Published 27 April 2009, doi:10.1136/bmj.b1368
Cite this as: BMJ 2009;338:b1368

Practice

The Competent Novice

How to handle stress and look after your mental health

¹ Department of Psychological Medicine, Institute of Psychiatry, London SE5 9RJ, ² Dewsbury and District Hospital, Dewsbury WF13 4HS, ³ Leeds Teaching Hospitals NHS Trust, Leeds General Infirmary, Leeds LS1 3EX

Junior doctors can take action to avoid stress and depression associated with their workload. This article explains how, and gives advice on who to seek help from if the need arises

Key points Stress is common among junior doctors A proportion of stressed doctors will develop mental health problems Factors that contribute to stress can be identified and modified Many confidential and free sources of help are available for doctors

Twenty years ago Firth-Cozens reported that among doctors in their first year of graduating 50% were estimated to have emotional disturbance and 28% fulfilled criteria for depression.¹ Since then, working hours have decreased, and the way that doctors are trained and managed has changed substantially. Despite this, the proportion of doctors experiencing psychological distress has remained constant, at about 28%, compared with about 18% in the general working population.^{2 3} For junior doctors, 79% of those caught up in the recent problems of MTAS (the UK medical training application service, an online system for the selection of junior doctors) scored above the threshold for psychological distress and 21% had significant distress.⁴ Psychiatric morbidity and burnout among hospital specialists in the UK are also increasing, rising between 1994 and 2002 from 27% to 32% and from 32% to 41% respectively.⁵ The four fictitious case scenario boxes illustrate a typical experience of a junior doctor becoming increasingly stressed.

Stress

Stress is a controversial term but is broadly understood to result from an "imbalance between demands and resources" or occurring when "pressure exceeds one’s perceived ability to cope."⁶ Although stress is not unique to medicine, commentators have suggested that the following combination of factors may contribute to stress in doctors: excessive workload⁷; dealing with patients’ suffering and one’s own mistakes or fear of them; and lack of professional support and training, particularly in the areas of communication, leadership, and management.

These factors contribute to a subjective sense of overload and inability to cope, which may then be compounded by maladaptive responses such as working long hours or drinking heavily.⁸ A longitudinal study of 1668 UK doctors found that perceived high workload and lack of support correlate with stress and burnout reported five or six years earlier, when the doctors were preregistration house officers carrying out entirely different jobs. The study also found that doctors with greater stress and emotional exhaustion had higher neuroticism scores.⁹

Why does stress matter?

Stress matters because a proportion of doctors experiencing prolonged job stress will develop a more serious problem such as burnout (defined as emotional exhaustion, depersonalisation, and decreased sense of personal accomplishment owing to work stress), depression, an anxiety disorder, and/or drug or alcohol dependence.¹⁰ The risk may be particularly acute for women doctors, in whom psychiatric morbidity is more common than in male doctors and suicide is twice as common as in women in the general population.¹¹

Stress matters for patients too. A postal survey of 1794 UK NHS hospital consultants found that those with poor mental health were more likely to report that they gave reduced standards of care to patients by, for example, taking short cuts.¹² A third of 225 doctors in another survey reported incidents where they believed that symptoms of stress had negatively affected patient care.¹³ These findings might indicate that stressed doctors are more likely to be self critical and thus report errors. However, more objective studies suggest that reducing stress for doctors is good for patients. A case-control study found that the introduction of stress management courses to 22 hospitals was associated with a substantial reduction in the rate of malpractice claims compared with the control hospitals.¹⁴

How to prevent stress from affecting your mental health

Prevention of stress related illness is currently the subject of a vast amount of empirical research. A recent systematic review of the literature on interventions to prevent burnout in junior doctors concluded that few of the existing studies undertaken were of sufficient methodological quality to be included.¹⁵ However, two interventions that used meditation-type practice did seem to improve mood disturbance in both junior doctors and medical students.^{16 17}

A postal questionnaire sent to 2456 UK doctors working in their first year showed that these doctors found that talking through their problems, either with a colleague or with someone outside medicine, was a helpful coping strategy.⁷ The responses indicated that these doctors’ workload often made it difficult for them to find the time for such discussions; formal mentoring schemes separate from appraisal and embedded in training rotations may therefore help.

Box 1 outlines key steps that doctors can take as individuals for preventing stress, and suggestions for organisations, educators, and leaders.

Box 1 Preventing stress* What can you do to keep yourself well? Find mentors to support you at different stages in your career.18 The London Deanery offers four sessions of mentoring for all doctors in training in the London Deanery (http://mentoring.londondeanery.ac.uk/mentees), and the Northern Deanery operates a similar scheme (http://mypimd.ncl.ac.uk/PIMDDev/news/mentoring-in-the-northern-deanery/) Adopt a regular self care practice as part of your routine (such as exercise19) Engage in reflection—acknowledge your emotions about difficult patients or challenging clinical scenarios (for example, by joining a Balint group, or similar)20 21 Familiarise yourself with basic techniques of cognitive behavioural therapy, which can help you to challenge unhelpful beliefs you may have about yourself or your work (for example, look at www.moodgym.anu.edu.au) Put time aside for family and friends7 Influence your own happiness through re-examining and honouring your personal values—for example, setting boundaries around work or making time for religious, spiritual, and social activity Specific skills such as time management may be useful if you are overwhelmed with work. Various courses are available in the UK (try googling time management courses) What can employers and educators do? At medical school Encourage mentoring and peer support networks through medical school and beyond22 Provide teamwork and leadership training from medical school onwards23 Educate students to be aware of their own health needs and reduce the stigma associated with asking for help24 For junior doctors Increase supervision of a new doctor for the first few weeks and at night7 Do not allow junior doctors to get sleep deprived7 Ensure juniors have time to discuss difficult or challenging cases, and encourage open and constructive discussion of errors20 21 Ensure that juniors have a work-life balance so they can get informal support from family and friends7 Throughout doctors’ careers Improve provision of flexible childcare Preserve clinical autonomy by allowing doctors some control over the way they work and the content of their workload *Based on surveys and interventional studies, except where indicated otherwise. Authors’ suggestions.

How to recognise when job stress has affected your or a colleague’s mental health

The General Medical Council advises that doctors should be "alive to mental health problems, depression, and alcohol and drug dependence [in colleagues]" and should "Act without delay if you have good reason to believe that you or a colleague may be putting patients at risk."²⁵

It is sometimes difficult to distinguish job stress from a more serious mental health problem. Box 2 gives some "red flag" symptoms that alert you to the possibility that you or a colleague may need further support or advice. If in doubt, the priority is to seek appropriate assessment for you or help a colleague to do the same.

Box 2 "Red flag" symptoms for depression* If you or a colleague have experienced some of these symptoms every day or nearly every day in the past three to four weeks, it is time for assessment. Having little interest or pleasure in doing things Feeling down, depressed, or hopeless Feeling tired or having little energy Having trouble falling or staying asleep, or sleeping too much Having a poor appetite or overeating Feeling bad about yourself—that you are a failure or have let yourself, your patients, or your family down Having trouble concentrating on things, such as reading the newspaper or watching television Moving or speaking so slowly that other people could have noticed, or being so fidgety or restless that you have been moving around a lot more than usual Having thoughts that you would be better off dead or of hurting yourself in some way *Based on the Patient Health Questionnaire-9 (PHQ-9)26

How to access services for yourself or a colleague

An overview of sources of help for doctors is outlined in box 3. Doctors need to be aware that most sources of help operate entirely confidentially and separately from internal bodies (such as trusts) or external agencies (such as the GMC) and that it is only necessary to breach this confidentiality in exceptional circumstances.

Box 3 Sources of help for doctors A comprehensive list of all general and specialist services for doctors in the UK, both regional and national, can be found on the BMA’s website (www.bma.org.uk/ap.nsf/Content/d4dmaingeneral/). Key sources are listed below. BMA Counselling Service—24 hour telephone line staffed by accredited counsellors from the British Association of Counselling and Psychotherapy (tel: 08459 200169) BMA Doctors for Doctors Service—Part of the BMA Counselling Service that enables doctors in distress or difficulty to speak in confidence to another doctor. The service is available to all doctors, is confidential, and is not linked to any other external or internal agencies (tel: 020 7383 6739; email: info.dfd{at}bma.org.uk). Telephone and face to face appointments are available. MedNet—Provides doctors and dentists working in the area covered by the London Deanery with practical advice about their career, emotional support, and access to brief or longer term psychotherapy. The service operates on a confidential basis (tel: 020 8938 2411; website: www.posts.londondeanery.ac.uk/specialty-training/mednet). Practitioner Health Programme—Newly launched, general practitioner led initiative offering free and confidential health care to any medical or dental practitioner living or working in the London area who has a mental health or addiction problem, or a physical health concern that may be affecting their work (www.php.nhs.uk) Doctors’ Support Network—Self help group for doctors with mental health concerns (www.dsn.org.uk) Royal Medical Benevolent Fund—Provides financial help for sick doctors (tel: 020 8540 9194; email: seniorcaseworker{at}rmbf.org; website: www.rmbf.org) Sick Doctors’ Trust—A proactive, self help organisation for addicted physicians (24 hour helpline: 0870 444 5163; website: www.sick-doctors-trust.co.uk) Help and advice is also available from general practitioners, medical defence organisations, occupational health departments, colleges, and postgraduate deaneries.

How to best help and support an unwell colleague is a complex matter, and little empirical evidence currently exists to guide doctors about the best way to proceed. An appropriate response will depend on the nature of your colleague’s apparent difficulty. If you think a colleague is stressed or may have depression, perhaps start by talking about your concerns gently but directly with him or her and then try to facilitate an assessment (by directing your colleague to a source of help).

If you believe that a colleague’s poor mental health may be influencing his or her ability to practise as a doctor, you will require more expert guidance about the best way to proceed. Your local hospital authority may have existing procedures that can offer you support and advice; hospital trusts’ guidelines vary but most would encourage you to share your concerns with a supervisor, trainer, or trusted colleague first. The medical defence organisations or the BMA’s "Doctors for Doctors" service also offer anonymous advice in such situations.

How to get well

All doctors should be registered with a general practitioner, who should be your first point of contact if you have any concerns about your health. Depending on the problem, various interventions are available. For depression, antidepressants and talking treatments based on cognitive behavioural therapy have the best evidence base currently.²⁷ Other types of talking treatment, such as interpersonal or psychodynamic psychotherapy, are also effective.^{28 29} For more information about these treatment options see the Royal College of Psychiatrists’ website (www.rcpsych.ac.uk/mentalhealthinfo/treatments.aspx), and for an accredited UK therapist in your area you can search on www.bacp.co.uk (for psychodynamic or interpersonal therapists) or www.cbtregisteruk.com (for cognitive behavioural therapists).

General practitioners can often recommend local therapists, and the new initiative Increased Access to Psychological Therapies will mean that cognitive behavioural therapy will become more widely available in primary care in England in the coming years. Other approaches that may be useful for depression include mindfulness,¹⁹ and exercise.³⁰

How the system can help

High quality services providing confidential counselling, coaching, psychotherapy, and treatment for alcohol and drug problems need to be visible and promptly available to doctors throughout their training.²³ Additionally, doctors should be able to access consultations, and admission if necessary, outside their area of work. The establishment of the new Practitioner Health Programme pilot in London is an innovative service model that is likely to appeal to doctors as patients (box 3).

What are the challenges?

Stigma
There is still a lot of stigma related to seeking help for stress related illness. This is partly because doctors fear lack of confidentiality or think that seeking help may result in challenges to their "fitness to practise" but also because of the wider culture of medicine in which "an image of invincibility is encouraged and vulnerability is denied."³¹ A culture shift is needed, starting at medical school.

Barriers to care
Doctors do not make good patients. Typically they do not follow their own health care advice, they self diagnose and self medicate, and they present late after "corridor consultations." Once unwell, doctors are often reluctant to consult a general practitioner (even if registered) or to take time off work.³² The General Medical Council is clear that doctors should not treat themselves and should avoid treating those with whom they have a close personal relationship, and it recommends that all doctors should register with a general practitioner who is not part of their family to ensure they receive independent and objective care.²⁵ Another barrier is that many doctors do not know where to seek help; box 3 lists key sources of help.

Workload
Doctors often feel that they "don’t have time to be a patient" or that they are somehow "letting the side down" by taking time off to consult or be treated. Such attitudes are unhelpful and perpetuate poor health in doctors; for example, one study has shown that when doctors finally allow themselves to take time off for ill health, they tend to be off work for longer periods because they consult so late.³³

Case scenario: part 1 Sarah Craven is a first year foundation doctor working on a busy and understaffed medical admissions unit. She has been skipping lunch and staying after work to try to finish all the jobs from the daily ward round and is getting tired and irritable as a result. The second year foundation doctor is off sick, and the registrar often has to deal with patients elsewhere in the hospital and seems stressed and short tempered when she calls him for advice.

Case scenario: part 2 Sarah becomes increasingly preoccupied by her workload and has not had time to go for a run, call her parents, or see her friends. In the evenings she feels exhausted and tearful; she feels ashamed of this as she has always been someone who "‘gets the job done" and "doesn’t let the side down." She drinks four to five glasses of wine each night to help her get to sleep.

Case scenario: part 3 It is becoming harder for Sarah to work as she feels exhausted and finds it hard to concentrate. She begins to doubt her own ability, but keeps going to work so that she doesn’t let her team down. She stays later and later to try to clear the mounting paper work. She begins to question whether she still wants to be a doctor. One morning, she feels so demoralised and tired that she "cannot go on" and she calls in sick

Case scenario: part 4 Sarah takes a week off work and decides that she needs to examine some of her own health needs to enable her to continue. She registers with a local general practitioner, signs up for a time management course, walks the two miles to and from work, and prepares packed lunches to ensure she does not miss out on a midday meal. She tries to be less self critical if she doesn’t manage to complete all her planned daily tasks. She talks to other foundation year doctors at her hospital to pick up useful tips on how to manage her workload. Unless an emergency arises, she makes sure that she leaves work on time and hands over any urgent jobs to her on-call colleague. She makes a commitment to herself that she will see friends and family at least once a week, regardless of how busy the ward is.

Cite this as: BMJ 2009;338:b1368

---

This series aims to help junior doctors in their daily tasks and is based on selected topics from the UK core curriculum for foundation years 1 and 2, the first two years after graduation from medical school.

Contributors: BR and KF planned the article and the scenario. AI prepared the initial manuscript. All authors had input in reviewing and refining the article. AI is the guarantor of the article.

Competing interests: None declared.

Provenance and peer review: Commissioned; externally peer reviewed.

References

1. Firth-Cozens J. Emotional distress in junior house officers. BMJ 1987;295:533-6.[Abstract/Free Full Text]
2. Firth-Cozens J. The psychological problems of doctors. In: Firth-Cozens J, Payne R, eds. Stress in health professionals: psychological and organizational causes and interventions. London: Wiley; 1999.
3. Wall TD, Bolden RI, Borrill CS, Carter AJ, Golya DA, Hardy GE, et al. Minor psychiatric disorder in NHS trust staff: occupational and gender differences. Br J Psychiatry 1997;171:519-23.[Abstract/Free Full Text]
4. Whelan P, Meerten M, Rao R, Jarrett P, Muthukumaraswamy A, Bhugra D. Stress, lies and red tape: the views, success rates and stress levels of the MTAS cohort. J R Soc Med 2008;101:313-8.[Abstract/Free Full Text]
5. Taylor C, Graham J, Potts HW, Richards MA, Ramirez AJ. Changes in mental health of UK hospital consultants since the mid-1990s. Lancet 2005;366:742-4.[CrossRef][Web of Science][Medline]
6. Lazarus RS, Folkman S. Stress, appraisal and coping. New York: Springer, 1984.
7. Paice E, Rutter H, Wetherell M, Winder B, McManus IC. Stressful incidents, stress and coping strategies in the pre-registration house officer year. Med Educ 2002;36(1):56-65.[CrossRef][Web of Science][Medline]
8. Ramirez AJ, Graham J, Richards MA, Cull A, Gregory WM. Mental health of hospital consultants: the effects of stress and satisfaction at work. Lancet 1996;347:724-8.[CrossRef][Web of Science][Medline]
9. McManus IC, Keeling A, Paice E. Stress, burnout and doctors’ attitudes to work are determined by personality and learning style: a twelve year longitudinal study of UK medical graduates. BMC Med 2004;2:29.[CrossRef][Medline]
10. Ghodse H. Doctors and their health—who heals the healers? In: Ghodse H, Mann S, Johnson P, eds. Doctors and their health. Sutton: Reed Healthcare, 2000.
11. Hawton K, Clements A, Sakarovitch C, Simkin S, Deeks JJ. Suicide in doctors: a study of risk according to gender, seniority and specialty in medical practitioners in England and Wales, 1979-1995. J Epidemiol Community Health 2001;55:296-300.[Abstract/Free Full Text]
12. Taylor C, Graham J, Potts H, Candy J, Richards M, Ramirez A. Impact of hospital consultants’ poor mental health on patient care. Br J Psychiatry 2007;190:268-9.[Abstract/Free Full Text]
13. Firth-Cozens J, Greenhalgh J. Doctors’ perceptions of the links between stress and lowered clinical care. Soc Sci Med 1997;44:1017-22.[CrossRef][Web of Science][Medline]
14. Jones JW, Barge BN, Steffy BD, Fay LM, Kunz LK, Wuebker LJ. Stress and medical malpractice: organizational risk assessment and intervention. J Appl Psychol 1988;73:727-35.[CrossRef][Web of Science][Medline]
15. McCray LW, Cronholm PF, Bogner HR, Gallo JJ, Neill RA. Resident physician burnout: is there hope? Fam Med 2008;40:626-32.[Web of Science][Medline]
16. Ospina-Kammerer V, Figley CR. An evaluation of the respiratory one method (ROM) in reducing emotional exhaustion among family physician residents. Int J Emerg Ment Health 2003;5(1):29-32.[Medline]
17. Rosenzweig S, Reibel DK, Greeson JM, Brainard GC, Hojat M. Mindfulness-based stress reduction lowers psychological distress in medical students. Teach Learn Med 2003;15(2):88-92.[CrossRef][Web of Science][Medline]
18. Sambunjak D, Straus SE, Marusic A. Mentoring in academic medicine: a systematic review. JAMA 2006;296:1103-15.[Abstract/Free Full Text]
19. Teasdale JD, Segal ZV, Williams JM, Ridgeway VA, Soulsby JM, Lau MA. Prevention of relapse/recurrence in major depression by mindfulness-based cognitive therapy. J Consult Clin Psychol 2000;68:615-23.[CrossRef][Web of Science][Medline]
20. Epstein RM. Mindful practice. JAMA 1999;282:833-9.[Abstract/Free Full Text]
21. Kjeldmand D, Holmstrom I. Balint groups as a means to increase job satisfaction and prevent burnout among general practitioners. Ann Fam Med 2008;6:138-45.[Abstract/Free Full Text]
22. Mann MP. Faculty mentors for medical students: a critical review. Med Teach 1992;14:311-9.[Web of Science][Medline]
23. Firth-Cozens J. Doctors, their wellbeing, and their stress. BMJ 2003;326:670-1.[Free Full Text]
24. Firth-Cozens J. Interventions to improve physicians’ well-being and patient care. Soc Sci Med 2001;52:215-22.[CrossRef][Web of Science][Medline]
25. General Medical Council. Good medical practice. 2006. www.gmc-uk.org/guidance/good_medical_practice/index.asp
26. Kroenke K, Spitzer RL, Williams JB. The PHQ-9: validity of a brief depression severity measure. J Gen Intern Med 2001;16:606-13.[CrossRef][Web of Science][Medline]
27. National Institute for Health and Clinical Excellence. Management of depression in primary and secondary care [amended]. 2007. (Clinical guideline 23.) www.nice.org.uk/Guidance/CG23.
28. Leichsenring F, Rabung S. Effectiveness of long-term psychodynamic psychotherapy: a meta-analysis. JAMA 2008;300:1551-65.[Abstract/Free Full Text]
29. Churchill R, Hunot V, Corney R, Knapp M, McGuire H, Tylee A, et al. A systematic review of controlled trials of the effectiveness and cost-effectiveness of brief psychological treatments for depression. Health Technol Assess 2001;5(35):1-173.[Medline]
30. Mead GE, Morley W, Campbell P, Greig CA, McMurdo M, Lawlor DA. Exercise for depression. Cochrane Database Syst Rev 2008(4):CD004366.
31. Davidson SK, Schattner PL. Doctors’ health-seeking behaviour: a questionnaire survey. Med J Aust 2003;179:302-5.[Web of Science][Medline]
32. Jones P. Doctors as patients. Oxford: Radcliffe, 2005.
33. Forsythe M, Calnan M, Wall B. Doctors as patients: postal survey examining consultants and general practitioners adherence to guidelines. BMJ 1999;319:605-8.[Abstract/Free Full Text]

CiteULike    Complore    Connotea    Del.icio.us    Digg    Reddit    StumbleUpon    Technorati    What's this?

Relevant Articles

The NHS elephant in the room

John Sharkey
BMJ 2009 338: b2099. [Extract] [Full Text]

Doctors, their wellbeing, and their stress

Jenny Firth-Cozens
BMJ 2003 326: 670-671. [Extract] [Full Text] [PDF]

Doctors as patients: postal survey examining consultants and general practitioners adherence to guidelines

Malcolm Forsythe, Michael Calnan, and Barbara Wall
BMJ 1999 319: 605-608. [Abstract] [Full Text] [PDF]

This article has been cited by other articles:

• Sharkey, J. (2009). The NHS elephant in the room. BMJ 338: b2099-b2099 [Full text]  

Rapid Responses:

Read all Rapid Responses

Physician Heal Thyself

Rahul Rao
bmj.com, 8 May 2009 [Full text]

Meditation not medication -a wonderful method to avoid stress

INDRANIL BANERJEE
bmj.com, 10 May 2009 [Full text]

Defining , measuring and managing stress.

Richard G Fiddian-Green
bmj.com, 10 May 2009 [Full text]

A view from the bottom

Chris E Nancollas
bmj.com, 11 May 2009 [Full text]

Re: Defining , measuring and managing stress.

Les O. Simpson
bmj.com, 11 May 2009 [Full text]

Time has the answer!

Nikhil C Kaushik
bmj.com, 13 May 2009 [Full text]

Peer Pressure

Christina Ryan
bmj.com, 13 May 2009 [Full text]

The NHS is the elephant in the corner

John Sharkey
bmj.com, 14 May 2009 [Full text]

Role of occupational health

John RB Cooper, et al.
bmj.com, 18 May 2009 [Full text]

Systemic , organisational and personal factors in occupational stress

Janet Thomas
bmj.com, 18 May 2009 [Full text]

The OASIS System: Can an acronym help in avoiding depression?

Digby J Quested
bmj.com, 22 May 2009 [Full text]

Online poll

Find out more on doc2doc >>