Career focus

Getting help for sick doctors

Doctors are a scarce and expensive resource and there are not enough of them to meet identified demands. Concerted action to prevent stress and ill health in doctors and consequent harm to patients and unnecessary loss of doctors should be a priority. The statements and conclusions in this article are based on the experience of the NCSSD since its inception in 1985 together with a review of some of the published literature. Doctors have high standardised mortality rates in respect of cirrhosis, accident and suicide.1,2 Surveys have shown high levels of stress and related disorders among hospital consultants,3,4 general practitioners,5 and doctors in training.6

Why doctors are vulnerable
Qualification in medicine brings automatic social status with expectations of good health, good income, an assured and satisfying job, and identification with a respected profession. At the same time membership demands an acceptance of the ethos in medicine which carries an expectation of dedication, hard work, and long hours. Commitment to the individual patient and to the service makes it difficult for the physician to abandon this obligation because of personal ill health. The structure of the NHS is such that if an individual doctor is unexpectedly absent because of illness there is often no one to provide alternative cover at the same level.

For a variety of complex reasons many doctors are reluctant to seek help in the normal way when they become stressed or ill. From the experience of the NCSSD there seems to be a deeply ingrained fear that admission of vulnerability or illness will result in loss of respect from colleagues and impaired future employment prospects. Any service connected with management, including occupational health, is often viewed with suspicion. Misunderstanding of the role of both NHS management and of the General Medical Council (GMC) is common.

These concerns are compounded by the fact that many doctors either do not have a general practitioner or sign on with someone with whom they work closely. Many doctors rely on informal consultation and sometimes, in the case of doctors in training, with those barely more experienced than themselves. Such consultations, often without notes or systematic investigation, may lead to inadequate care. From an early stage in their careers some doctors begin to self prescribe for convenience or to avoid embarrassment. This may progress to inappropriate and excessive self prescription; drugs may be used to conceal symptoms of stress or of illness.

Many doctors have reservations about using their local services for reasons of confidentiality or fear of meeting patients or colleagues. The extracontractual referral sysem can make it more difficult to consult outside the local facilities. If in patient care is arranged this can bring even greater discomfort to the doctor in the form of an unaccustomed state of dependence and loss of role, the chance of sharing the ward with patients they know or facing colleagues whom they fear may be unsympathetic, or a fear that subsequent professional relationships will be impaired. Thus doctors often wish not to be admitted to any hospital with which they have a working relationship. Two thirds of the doctors dealt with under the GMC health procedures are referred on account of alcohol and drug problems. Doctors who abuse alcohol or drugs develop a remarkable capacity to deceive themselves and others, and often colleagues turn a blind eye to the problem; patients sometimes do the same.

For these reasons doctors tend to present late with serious problemsÑthe average delay between onset and consulting about an alcohol or drug problem is more than six years; similar reluctance and delay is evident for psychological distress.

The Nuffield working party review
Services for sick doctors have been reviewed recently in a report published by the Nuffield Provincial Hospitals Trust.7 This reviewed the evidence of stress related morbidity in the profession, concluding that special services for doctors could be justified in terms of the conservation of a scarce resource. Current arrangements are ill understood, fragmentary, uncoordinated, and are failing to provide a satisfactory level of support. The report recognised that it is important to reduce avoidable stress, if necessary by changing working conditions and the nature of the job, as well as by providing adequate services for those who fall ill.

Key actions

All doctors should register with a general practitioner with whom they are willing to consult Self diagnosis and self prescription by doctors should be strongly discouraged Accurate information about sick doctor services should be easily available locally Training in the management of stressed and sick colleagues should be provided All parties involved should examine together how they can improve the management of health problems in doctors

Independent regional bodies needed
The central proposal of the trust's working party is the creation of a network of fully independent regional bodies to be responsible for reviewing the services available for doctors with health problems, identifying steps that should be taken to improve working conditions where these are found to be needlessly contributing to stress, drawing up recommendations for a longer term programme of improvements, monitoring progress, providing information about local and national services, keeping up with service development, and publishing an annual report.

Self help when stressed or ill
Ideally any doctor who is experiencing stress related problems should be able to consult colleagues, NHS management, the NHS occupational health service, or other local resources with the confidence that help will be provided to tackle the problems constructively.

Sources of help
General services for doctors The National Counselling Service for Sick Doctors (0171 935 5982). The service provides general information and advice. Callers can also be given the name and number of one of the 100 NCSSD medical advisers to whom they can talk in confidence. NCSSD advisors are also available to talk to groups and the media about sick doctor issues. The BMA 24 hour stress counselling service (0645 200169). Callers are able to speak to trained non-medical counsellors. Local medical committees (LMCs) can help GPs access appropriate services and assist with practice difficulties. The Overseas Doctors Association's health counselling panel (0161 236 5594) can be helpful for doctors where cultural or linguistic factors are prominent. The GMC's Fitness to Practise division (0171 580 7642) can provide informal advice and guidance about invoking the GMC's health procedures. The Association of Anaesthetists (0171 631 1650) operates its own scheme for all anaesthetists, including those in training. Doctors and dentists in training can get help from local college tutors, clinical tutors, GP course organisers, postgraduate deans and directors of postgraduate general practice education. Postgraduate deans can also help tackle problems in senior doctors reported to them in confidence by doctors in training. Some regions have counselling services specifically for doctors in training. Career advice in the event of ill health can be obtained from regional postgraduate deans, directors of postgraduate GP education, and from royal college regional advisers.
Services for dentists The British Dental Association (0171 935 0875) can give information about help for sick dentists. Dentists' HelpLine (0171 487 3119) provides a confidential sick dentists' service.
Drug and alcohol problems The Sick Doctors' Trust national helpline for addicted physicians (01252 345 163) provides a 24 hour advice and an intervention service. The British Doctors' and Dentists' Group (accessed via the Medical Council on Alcoholism on 0171 487 4445) provides on going group support from recovered drug and alcohol abusers. It also welcomes students. DrinkLine/National Alcohol Helpline. (London: 0171 332 0202. Rest of the UK 0345 32 02 02. All calls charged at local rates.) The helpline refers callers to local agencies and provides general infomation.
HlV/AIDS and hepatitis Department of Health UK Expert Advisory Panel on health care workers infected with blood-borne viruses (0171 972 4378) provides guidelines on HIV/AIDS, hepatitis, etc
Financial help The Royal Medical Benevolent Fund (0181 540 9194/5) may be able to provide financial help to registered doctors and/or their dependants. The British Medical Association regional offices can provide advice on other possible sources of help.

The appropriate first stop is the doctor's general practitioner, who can assess the problem objectively and arrange more specialised help through the normal services if required. Where a doctor is unwilling to approach a colleague locally, help can be obtained from national services (see box).

Helping a colleague in need
Any doctor who gives rise to concern should first be approached by colleagues willing to share their concern and offer help and information. This task requires skill and experience. Doctors in training and other health professionals need to be assured that they can discuss concerns about the health of senior colleagues in strict confidence and without any risk to their own careers. Where the problems are clearly medical and the doctor concerned seeks help from a general practitioner or appropriate specialist, treatment will usually be possible on an out patient basis. If admission is required, either because of the nature of the problem or to protect patients, this should be arranged quickly in a unit that will provide the maximum opportunities for recovery.

If the doctor does not seek and benefit from help then several alternatives should be considered. All doctors should keep in mind that regardless of their wish to help a colleague their prime responsibility is to ensure the prevention of harm to patients.8 There may be local mechanisms such as the "three wise men" procedure.9 Trust medical doctors, local medical committee secretaries, and health authority directors may need to be involved. The GMC can be consulted for informal advice. The key is to get the problem sorted out locally before any harm to patients occurs.

Alcohol and substance abuse
Where alcohol or substance abuse is a factor, the general practitioner needs to be involved and referral to a specialist service arranged. The Sick Doctors' Trust's national helpline for addicted physicians provides 24 hour advice and an intervention service. The British Doctors' and Dentists' Group, constituted by those in recovery from addiction, provides support groups. It also welcomes students. DrinkLine, a national alcohol helpline, gives advice to those concerned about their own or someone else's drinking.

Jolyon Oxley,
Secretary,

Sydney Brandon,
Chairman,

NCSSD,
1 Park Square West,
London NW1 4LJ

References

1 Balajaran R. Inequalities in health within the health sector. BMJ 1989;299:822-5

2 The morbidity and mortality of the medical profession. London:BMA, 1993.

3 Caplan RP. Stress, anxiety and depression in hospital consultants, general practitioners and senior health service managers. BMJ 1994;309:1261-3.

4 Ramirez AJ, Graham J, Richards MA, Cull A, Gregory WM. Mental health of consultants: the effects of stress and satisfaction at work. Lancet 1996;347:724-728.

5 Sutherland VJ, Cooper CL. Job stress, satisfaction, and mental health among general practitioners before and after the introduction of the new contract. BMJ 1992;304:1545-8.

6 Firth-Cozens J. Emotional distress in junior house officers. BMJ 1987;295: 533-36.

7 Taking care of doctors' health. London: Nuffield Provincial Hospitals Trust, 1996.

8 Duties of a doctor: good medical practice (pp 6-7). London: General Medical Council, 1996.

9 Prevention of harm to patients resulting from physical or menial incapacity of hospital of community medical or dental staff. HC (92) 86 London: DHSS, 1992

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