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Safeguarding the wellbeing of doctors

The RCPI’s Director of Health and Wellbeing Prof Gaye Cunnane speaks to Paul Mulholland about her role and why wellbeing should be at the forefront of doctors’ professional lives

When Prof Gaye Cunnane was doing a three-year clinical and research Fellowship at the University of California, San Francisco, US, she received an acknowledgement from a senior medical colleague that has stayed with her ever since.  She was specialising in rheumatology, with new treatments for lupus the focus of her research.

“I was on-call, and in the middle of the afternoon, I was asked to go down to the emergency department to see a sick patient,” Prof Cunnane told the Medical independent (MI).

“I went down to see her and chat to her and her husband. I figured I knew what was going on, even though nobody else had figured it out because it was a rheumatological disease. And I took some fluid from her knee; I went off to the lab to look at it myself; and I came back to say I knew what the diagnosis was, and obviously the treatment.

“There were a few junior doctors there, and there was an older guy who I knew to be a consultant. I told them about the situation and how I had come to the diagnosis and what the treatment was. And then I left as I would do on a normal afternoon, nothing to remember.

“Except that a few days later, I got an email from my boss. And this email had been written by the chief of the emergency department, who was the older guy I had been talking to, but I didn’t know who he was. And he just wrote about what a wonderful experience it was having me down there; that I had assessed the patient thoroughly; I had come up with treatment plan; I had taught the junior doctors; and had done a good job in terms of patient satisfaction.

Prof Gaye Cunnane

“But in fact, when you look at all those things, they’re just ordinary. That’s what you do every day, but nobody recognises it. I was really thrilled that something as simple and as core to being a doctor was actually recognised and put in writing. So they were able to recognise the good things for what they were. That has nothing to do with money; it’s everything to do with a doctor and a patient and students doing an ordinary good job.”

Prof Cunnane is Clinical Professor of Rheumatology and a Consultant Rheumatologist at Trinity College Dublin and St James’s Hospital. Almost a year ago, in April 2019, she was appointed to the new role of Director of Health and Wellbeing in the RCPI. The interaction with the senior colleague in the US has been fundamental in shaping her view of how senior medics should communicate with their junior colleagues.

In the RCPI’s office in No 6 Kildare St, she told MI that the reason this does not happen more often is that consultants are under intense pressure due to staffing and resource shortfalls. Also, she said it is “not part of our culture to recognise and praise”.

Prof Cunnane provided two examples of this reluctance to praise. The first was when she was home from the US on a short visit.

“I was at a party where there were a lot of other medics,” she said.

“I was telling them what a great time I was having, how wonderful everybody was, and how much I was praised. A consultant had overheard [what I said]. The consultant turned around and said: ‘Surely you don’t believe all that rubbish, do you?’ I thought it was a good contrast between the two systems.”

The other example was when Prof Cunnane had returned from the States and had taken up a role as consultant in St James’s.

“Not long after I returned, I was doing a post-call general medical ward round,” she said.

“It was near the end of the round. The junior doctors had been up all night and had been very busy. I said: ‘Thank you all very much, you have all done a wonderful job. You really admitted the patients very well’. I turned around to the next person and said: ‘You’ve done a great job there. Well done for spotting that abnormality.’ And one of them started to cry. I said: ‘Oh gosh, I didn’t mean to upset you by what I was saying. What did I do to upset you?’ And she said: ‘No, it’s just that I’d never been praised before.’ I think it is a function of busyness and stress. It is a lack of a culture, but it is also a lack of role modelling.”

Director of Health and Wellbeing

It is this culture that the RCPI is trying to change with the creation of the role of Director of Health and Wellbeing. Physician wellbeing has been a high-priority issue within the RCPI for the past number of years. The College has provided support, training and information to doctors at all stages of their careers through its physician wellbeing programme since 2014. The Director of Health and Wellbeing is responsible for overseeing initiatives to help trainees cope with the pressures of a career in medicine. Prof Cunnane is charged with developing a strategy for health and wellbeing in the RCPI and will be an advocate and spokesperson on behalf of the College to increase awareness of the importance of doctors’ wellbeing. In October  2019, the health and wellbeing department was formally launched. It is staffed by a full-time psychologist, Ms Hadas Levy.

“I think it was recognised by the College that there are an awful lot of stresses involved in being an NCHD,” according to Prof Cunnane.

“There was huge concern about the whole issue of retention of junior doctors, and the fact that they were and still are, unfortunately, exiting in their droves. So it was really for those two reasons. Unfortunately, there had also been some suicides.

“And there was really an opportunity to ask questions about what we can be doing better, and how can we prevent that enormous level of stress. It was really there to deal with those issues but also to proactively help trainees, to proactively support them and not wait until a crisis develops but actually see can we make this a better environment for training.”

Prof Cunnane’s role is for two days a month, which she said “is very little”, though this may evolve in the future. However, she said the role is important in demonstrating that the College is taking wellbeing seriously, and for providing a new resource for young doctors who are struggling, either professionally or personally.

“It allows us to actively support trainees in difficulty,” she said.

“We actively encourage trainees themselves who are struggling in any way, whether it be a physical or a mental condition, or a psychological issue, a bereavement, a training difficulty, not being able to keep up. If there is anything at all, the door is open for them to contact us.

“Our job then is to try and figure out a path for them. We are not obviously going to solve any of those individual problems, but we will help them navigate the system. Where there are issues of professionalism, we would work directly with the NCHD or the trainee to help them develop the skills to be more professional, to help them develop insight as well.

“Sometimes it is about career choices, career dilemmas, and again, we will help them with all of that. But it is also about giving a voice to the whole issue of wellbeing because previously, it was thought that wellbeing wasn’t that important.” (See panel 1 for details on referrals to the department.)

Basic factors

Prof Cunnane said that often basic factors can affect a doctor’s wellbeing.

“It is about something as simple having enough food when you are on-call,” she said.

“Believe it or not, that doesn’t necessarily happen. A lot of the canteens are not open. When I was a junior doctor, I used to have this big bar of chocolate that I used to make my way through because sometimes it was my only sustenance for 36 hours. And it hasn’t changed that profoundly since then. There is often not a degree of healthy or suitable food.

“It involves being adequately hydrated at work. Often there aren’t opportunities if the junior doctor is very busy to be adequately hydrated.

“It also involves sleep. Obviously, as a doctor you have to do call, and not having sleep is part of the job but it doesn’t have to take over to the extent that it ruins somebody’s life. And I think we need to have further conversations about on-call and how to do it optimally so that patients are looked after, but also that doctors aren’t suffering unduly because of it.”

Prof Cunnane also said it is vital doctors have time for “reflective practice”. Unfortunately, with the pressure staff are under, this is not always possible. She pointed out that some hospitals have Schwartz Rounds. These provide an opportunity for staff from all disciplines across a healthcare organisation to reflect on the emotional aspects of their work, which can be very beneficial.

“If you were working all day, seeing loads of patients, and then you go home, what have you learned from that? You have learned that you are very tired but you actually haven’t learned much about whether you have done something excellently, or half-right, or maybe not right, so having that time to discuss patients and have time for reflective practice is something we badly need to build into the system, and something we really don’t currently have.”

EWTD

Other reasons for burnout are not so straightforward to address. Prof Cunnane cited research showing that between 50 and 70 per cent of physicians are burned-out at any one time.

“So it is not due to individual lack of resilience. Studies have shown it is a work-related phenomenon, so it is due to the environment.”

Burnout is different than simple tiredness, she said.

“What it basically boils down to is a pervasive sense of loss of purpose and a pervasive exhaustion. So it is not just feeling ‘I’m tired because I’ve doing a bit of call’; it’s actually a much more pervasive and dangerous phenomenon than something as simple as that.”

Initiatives to address burnout should take place at an institutional rather than an individual level. This can be complicated. Take the European Working Time Directive (EWTD) as an example. While it was introduced to reduce the working hours of junior doctors, Prof Cunnane feels it has had unintended consequences.

“It is better in terms of working hours, obviously,” she argued.

“But the downside of the European Working Time Directive is that it has ruined the sense of team. Previously, if you were working under a consultant, you were part of his or her team, you had a sense of purpose, a combined purpose. Even if it was difficult, you were all in it together. But with the working time directive, people are doing more shift work, and so you don’t get to know your consultant as well; the consultant doesn’t get to know their NCHD as well. And I think that has contributed to a sense of floundering and a sense of not being properly anchored.”

To address the problem, Prof Cunnane said the RCPI has been encouraging consultants to meet with their NCHDs at the start of their rotation. However, this erosion in the ‘team’ is one reason she feels that the problem of burnout is deeper and more entrenched than in the past.

“Also, the population has increased without a commensurate increase in resources, so there are more people coming in on-call into the emergency department. GPs are busier. That’s all leading to greater business,” Prof Cunnane stated.

“Technology, while again I support it, it is fantastic, I think that whole issue of social media is contributing to burnout as well. You get information faster, but that puts pressure on as well. There are greater expectations on the part of patients as well, and again that puts pressure on.”

Wellness officers

Are wellness programmes only a sticking plaster to cover resource deficits in the health service? Can progress only ultimately be made if gaps in staffing and service provision are filled? Prof Cunnane responded “yes” to these questions, but added that wellness programmes are of immense value and give “hope” to doctors individually, and as a group.

“And hope comes from knowing we have a concerted effort to have a voice that improves things,” she said.

“I think that is very important, that we all work together to improve, and to keep telling the politicians, and for the NCHDs to see that we are doing that, that we are not just accepting the status quo. We are saying that it isn’t good enough and we need to do more.

“Where the wellness programmes come in is to make sure the NCHDs and the trainees do have the skills to manage, because we are all taught about the patient. It is all about the patient, it is all about if the building is on fire you get everybody else out before yourself, which is fine, except that issue of self-care is something we were never taught in college. And actually we need to know about self-care, we need to know about boundaries, all of those things are very important just to function in a system that is as busy as the hospital and medical  environment.”

Prof Cunnane would like to see a system of peer support introduced, whereby senior trainees are trained to offer support and be a point of contact to younger colleagues who are having difficulties. These senior trainees would have to be adequately supported themselves, she added.

Both she and the department’s psychologist will be meeting hospital managers throughout the country later this year to highlight the RCPI’s wellness initiative and the importance of wellness in general. Prof Cunnane said some hospitals take the issue more seriously than others.

“A hospital that I won’t mention that is familiar to me, their ‘wellbeing’ involves a colourful A4 page, with all sort of nice circles on it, but that’s very meaningless.

The phrase is, ‘we don’t need yoga or an apple; we want more real support’,” she said.

“What I would really like to see, and what is very commonplace in the States, is to have to have a wellness officer in each hospital and that person is responsible for the health and wellbeing of the staff to make sure these processes are in place. And that is where I would ultimately see this role going.”

The Health and Wellbeing Department is available to all trainees who are in difficulty. Trainees can self-refer by emailing wellbeing@rcpi.ie or be referred through their NSD/trainer/RDP.

Panel 1

The practicalities of support

Since Prof Gaye Cunnane was appointed as Director of Health and Wellbeing at the RCPI, there have been approximately 30 referrals to the service. Trainees can make contact with the wellbeing department, either by phone or email. Trainees can also be referred by their trainers.

“Some of the data we have out of those 30 people who were referred is that most of the distress seems to happen at a young age and an earlier stage in their career,” Prof Cunnane told the Medical Independent.

“So if you reach SpR stages, you probably have the mechanisms to deal with most of the stuff you come across. But when you are at a younger age or [earlier ] stage, you may not have those skills.”

Another commonality among those who have been referred to the service is that they often do not have family members who are also medics, according to Prof Cunnane.

“In terms of being able to talk things out, that can sometimes be a very useful resource,” she said.

“That would be the other major piece of evidence just from that small cohort.”

Part of the office’s role is to provide trainees with information about support services that are available, such as the HSE’s Employment Assistance and Counselling Service and the Practitioner Health Matters Programme, run by Dr Íde Delargy.

Prof Cunnane said many trainees are not aware of the supports available to them.

In time, Prof Cunnane would like to see the RCPI’s service play a greater role in prevention. She also believes that more support should be provided to trainers.

“There is another thing that isn’t within my remit, but I think is really important, and that is support for trainers,” she said.

“Because if you have a trainer who is burned-out it is going to be really difficult for them to support the trainees and they are not going to be a good role model in terms of the junior doctors either.

“I think that is a separate issue, but it is an important issue. What I would really like to see is this whole concept of wellbeing from students right up to retirement and even beyond retirement, because of course people suffer in retirement as well. That is really important.”

Panel 2

A career in rheumatology

After graduation from medical school in Trinity College Dublin, Prof Gaye Cunnane completed her basic clinical training in medicine and then undertook PhD studies at University College Dublin and St Vincent’s University Hospital, where she investigated serological and tissue prognostic markers in early inflammatory arthritis, in collaboration with universities in Switzerland, (Zurich), The Netherlands (Leiden), the UK (Cambridge) and Sweden (Karolinska, Stockholm). She then completed a three-year clinical and research Fellowship at the University of California, San Francisco, US, where the focus of her research was on new treatments for lupus.

In 2001, she moved to the UK to work as a Senior Lecturer at the University of Leeds, and in 2003 returned to Ireland to take up her current post in St James’s Hospital.

She was the National Specialty Director for Rheumatology training in Ireland from 2005-2012, Programme Director for Basic Specialist Training with the RCPI from 2009-2017, and is a past-President of the Irish Society for Rheumatology.

Her recent research interests have focused on lifestyle risks in rheumatic diseases.

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