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More than resilience: why we need to shift the conversation around doctors’ wellbeing

 

You’re a keen, first-year medical student. Today, you’re practising breaking bad news to patients – actors of course, but boy does it feel like the real deal. Before you begin, the whole room stops. You all close your eyes, and practice mindfulness – just for three minutes – but as you return to the room, you find you’re truly present and ready to take on this consult. You each have your turn breaking bad news. You have to tell a father that his six year old daughter has died. You fumble through the conversation. You almost cry with him. You collect your things and leave, once all your colleagues have had a turn, but you return to that workshop later that evening through your reflective journal. What did you learn about this skill? More importantly, what did you learn about yourself? And how, when you’re faced with this in future, are you going to do better, or differently?

Medical school equipped me with a skill set in addition to that of clinical medicine. The extras included how to manage difficult relationships in the workplace, dealing with emotionally challenging experiences, how to be vigilant of my own health and wellbeing, and simple practices I can employ throughout my practice and life to make myself the best doctor I can be. These skills were reinforced in my intern education sessions and at multiple conferences. I’m now a junior doctor – an occasionally very stressed, often very busy, and at times burnt-out junior doctor.

We know doctors have high rates of emotional distress and mental health issues. But our conversation around this is fixated around teaching more personal resilience skills at medical school. I’ve been taught these skills, and many medical schools have a similar emphasis to mine. Why, then, does this continue to be the centre of our conversation on doctors’ wellbeing? Yes, we should continue to pressure medical schools, teaching hospitals and training colleges into fostering these skills in their trainees. But we urgently need to broaden the conversation.

Junior doctors are often put in positions where we are stretched to our limits both personally and professionally, with immense workloads, long hours, having to adapt to a new department, system or even hospital every five to ten weeks. On top of this, we need to remain competitive and employable by doing research, extra degrees and study for training programs. We exhaust all our energies and wellbeing strategies managing these challenges, leaving us with little to give when faced with a difficult case, complex scenario, or personal challenge.

The daisy in the desert

A daisy won’t grow in a desert. We’ve made enormous strides in teaching doctors resilience: now need to broaden our focus to the system itself. We work in an environment where the bar is set close to perfection. We rarely forgive ourselves for our mistakes. We work ourselves harder than we could have imagined, to ensure the very best for our patients. We work unpaid overtime, we skip meal breaks. Honestly, there are days when I wonder if my own creatinine isn’t higher than my patients’.

So let’s do some primary prevention. Let’s work on the things further upstream that affect our wellbeing. Perhaps we need to start with the simple things: making sure we take a lunch break. Or even just a water break, so we’re not so dehydrated we don’t even need to go to the bathroom. We need supportive and positive feedback, not only highlighting what could have been done better. We need leaders who encourage and support us in these endeavours. Find the issues causing your colleagues to burn out, and find a way to create change. We need to look at the bigger picture and see how we can alter the desert, not the daisy.

This conversational shift comes with a risk. Let’s go back to some high school physics – bear with me, I promise it’s worth it. Force = pressure x area. We’ve been focussing on one part of the conversation – a small area. So a little bit of pressure, and we get a reasonable force. If we broaden the conversation without the extra pressure, we risk reducing our impact. The challenge is to not get lost in the vastness of this problem – find the next, impactful step and take it, and remember the endpoint. The goal should not be more resilient doctors. It should be doctors working in environments that allow and encourage them to be healthier, happier people. That allow us to use our resilience skills to tackle challenging scenarios, not the everyday.

With all this in mind, my challenge to you is this. Find one small change to make, that will make you happier and healthier at the end of the day. Find it, and make it happen. Let’s share our simple step with a colleague from a different practice or hospital, find what they have changed and swap ideas. Let’s encourage leaders to support this, and advocate for changes that need to occur. Let’s create a subtle creep of wellbeing that isn’t taught in a lecture theatre. And then, let’s tackle the desert.

Dr Nicola Campbell is a resident medical officer currently working in regional Queensland. She studied medicine at Griffith University and aspires to be a rural GP with an advanced skill in mental health.

Doctorportal hosts a dedicated doctors’ health service providing support in the medical community.

For further support and information, call Lifeline on 13 11 14

What are we training medical students for?

 

When young people go to medical school they are called medical students. They know that they are to learn about medicine. Everything about medical school is about learning about medicine. In fact, every waking moment is about learning about medicine.

We learn about anatomy, physiology, statistics, how to read a research paper, how to do a research project, we learn about diseases, pathology, histology, how to examine patients. We learn the right questions to ask in the right way to get the information that is needed.

We endlessly learn about rare diseases, treatment protocols and how to do various procedures and operations. Our whole lives are consumed with medical information.

But is this all that there is to medical school?

Of what value is all the medical knowledge in the world if the person holding that knowledge is miserable and unwell themselves, struggling to work and struggling to cope with people?

Students graduate at the age of 24 (at least) after the most intensive periods of their lives where literally every moment is dedicated to learning as much information as possible.

It has even been said that medical school is a prolonged period of adolescence where life skills are not learned, but one simply has to learn what other people tell you.

There is no time to notice anything else about life. Finances, relationships, property, politics, community engagement……sleep….. everything comes a distant seventh to medical school and learning. Life itself is an afterthought, something that one attends to only if one has to.

Our medical students are not taught about how to conduct or engage themselves in an empowered way in day to day life. They are taught how to recall information, pattern recognise and survive ward rounds.

But how to be in all aspects of life determines how well we are in life, not how much we know about facts.

Our statistics tell us how unwell our medical students and doctors are.

Medical students and junior doctors are not taught how to take care of their own health and well-being, and in fact the very nature of the setup of medical training encourages and fosters them to ignore their own health and well-being.

Our high rates of mental ill health, suicide and physical ill health are a painful reflection of these low standards of self-care in medicine.

  • Medical students are not taught how to take care of finances.
  • They are not taught how to be empowered and to run a business.
  • They are not taught the basic skills of marketing and business administration that people in engineering or even beauty school are taught, even though finally after a prolonged period of education and working they will be working in businesses in the community.
  • They are not taught how to have relationships with people that are equal, loving and caring that go beyond the arrangement of role of doctor and patient.
  • They are not taught about the importance of caring for their physical bodies, and indeed much of medical culture in fact promotes the stressing of the human body and mind, asking it to go beyond its limits without care for how it needs to be literally cared for.
  • They are not taught how to take care of their mental health, with instead judgement and criticism, condemnation and the drive for unattainable perfection being the daily ingrained forms of communication in medicine, none of these building self-esteem or self-worth.

The health and well-being of us doctors is poor. We are not happy; over 50% of us are burnt out. Our suicide rates are at least 2 times higher than the general public, with some studies pointing to 5.7 times higher, and these are only the suicides that we know of. We have higher rates of anxiety and high psychological distress than the general public.

The pressures on us doctors are very real and put simply, in the health care profession we are barely surviving, and most certainly not thriving.

We know medical facts, but we do not know how to take care of ourselves and keep ourselves well in life.

Doctors are disempowered as people and do not consider themselves as human beings with equal human rights, and instead in the role of ‘doctor’ in training learn to simply accept and put up with the circumstances that they find themselves in.

They agree to working arrangements that would not be accepted anywhere else in the corporate world, with many of them seeing bullying as so normal that they don’t even realise that they are being bullied, or that they are engaging in bullying.

Working relationships in hospitals are toxic between doctors and between doctors and other health care professionals. And let’s not even begin with the relationships that doctors have with administration!! This is accepted as ‘normal’ and something to ‘survive’.

Toxic relationships build bad teams and are bad for our mental health and well-being. This has a knock on effect on patient care.

We know that there are multiple determinants of health and well-being. We need to address all of these in our lives to build health and well-being

  • How are we in relationships? Are we loving and caring?
  • How are we with food? Is it for indulgence and coping with life, or nourishing the body?
  • How do we take care of our bodies?
  • How are we with our finances?
  • How are we with taking care of ourselves, valuing and empowering ourselves?
  • How are we with sleep?
  • How are we with our self-talk, our emotional and mental health?
  • Do we know how to be who we truly are in all aspects of life? Or are we boxing ourselves in, acting in different ‘roles’ in different circumstances?

As health care professionals we need to be the ones to lead the way in the health and well-being stakes to inspire our patients.

Instead at present as a whole we are more anxious, stressed and suicidal than the general public. Something is wrong here.

There are many reasons that our doctors are not thriving.

Rather than focussing on developing doctors who are simply minimally ‘resilient’ to the current stresses and strains, I propose that as part of our care and responsibility for those we train, that we prepare people to be well in life as a whole, in both medical school and in doctor training in hospitals.

If we don’t prepare our students to be well, then we are leaving them vulnerable with an incomplete education in the world. And thus far the statistics are speaking for themselves.

We need to prepare our students to be well. And we need to design our systems to support our doctors to be healthy and well and not simply ask them to put up with systems the way that they are when they are not honouring of dignity, decency or respect of general human rights.

Care for people is the foundation of health care. To move forward as an institution that leads the way in health care we need to place care for all people firmly at the foundation of our training and our work ethos, beginning with our medical students.

As part of that care, it is important for us to design programs that not only teach students about the nitty-gritties of medical knowledge and information but arm them with the tools to thrive and to live well in all areas of life; how to take care of themselves, value themselves and empower themselves in all areas of life.

Our educational processes and health care systems themselves need to empower our doctors and our students.

Only then will we have a profession that is healthy, well and able to consistently care for others in all avenues of life.

Dr Maxine Szramka (pictured above) is a Sydney-based consultant rheumatologist. She blogs regularly at Dr Maxine Speaks.

Doctorportal hosts a dedicated doctors’ health service providing support in the medical community.

Doctors’ health: the wrap

 

All this month at doctorportal we’ve been highlighting the critical issue of doctors’ health and wellbeing.

The doctorportal website hosts the online resources of Doctors’ Health Services Pty Ltd, an organisation funded by the Medical Board of Australia and coordinated by the Australian Medical Association. Its aim is to ensure doctors and medical students, no matter where they live in Australia, have access to consistent and readily available services, including advice, referral and health-related triage.

Here’s a roundup of doctors’ health stories we’ve covered at doctorportal this June:

For more information about health issues for doctors, access a range of online resources from Doctors’ Health Services Pty Ltd.

Or phone:

NSW and ACT … 02 9437 6552

NT and SA … 08 8366 0250

Queensland … 07 3833 4352

Tasmania and Victoria … 03 9495 6011

WA … 08 9321 3098

New Zealand … 0800 471 2654

Lifeline on 13 11 14

beyondblue on 1300 224 636

How a stroke made me face up to my depression

It took a minor stroke before I was able to take much-needed leave from work. But it wasn’t the stroke I needed to most recover from – it was the severe depression I had that was many times worse. The stroke afforded me the time and space I had wanted, and needed, in order to recover.

– Geoff Toogood

 

In 2013, I faced major stresses at work and my marriage was ending. It got the best of me. I had experienced moderate depression a few years prior – moderate enough that I could work through it – but this time it was a lot more severe. I was so depressed and stressed that I had suicidal thoughts. I confided in some people at work; I told them I was suicidal. I told them I wanted to take leave. But it was the stroke symptoms that allowed me to get the leave more easily approved. I took about a month off. As a result, I had to make the decision to step down as head of my department for a while.

The culture of the health industry doesn’t offer the best support for health professionals experiencing mental health issues. That was certainly my experience anyway. Some health professionals frown upon taking sick leave. There’s a perception of weakness. beyondblue research actually confirms that perception from people in our industry.

According to a beyondblue survey of Australian doctors, approximately 40 per cent of doctors felt that medical professionals with a history of mental health disorders were perceived as less competent than their peers. Almost 59 per cent of doctors experiencing depression find it is embarrassing for them. Even more worryingly, almost 50 per cent of doctors feel those with mental health disorders could face setbacks in their career progression.

Additionally, beyondblue’s research showed that one in five medical students and one in 10 doctors had suicidal thoughts in the past year. It’s not difficult to see the significant issue of the health industry dealing with, or in some ways failing to deal with, mental health issues. Though it’s positive to learn from the research that doctors show great resilience, personally and professionally, to the negative impacts of mental health.

My road to recovery was gradual. It took me a while to summon up the courage to see my GP. Instead of booking an appointment I used natural remedies, such as taking B vitamins, as a way of self-medicating. It made little difference. What I needed was counselling and medication: professional help.

Admitting to myself that I had a serious illness and seeking help was a major turning point. Part of my self-admission came after a long-time friend texted me saying ‘I’m concerned about you’, and provided me with the beyondblue Support Service number. Having a friend recognise and voice the seriousness of my situation also reinforced my need to seek help.

I finally called my GP. She took control and told me what we needed to do so I could start to recover. Following her advice and treatment plan was pivotal. A compassionate doctor will understand exactly what you’re experiencing, as an individual and as an industry peer. Now I’m well and back working as a senior cardiologist at The Alfred and Peninsula Health.

I really feel for today’s junior doctors. I think pressures on them have increased since I was in their position. The health system has changed, which has increased pressure to get more things done in less time.

There are also so many challenges that haven’t changed: the pressure high achievers put on themselves to perform continuously at a high level; and the pressure to keep up with peers, whether it’s managing high workloads or giving accurate diagnoses the first time, every time.

The stress of the high workload for junior doctors can’t be ignored. You’re working 50- to 60-hour weeks and then studying for 20 or more hours. Exam study adds to the intensity. You always have that uncertainty of passing, which everyone goes through.

Throw in the unsociable working hours, as well as job instability due to short contracts and frequent rotations, and it’s easy to see the impact on young doctor’s mental health.

Still, even when doctors aren’t well, we often put our own health second.  You tell yourself to always put patients first. But we need to fit our own oxygen mask first. If we don’t look after ourselves, our patients won’t have a doctor to look after them. A doctor needs to be well to provide high-class care to their patients.

Here is what I’d advise young doctors do to stay well:

  • Look after yourself by doing what you can to develop work-life balance. This could mean making extra effort to catch up with family and friends, establishing an end-of-day routine to unwind, or planning a holiday;
  • Develop interests and passions outside work. I’ve taken up ocean swimming. What I love about swimming is the need for minimal equipment, getting time to myself so I can practice mindfulness, and I always feel great afterwards;
  • Realise that you’re more than a doctor, you’re human. Yes, we too can be ill, and we need to follow the advice we give our patients about self-care;
  • If you’re struggling, seek help early;
  • Make sure you have your own health professionals, especially a GP, that you trust and can be open with;
  • If you see a colleague struggling, reach out to them. Offer to catch up over coffee or just offer support. When hospital culture is positive, it can feel like you’re working in a small town or community so you notice and react if someone isn’t well. beyondblue has a range of resources to help you have these conversations;
  • Show leadership at work by not tolerating poor behaviour towards mental health issues;

As a beyondblue speaker, I’m proud that our education and research tools have helped break down stigma surrounding mental health conditions. There are also other great resources such as ‘Keeping Your Grass Greener: A wellbeing guide for medical students’.

I definitely encourage doctors who might be experiencing mental health issues to talk to someone. It might even be best to speak to a trustworthy friend outside of the workplace to ensure confidentiality. If you need to speak confidentially to a professional, your state Doctors Health Service and employee assistance programs can provide support. beyondblue has several confidential support options for doctors. The Support Service provides free impartial, solutions-focused counselling from mental health professionals by phone 24/7 on 1300 22 4636, online at www.beyondblue.org.au/get-support or via webchat from 3pm to midnight AEDT.

Sharing my experience of depression with other medical professionals has shown two sides of the industry. I have doctors approach me at conferences to thank me, and to share their own mental health issues. Unsurprisingly, they often tell me they haven’t spoken to anyone else about their struggles. That in itself speaks volumes about the relationship between mental illness and our profession.

When senior executives from our industry attend and engage with my beyondblue advocacy talks – including Grand Rounds – that’s when change and improvements most often happen. Support from the top is imperative. Leaders must walk the positive talk.

beyondblue provides organisations free practical information and resources about how to create mentally healthy workplaces. The Heads Up website is developed by beyondblue in collaboration with the Mentally Healthy Workplace Alliance. Heads Up has specific resources for doctors and medical students to support their mental health at work. To learn more, visit http://www.headsup.org.au/doctors.

Dr Geoff Toogood has been working in medicine for 30 years, specialising as a cardiologist for the past 20 years. He works at The Alfred Hospital and Peninsula Health, at which he has held director roles.

This blog was originally published on www.onthwards.org.  Read the original article here.

onthewards is a website dedicated to delivering practical, high quality free open access education for medical students and junior doctors.

 

For more information about health issues for doctors, access a range of online resources from Doctors’ Health Advisory Services Pty Ltd.

Or phone:

NSW and ACT … 02 9437 6552

NT and SA … 08 8366 0250

Queensland … 07 3833 4352

Tasmania and Victoria … 03 9495 6011

WA … 08 9321 3098

New Zealand … 0800 471 2654

Lifeline on 13 11 14

beyondblue on 1300 224 636

 

New focus on Top End doctors’ health

Practising medicine in the Northern Territory can be as rewarding as anywhere else, but it has its own particular challenges. Many NT doctors work in remote and isolated regions where they have to be able to rely on themselves, without the kind of support they’d find in the capital cities.

Until recently, there were very limited health services for NT doctors and no dedicated support network. But in 2016, a group of Adelaide-based health professionals stepped into the breach and set up Doctor’s Health NT, which offers a 24-hour advisory helpline, telemedicine and a network of local GPs trained to see doctors and medical students as patients.

“The NT medical community is small, with only about 1000 doctors,” says Adelaide-based GP Dr Roger Sexton, who as director of Doctors’ Health SA was instrumental in setting up the NT satellite.

“There are interesting challenges in doing medicine out there. There’s a wide range of workplaces, from aboriginal communities to work out on the islands or in remote communities, and doctors are expected to be well-rounded and pretty self-reliant. But when it comes to their own health, one solution doesn’t always work for all doctors.”

Dr Sexton says it’s easy for NT doctors to get isolated because they personally know most of the other doctors in the Territory, which means they can’t easily get treated anonymously.

“A lot of the doctors find the convenience of self-treatment too easy. If you’re a dermatologist in Melbourne, you’ve got a very good choice of who you can see. But in the NT the options are limited. Many doctors have concerns about confidentiality, and there’s always the issue of notification sitting in the background.

“When they do seek help, they often do it selectively. They’ll see a GP for some issues but not for mental health. Often they practice a form of blended care where they do a bit of self-investigation, self-prescribing and self-referral.”

Doctors’ Health NT has a 24-hour helpline, but Dr Sexton says the penetration is pretty low, which means things have to be done a little differently.

“We’re running a trial for GP teleconsults, which gives doctors the chance to consult with a doctor who is not necessarily part of their personal network. We’ve had very strong support for that model: it’s a great way for an initial talk about an issue and some follow-up.”

He says telemedicine is an excellent way to break down isolation, particularly for doctors who pride themselves on being tough and are reluctant to admit they’re struggling.

But Doctors’ Health NT has also established a network of GPs on the ground who are trained to treat other doctors and medical students.

“We’re trying to grow that network. We have ten GPs at the moment which we hope to expand to 30.”

Dr Sexton says having a GP-centric model for doctors’ health is critical because it can address both physical and mental health issues.

“With a psychiatrist-based model you miss out on all the physical stuff, which can be very important. GPs are also a non-stigmatising way of getting a foot in the door. You can say to doctors that the approach is physical, and along the way we’ll be asking you about your life as a doctor.”

You can access the services of Doctors’ Health NT here.

For more information about health issues for doctors, access a range of online resources from Doctors’ Health Services Pty Ltd.

Mandatory reporting: the “low hanging fruit” in doctors’ health

Mandatory reporting came under fire at a panel discussion on doctors’ health at the AMA National Conference held in Melbourne late last month.

Currently all states, with the exception of Western Australia, have regulations which require health practitioners to report colleagues who they feel may be a threat to their patients to AHPRA or the Medical Board of Australia.

Although mandatory reporting requirements are well-intentioned efforts to protect patients, many professionals worry they are a major barrier to doctors seeking help for their mental health issues.

Speaking on the panel, Dr Bav Manoharan, a Queensland-based radiology registrar who has been involved in resilience building projects, said there was confusion around mandatory reporting legislation and what the threshold was for reporting colleagues to AHPRA.

“That is a real concern,” he said. “There’s a stigma around a doctor approaching a health service and asking for help in environments where there is mandatory reporting.”

He said that changes to manadatory reporting requirements and a clearer understanding of them were the “low-hanging fruit” in the debate around doctors’ health.

Dr Janette Randall, a Queensland-based GP who is chair of Doctors Health Services Pty Ltd, noted that the threshold for reporting was actually quite high but there was a lot of subjectivity and doctors were getting inappropriately reported.

“We have a strong sense of fear and reluctance to present for care and this is one of the barriers. I do think the time has come to remove the onus on treating practitioners to report. That’s not to say we don’t all retain an ethical and professional responsibility in that space, but we’ve got to be able to create safe environments for people to seek care.”

Marie Jepson, who has been involved in research into depression in the legal community, said mandatory reporting tended to drive mental health issues underground.

“We found there were lawyers who would deliberately not go to the doctor, even though they were quite ill, so they didn’t have to lie on their application for a practising certificate. It meant that they complied with the regulation, but it was a timebomb waiting to go off.”

The issue of revamping mandatory reporting requirements does seem to be gaining traction, particularly in New South Wales, where Health Minister Brad Hazzard has announced he will review the legislation.

Mr Hazzard met with health stakeholders at a forum this week in Sydney to discuss measures to improve the mental health of doctors, after several high profile cases of doctor suicides in the state.

“It’s really critical for people with mental health issues to be able to talk to someone with absolute confidence and know that person is there to help and not to judge them – that’s the critical problem with mandatory reporting,” Mr Hazzard told the forum.

“Having listened to the young doctors it may be that the mandatory reporting requirements are technically not the problem, but practically they are, because that perception among young doctors is by seeking mental health help they may be damaging their career. It looks to me that mandatory reporting provisions do need changing.”

For more information about health issues for doctors, access a range of online resources from Doctors’ Health Services Pty Ltd.