Doctors Health and Wellbeing. PROFESSOR AMANDA HOWE, MD FRCHP Keynote lecture 26 June 2013 Wonca World Conference Prague

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1 Doctors Health and Wellbeing PROFESSOR AMANDA HOWE, MD FRCHP Keynote lecture 26 June 2013 Wonca World Conference Prague

2 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!

3 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.

4 Doctors health and wellbeing Why does it matter? What affects it? What can be done to maximise it Personally Organisationally Professionally Next steps

5 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

6 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!

7 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

8 Risk factors for doctors Personal factors 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)

9 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

10 Revalidation Support Team & NCAS Concerns coming forward Behaviour/misconduct 57% 24% Clinical concerns including governance/safety 64% 22% 30% 4% 7% 6% 7% Health concerns 24% Data: n= 1472 cases NCAS

11 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

12 Personal risks 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

13 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.

14 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.

15 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

16 Key constructs RESILIENCE PROFESSIONALISM LEADERSHIP

17 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!

18 RESILIENCE 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

19 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!

20 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

21 Organisational interventions 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

22 Recognition of doctors with problems Presentation Behavioural changes Absenteeism / less reliability Third party concerns Self presentation Police / legal concern Medical intervention signed off sick 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

23 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

24 And what about the system? Should work with these principles not against Additional protective factors at organisational level > 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

25 Tests of resilience family medicine approaches work for difficult situations 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

26 Is Wonca a resource for resilience? Meets criteria Support networks External status Shares innovations Persistent / committed Makes FM more meaningful May need to consider Infrastructure Sustainability Inclusivity =? Re. efficacy and planned approaches Risk assessment and management External alliances More research!

27 Eight principles for being a resilient doctor 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. /doctorshealth

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