in 2015 of the Practitioner Health Matters Programme (PHMP), an independent initiative with which the Council has signed a Memorandum of Understanding (MoU), and also the development of supports and resources by a number of membership/postgraduate colleges.

Complexities

It is well-recognised that there are particular complexities around doctors presenting to health services. They often don’t access healthcare in a conventional manner (eg, ‘corridor consultations’), suffer higher levels of burnout than the general population, and frequently present late and in crisis where issues arise. They also have easy access to prescription medicines.

These factors intersect with perfectionistic traits within the profession, the huge demands of medicine and stressful working environments. Moreover, many doctors have a reluctance to present for mental health treatment due to fears over confidentiality.

According to the 2011 paper in the Journal of Mental Health, ‘Review of literature on the mental health of doctors: Are specialist services needed?’ (Brooks et al), there are “contradictory reports about the prevalence of mental ill-health in doctors, but it is generally agreed that doctors face a large number of risk factors, both occupational and individual; and help-seeking is difficult due to complexities surrounding a doctor becoming a patient”.

In his role as Clinical Director at St John of God Hospital, Dublin, Dr Richard Blennerhassett sees doctor-patients “suffering from stress and the gamut of psychiatric conditions”. However, he notes that most people in demanding jobs “are more stressed these days”.

‘It is a time in their lives when maybe they are thinking about getting married, having children, buying houses…’

 “Contact with patients does put a particular demand on doctors, as they are seeing people at their most distressed, expectations have never been higher, alongside a more litigious environment,” adds Dr Blennerhassett.

He acknowledges that medical schools and postgraduate training colleges are now more aware of the need to help doctors better manage their own health.

Tragedies

The RCPI arguably has the highest profile of the postgraduate training bodies in the area of doctor health. Its ‘Physician Wellbeing Programme’ encapsulates a number of courses and workshops tailored towards doctors to help manage stress and “workplace challenges”.

Dr Blanaid Hayes, Dean-Elect of the Faculty of Occupational Medicine, RCPI, refers to growing recognition in recent years that education of doctors needs to “integrate wellbeing themes”.

Dr Hayes recalls tragic circumstances whereby two young doctors in Ireland died by suicide in 2012. This was a poignant catalyst to the College increasing its focus around doctor health. While doctor suicides had happened in the past, the fact that these two tragedies occurred in relatively close proximity – and both involved young medical SHOs – struck a chord with a profession that was beginning to contemplate the delicate issue of doctor health.

Dr Hayes recalls a meeting being convened at the College and one of the outcomes was a commitment to researching the area.

Since 2014, Dr Hayes has been leading an important research project into the wellbeing of hospital doctors in Ireland. It is a collaborative project governed by a multi-stakeholder steering group that includes representatives from the RCPI, RCSI, College of Anaesthetists, College of Psychiatrists of Ireland, Irish Association of Emergency Medicine, and Dublin City University.

The first findings were reported in BMJ Open in December 2015 (‘Quality care, public perception, and quick-fix service management: A Delphi study on stressors of hospital doctors in Ireland’).

According to the paper, over 90 per cent of consultants and trainees interviewed considered work stress to be a very significant or highly significant problem. Consultants indicated that their greatest concern was lack of long-term planning. “They feel insecure within the system of which they are part and powerless to influence what matters to them. This is an important finding as lack of control is well recognised as a predictor of workplace stress.”

The top-ranked stressor for trainees was the revision to the consultant contract “with its attenuated terms and conditions”, which had “devalued the role of consultant, contributing to low morale”.

Trainees “perceive their employer and the media as having contributed to a negative working environment and lack of trust”, noted the paper.

Grave concern

The second stage of the research project will centre on results from a national, randomised, cross-sectional questionnaire study carried out in 2014. This data captures prevalence of stress, depression, anxiety, and burnout among hospital doctors. The findings have yet to be submitted for publication, but it is safe to say that they won’t make pleasant reading.

“It is drawing a picture that I think is a source of grave concern,” comments Dr Hayes.

She hopes the measurements were taken at possibly the worst time in respect of the pressures on people working in the health service and that future research will present a brighter picture.

“I am hoping we will do the measures again, or very similar measures, maybe next year and that we might find things to be a little bit better,” she says.

“But certainly the measures we took used internationally well validated instruments that have been used on similar populations of doctors. We found the levels of psychological distress – and all of the negative markers – we found them to be very high, compared to other comparable studies in other countries; very, very high. So I won’t be coming out with good news. And anyone who is trying to say ‘but oh, it is different’, I will be saying, ‘I used the very same instrument as other people have used and this is what we found.’”

Dr Hayes feels that doctors are beginning to recognise that there is a need for them to think about themselves. “And certainly this group of trainees now is much more informed than trainees would have been even 10 years ago – that it is okay to think about your own needs and how you might address them and where you might look for help.”

The RCPI has included a page on wellbeing in the curricula of its basic specialist and higher specialist training programmes. 

“I think it is very gratifying that now there is a whole page in those curricula that is dedicated to wellbeing and that has only really just happened in the past year. In other words, all of the attention was on all skills and competencies that you need to be a good doctor, for your patients, but now we are not just paying lip service – ‘oh you need to look after yourself’.”

Dr Hayes acknowledges that inclusion of wellbeing in curricula won’t change things overnight “but it is another step in the right direction – making it legitimate and okay to think about how we look after ourselves”.

There are also a number of specific courses run by the RCPI. Physician Wellbeing and Stress Management (formerly SafeMed) is available to basic specialist trainees; the building resilience programme is mainly availed of by senior trainees and by some trainers; and there is also a meditation training programme. Another course, Identifying and Managing the Distressed Trainee, is run for trainers.

She also recognises the wider workplace and societal factors that impact on doctor health. The  study in BMJ Open reflected a very difficult workplace environment. 

Dr Hayes believes that HSE National Director of Human Resources Ms Rosarii Mannion is “very engaged” with these issues.

“She has appointed a National Clinical Lead in Occupational Health but the organisation is so big and unwieldy and there is so much of a legacy of understaffing and so on, that really, until those things are turned around, it is very difficult to get any traction on the kinds of things she might be wanting to implement.

“We certainly fed back that information [from the study], but I think what they are particularly interested in now is the further data, the quantitative measures, the measures of burnout, distress and all of that….”

In a health sector that lurches from one crisis to the next, it is difficult to attract a sustained focus on the health of those delivering services. Ultimately, under-staffing impacts hugely on stress levels, outlines Dr Hayes.

“You can talk all you like about wellbeing, mindfulness and so on, but if you actually haven’t got the bodies on the ground to deliver the care, then it sounds a bit cynical to be coming and trying to fix it with wellbeing tools like mindfulness, when really what it needs is more bodies on the ground, more staff.”

Meanwhile, Medical Council research found that while many trainees reported positive mental health and wellbeing, two-in-10 had scores which “indicated that they may be in need of mental health and wellbeing support services”.

“Trainees who reported experiencing ‘bullying’ and ‘undermining’ also reported poorer health and wellbeing across a number of indices, including: general health, quality-of-life, mental health, and wellbeing and work engagement,” said the Your Training Counts special report on health and wellbeing, based on 2014 trainee survey data. “Trainees who reported working a greater number of hours per week also reported poorer health and wellbeing across a number of indices, including: general health, quality-of-life, and mental health and wellbeing.”

Trainees in larger hospitals were significantly more likely to rate their quality-of-life as less than good (43 per cent) compared to trainees in GP practices (22 per cent).

Does the RCPI and other training bodies need to be more rigorous in inspection of training sites?

“I think the colleges are getting more rigorous,” says Dr Hayes.

 “There are difficulties, though, because sometimes the trainees – very understandably – can be very reluctant to give negative feedback because they are concerned that might impact on their own career progression…”

She says this is something the College is working on with trainee representatives. “I think the training bodies are very mindful that that is a concern and that we need to get meaningful feedback that can be acted upon.”

Does she find that consultants have been slower compared to trainees in recognising their own health needs?

Dr Hayes says many consultants have been “at the forefront” of promoting doctor health. Nevertheless, there are generational and societal aspects to consider, independent of any dichotomy between consultants and trainees in this area.

“It is unwise to pick out consultants versus trainees and ignore the societal context from which those populations are drawn, which is a very different experience, very different generational moulding if you like,” she says.

More broadly, there is a need to examine how younger populations are being brought up, suggests Dr Hayes. “They need to learn that it is okay to fail sometimes,” she says.

‘I wouldn’t be alive today’

Fear should not prevent doctors reaching out for help.

This is a message from a GP in practice, who has had engagement with the Medical Council’s Health Committee. This doctor reports being sober following a long history of active alcoholism. They wished to remain anonymous for this article.

Some years ago, the doctor came to the attention of the Council and strict conditions were imposed on their practice. “I fully believe but for these conditions that were imposed on me and moreover the commitment shown by two of my [medical] colleagues to make sure I complied, I wouldn’t be alive today.”

The former Sick Doctors Scheme (which has since been subsumed into the Practitioner Health Matters Programme) was helpful, as was the Council’s Health Committee.

Since resuming practice, the GP has encountered from colleagues “nothing but the offer of support and practical help”. In a broader context, some in the profession had “less than generous” views, but levels of support outweighed these sentiments.

The GP says their patients were “remarkably loyal” and “extremely understanding and supportive”.

They also had a sponsor through Alcoholics Anonymous (AA) who became a “mentor and friend” and was a hugely valuable support.

Some doctors with health issues have experienced less positive interactions. Dr Maria Monica Harriet Stack, a registered doctor with a Co Kerry address, has health-related conditions attached to her registration.

She says that her case of trigeminal neuralgia type 2 was mistaken in some quarters for psychological illness. Dr Stack, who is a qualified GP, says she tried to work through the pain. She was referred by a colleague to the Medical Council without consent, she contends.

Dr Stack claims that the Council is much less interested in medical issues affecting doctors.

“You are not side-lined by the Medical Council if you’ve got a medical diagnosis, they don’t want to know. They are not interested if you have got diabetes, hypertension; you could be on death’s door with congestive cardiac failure or anything else and they think you are perfect.”

However, if it is considered that one has a psychological condition, the Council is wary of encouraging the doctor to return to work, she claims. She believes there is a deficit of supports for doctors returning to practice after absences due to various forms of leave and ill-health.

However, she points out that the ICGP holds an intensive refresher course in therapeutics and recent advances in general practice. Nevertheless, the course fees, travel, and accommodation in Dublin amount to an investment of several thousand euro. She is currently enrolled in the course and is also undertaking other educational activities. Dr Stack says she is not practising at present.

“There is no system in place to get people back into education, to upskill so they can get back into practice, and then of course people are left by the wayside… the whole thing needs to be overhauled. Tweaking here and tweaking there isn’t going to work. You know what, it is like Ballymun flats – the system has to be knocked.”

Occupational health

Dr Hayes is a Consultant Occupational Physician at Beaumont Hospital, Dublin. Occupational health services are sometimes viewed through a prism of suspicion by healthcare professionals and Dr Hayes says this is another issue that requires further attention.

“My own experience working in a hospital where we have an onsite service is that people are much more open to using occupational health now. But that is maybe partly as we have an onsite service, I am out there, I am presenting at ‘grand rounds’ and people see me around, and so on. It might not be quite the same if the service is 30 miles away.”

Her sense is that healthcare professionals are beginning to view occupational health “as a resource they can access” rather than as a service to which they are referred as a ‘reprimand’.

Practitioner health programme

One of the most notable developments in addressing doctor health in Ireland took place in 2015 with the establishment of the PHMP. It was born from growing evidence that specialist confidential services can help medical professionals present earlier and avoid full-blown crises that may affect or endanger their practice.

The independently-run programme offers confidential assessment, support, and treatment to any doctors, dentists, or pharmacists concerned about mental health or substance misuse issues.

It operates on a not-for-profit basis and is funded primarily by voluntary contributions and professional associations. The PHMP has developed a MoU with the Medical Council, which defines a narrow set of circumstances where the PHMP would be obliged to refer a doctor to the Council; principally in circumstances where the doctor represents an immediate risk to themselves or the public interest. Presenting doctors are informed of this obligation when they first enter the service.

PHMP Clinical Lead Dr Ide Delargy says awareness of the service, which was launched a year ago, is growing.

“We are having a steady flow of people referred to the programme, mostly self-referrals, so I think the word is getting out there,” she tells the Medical Independent (MI).

Dr Delargy says the “main group of people we are seeing are trainees – they are young doctors mostly in training. They are the bulk of the people we are seeing, with (also) a number across disciplines; a number of GPs, a number of consultants, and a couple of referrals from medical students.”

She indicates that stress and mental health problems are the main issues.

Dr Delargy says trainees are under particular pressures for various reasons: Chief among these is their working environment and personal stressors.

“It is a time in their lives when maybe they are thinking about getting married, having children, buying houses – it is a time when all of those additional pressures are on them as well as the pressures to progress through their career.

“So I think there is a recognition that it is a particularly stressful time in their lives and if anybody has underlying vulnerability – be that of a mental health nature – when you put on these additional stressors, then sometimes it can be enough to tip them into difficulties and they need some help and support in terms of how they might cope with those. That is what the service will provide – a full assessment of their needs, support them in the journey of recovery, and get them back to health again.”

The service’s first annual report will be published in early 2017 and will include broad information on the numbers presenting.

“In the scheme of things, the numbers are relatively small. We are talking upwards of 35 people – that’s the general number at the moment (across the health disciplines).”

Dr Delargy says that doctors presenting to the service appear to be aware that it operates independently of the Council, which she is “relieved” about.

She says much effort has been focused by various organisations on doctors becoming more aware of their own health and wellbeing. But more work is required at an earlier stage in doctors’ development.

“I guess human nature being what it is, most people think it doesn’t refer to them until they are in crisis or in difficulty. I believe it really needs to be flagged at an earlier stage and one of our aims and goals is to develop a module we could deliver at undergraduate level,” she says.

There is some work undertaken at medical schools but it could be enhanced, she concludes.

Meanwhile, the ICGP Doctors’ Health in Practice Programme is another valuable health resource for GPs and their families.

Its healthcare networks and helpline can be accessed by GPs and their families (www.icgp.ie/go/in-the-practice/doctors-health).

*Dr Blanaid Hayes will address the National Education Day for Doctors in Training (Wednesday, 19 October) at the RCPI St Luke’s Symposium 2016, which runs from 18-22 October. The overarching theme of the trainee day is physician health and wellbeing and a special booklet for trainees will be launched. To book your place, visit www.rcpi.ie/stlukes2016/

*For further information on the PHMP, visit www.practitionerhealth.ie.

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