Date: 21 June 2018
Category: Staff wellbeing
There is a moment in Shaw’s play ‘The Doctors Dilemma’ in which the protagonist, Doctor Ridgeon, interrupts another doctor (Blenkinsop) who is starting to talk about his work and health problems:
RIDGEON [restlessly] Don’t, Blenkinsop: it’s too painful. The most tragic thing in the world is a sick doctor.
The scene, and in particular the words: “The most tragic thing in the world is a sick doctor” effectively depict the heart-breaking and worrying paradox that those who are supposed to care for patients are often too sick to do so.
A growing number of doctors, from medical students to senior consultants, are experiencing mental-ill health including stress, burnout, alcohol and drug addiction, depression and suicide. To give a recent striking example, in the 2017 NHS staff survey, 38.4% of staff (up from 36.7% in 2016) reported being unwell because of work-related stress. These data relate to the NHS, but the problem is not limited to the UK.
The issue of mental ill-health in doctors, while critically important in itself, is also linked to wider immediate and long-term healthcare workforce problems such as absenteeism (doctors taking sick leave), presenteeism (doctors working while unwell), retention of workforce (doctors leaving the profession), and the quality of patient care. Numerous bodies and organisations including health think tanks, the House of Lords, and NHS leaders have been calling for long term strategies to ensure a motivated work force – highlighting how this is at the heart of the sustainability of the NHS.
So, what can be done?
It seems that doctors are not completely abandoned. There are services like the Practitioner Health Programme which provides confidential specialist support to doctors experiencing mental ill-health.
However, these services often see doctors who are already very sick. An alternative and additional strategy is to try to prevent doctors getting so sick in the first place. In other words, alongside treating the illness once they manifest, we must identify and treat the causes of the problem - i.e. develop preventative measures.
Current research on stress, burnout and mental ill-health in doctors primarily focuses on individual management, looking for ways to increase ‘productivity’ and ‘resilience’. Although individual resilience is important, it is probably not the only solution – especially when the problems are structural.
Doctors, like all humans, are not isolated beings; their health and wellbeing depend also on the world around them and (for example) good relationships with other people. If their work does not allow this, then this may cause dissatisfaction, stress, and mental ill-health.
Focusing on, and arguably laying sole responsibility upon, the individual doctor and their performance can also potentially aggravate the situation and contribute to the emergence of mental ill-health.
Moreover, the NHS, like many other health services worldwide, is experiencing extraordinary pressure to work within limited resources. This likely contributes to low morale and difficulties in recruiting and retaining new doctors and other NHS staff.
Apart from structural problems, there are also important cultural aspects to consider. One is the stigma often associated with mental health – which may be even stronger in healthcare than in other sectors. Such stigma, and perhaps its corollary of fear of career repercussions, may explain why even when support is available, it can be very difficult for sick doctors to engage with it.
The few examples provided above give an idea of the complexity of developing interventions to tackle such a multidimensional problem. But there is more. It is also challenging to think about how to embed these interventions. In the current pressurised healthcare context, there is a serious risk that doctors may perceive interventions as an additional unwelcome or unfeasible task they need to perform.
In summary, the growing number of sick NHS staff suggests that current interventions are not working or are not being delivered optimally. If we are to address this issue, we need to understand what is going on. A way of doing so is to conduct an interdisciplinary examination of current studies and interventions. This will not only maximise our understanding of the issue, but will also inform the development of new research methodologies and approaches capable of dealing with the highly sensitive and complex nature of the issue – combining individual, organisational and the wider socio-cultural and historical contexts.
I am part of the Care Under Pressure project – we are a multidisciplinary team who are in the process of tackling this issue. We are conducting an evidence synthesis – realist review – of interventions to tackle doctors’ mental ill-health and its impacts on the clinical workforce and patient care, drawing on diverse literature sources. Realist reviews are a form of theory-driven approach to synthesising the literature - especially of complex health or social problems. We are also engaging iteratively with diverse stakeholder perspectives (e.g. doctors who have experienced mental ill-health, representatives of patients and public, other healthcare professionals, policy makers, charities) in order to produce actionable theory. This will lead to recommendations that support the tailoring, implementation, monitoring and evaluation of contextually-sensitive strategies to tackle mental ill-health and its impacts.
"The most tragic thing in the world is a sick doctor." A growing number of doctors, from medical students to senior consultants, are experiencing mental-ill health including stress, burnout, alcohol and drug addiction, depression and suicide.
Doctor Daniele Carrieri from University of Exeter