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Rapid Responses: Rapid Responses published:
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Not the full picture
- Chris E Nancollas (16 November 2008)
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Substance Misuse in the Undergraduate Medical Curriculum
- Ken Checinski, Ferhal Utku (17 November 2008)
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Doctors' distress and mental 'illth'
- Christopher L. Manning (18 November 2008)
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Re: Doctors' distress and mental 'illth'
- Woody Caan (19 November 2008)
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Research into medical student well-being
- Helen Macdonald, Dr Harriet Stewart Consultant, Dr Alyson Hall Hon Consultant, Dr Karrie Fehilly Specialist Registrar in Child and Adolescent Psychiatrist, London (26 November 2008)
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Re: Research into medical student well-being
- Woody Caan (27 November 2008)
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Chris E Nancollas, Retired GP Yorkley, Glos GL15 4TX
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These articles are fine as they go, but they omit to mention the root cause of so many doctors health problems - the job itself. I have suffered from depression, and although lifestyle issues play a part there are two other factors which were significant. The first was twenty five years of intermittent sleep deprivation cause by trying to provide an out of hours service alongside the day job. Secondly, the attempts by various politicians to turn the NHS into a lunatic asylum. I ought to add that the BMA ignored the former for far to long, and has actually connived in the latter. I am sure there are hundreds, perhaps thousands, of doctors out there who despair at all the guidelines, and targets, and covert rationing, and all the rest of the rubbish, and wish that they could just get back to treating patients without interference. Not all of them will become ill, of course, but those that do deserve better than to be patched up and sent back into the machine. To adapt a favourite phrase, it's not about changing doctor behaviour, it's about changing the system's behaviour. Competing interests: None declared |
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Ken Checinski, Senior Lecturer in Addictive Behaviour St George's, University of London, London SW17 0RE, Ferhal Utku
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Brewster's editorial elegantly draws together the diverse but linked threads contained in the four original research articles about doctors' health. It is no accident that this landmark edition of the BMJ has been published on the eve of the BMA conference "Doctors’ Health Matters – Finding The Balance". What fewer people may know is that the International Centre for Drug Policy at St George's, University of London (ICDP Director: Hamid Ghodse) is launching the first wave of development projects in UK medical schools aimed at substance misuse education in the undergraduate curriculum. This is a Department of Health funded project to provide practical support to deliver learning in six key areas, one of which is "Professionalism and self-care". Doctors' health is not the exclusive province of the addiction specialist, psychiatrist or general practitioner: it is everybody's business. Nevertheless, most doctors with health issues affecting their fitness to practise have an addiction problem, with or without an additional mental disorder. The stigma attached to substance misuse, the sometime doubt as to its legitimacy as a health problem and the sense of therapeutic nihilism must all be addressed through group and peer processes for there to be a sea change in professional behaviour. This is a formidable task but the ICDP project has the highest level of support from regulatory, educational, managerial and professional organisations. We have been struck by the enthusiasm shown by all medical schools approached to be involved in the project. Similarly, at St George's, where teaching in many of the key areas is well established, students continue to choose further elective modules in substance misuse topics (including students' and doctors' health): 35-40% of St George's graduates will have taken at least one of their four Special Study Modules in this field. In the same way as the late Sir Richard Doll set in motion a change in doctors' smoking over 50 years ago that led to the improved health of the population, perhaps it is the time again for doctors and other health care professionals to do the same for drug and alcohol use and mental health? Competing interests: None declared |
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Christopher L. Manning, Director. Upstream Healthcare Ltd Twickenham TW11 9HG
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Dear Editor, I greatly welcome this BMJ issue. Brewster lists the important issues that the four studies delineate: -Primary prevention in medical school
The development of psychological mindedness is a deeper principle that needs to course through all of the above, since all doctors throughout their training and career need to be skilled in dealing with distress - within themselves, each other and their patients. Further, if mental health 'first aid' is so effective for the public, then surely - as people first and foremost, the same applies to doctors and they can be similarly trained? Checinski details the opportunity for informing young (and importantly still synapsing) minds. There are particular aspects to the provision of medical care that place considerable burdens on these minds even before they work in, or for, the world's now largest employer. Nancollas details some of the many psychotoxic influences that play out in the arena. We do indeed need to fix the overall NHS and party political egosystems and not just the canaries who try their best to sing within them. Of course, there are many forms of misuse and these can include maladaptive behaviours - bullying and addictions - being 'hooked' on the medical job itself; it is possible both to have a life outside of medicine and without it. The 'macho' culture of medicine still has a lot to answer for and it is to be hoped that doctors are also being trained to understand that, within the biopsychosocial approach to the delivery of care, they play but a part. This is an important message for the public too. We do no- one any favours by continuing our culture of supposed invincibility or creating environments in which people cannot name their worst fears earlier or speak as freely as they need to. Brewster also asks the question: "how can we produce healthy doctors who will use voluntary programmes if they need help?" Well, there is 'voluntary' and there is 'voluntary' and when enfeebled the perceived difference can determine what help a person may seek. As someone who served on the DH Group that produced the Mental Health Needs of Doctors Report, I was personally disappointed that, whilst it named the voluntary organisations that have the lived-experience expertise of doctors who are available to offer anonymous and confidential peer-support, it did not underline the principle of involving such organisations. They are the lynch-pin of service provision to a wide variety of professionals who are well known to be diffident about seeking help from within a system that has to manage its own risks, rather than their best interests. Mental health policies are replete with the importance of involving the voluntary sector - its expertise, values and value for money. Not to do so is both short-sighted and could be negligent. At least 50% of the public in mental distress do not chose to be involved with statutory health services and unless and until people feel safe, sound and supported by systems that have THEIR best interests at heart, then their engagement will continue to be tardy and sub-optimal. The NCAS initiative in London is most welcome, but I am still far from convinced that the national will is there to involve voluntary sector organisations in proactive and sustainable ways. Not to do so is short- sighted, ignores the evidence-base and all the policy developed on the back of it. Not a week goes by that I do not counsel yet another doctor or health service manager who is less than keen to 'volunteer' their problem or seek help for it (even from their own GP) from within the system for which they work. And if we think we are close to solving this issue, perhaps I could pose two questions: 1. Why does the NHS not undertake random substance and
alcohol testing on all its staff?
Why would any so-called civilised, first-world country be unable to do either or both? Yours Sincerely
Competing interests: None declared |
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Woody Caan, Professor of public health Anglia Ruskin University, Cambridge CB1 1PT, UK.
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Manning [1] makes an important point about the valuable, voluntary sector contribution, within an extended system of mental health provision. We reviewed the literature on mutual aid groups across a very wide range of settings and members.[2] The UK medical groups like Doctors Support Network fitted in coherently with the wider developments (and benefits) from such mutual mental health support. 1 Manning C. Doctors' distress and mental 'illth'. Rapid response, 18 November 2008. 2 Baldacchino A, Caan W, Munn-Giddings C. Mutual aid groups in psychiatry and substance misuse. Mental Health and Substance Use: dual diagnosis 2008; 1: 104-117. Competing interests: Elected Governor of the Cambridgeshire and Peterborough NHS Foundation Trust, a provider of mental health care |
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Helen Macdonald, junior doctor and ex-welfare officer London, Dr Harriet Stewart Consultant, Dr Alyson Hall Hon Consultant, Dr Karrie Fehilly Specialist Registrar in Child and Adolescent Psychiatrist, London
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We are glad that the issue of doctors’ health has been highlighted by the BMA conference and the BMJ’s collection of research papers. We are a group of researchers investigating the mental health of medical students. Research shows that problems that start at medical school can persist into working life (1). Medical students, like doctors do not always report mental health problems. The same is true of students in general. In 1999-2000 only 4.5% of students (including non medical students) declared a disability, and only 0.12% a mental health disability (2). University affects all students differently. Medical students face unique challenges: more exams, more debt, highly competitive peers and difficult professional circumstances. When they encounter difficulty their ability to recognise problems, seek and access support may also be different to other students. In addition, medical students may be fearful of fitness to practice issues, and that information regarding their mental health may be damaging to their future career and professional reputation. The mental health of the UK student population as a whole has been studied (3, 4). However a literature review reveals there has been little work done with samples that might be representative of UK medical students. Samples are often small and / or lacking control groups. The research generally has a narrow focus, lacks validated questions, and is unable to show trends over time. The four papers published in the BMJ issue on doctors’ health reflect these limitations. None of the four studies were done in the UK. Our project developed from a team member’s post as a student welfare officer for a London medical school in 2003. It grew out of a concern that current university services were outdated, and not designed for the diverse and expanding population of students. Mechanisms to identify students in difficulty, such as self-reporting or using exam performance as a proxy for well-being, seemed unsatisfactory. Students often approached the welfare officer for advice on their friends’ mental health. We designed a cross-sectional questionnaire to help services develop in a more evidence based way, with the support of the medical school. The questionnaire examined the frequency of mental health symptoms in medical students (as detected by the General Health Questionnaire (GHQ12) (5). It aimed to identify factors that could identify students at risk, the support services medical students were using or wanted and how this compared to non-medical students at the same university. Unfortunately, in 2006 medical school officials decided that they could no longer support the project. There was concern about publishing findings that might harm the medical schools’ reputation, in particular statistics on drug and alcohol use among their students. Without backing from the medical school it was not possible to gain ethical approval. However the medical school said they would consider consenting if at least two other medical schools were involved, the drug and alcohol questions were removed, and the results from all the medical schools were merged. In 2008 another welfare officer at the same university rallied near pan- London student support to restart the project. It will run at most of the London medical schools in 2009, but the results will not be published. It is clear this important research area is still dogged by stigma and that raising the profile of doctors’ health by conferences like this will help. We hope the medical students’ willingness to reflect on and tackle their own mental well-being will set a precedent for future research. References 1. Royal College of Psychiatrists Council Report CR112 (2003): The Mental Health of Students in Higher Education. 2. Higher Education Statistics Agency (2000): Students in Higher Education Institutions 1999-2000. London HESA. http://www.hesa.ac.uk 3. Grant, A (2002): Identifying and responding to students’ concerns: a whole institutional approach. In N. Stanley and J. Manthorpe (eds) Students’ Mental Health Needs: Problems and Responses. London: Jessica King Publishers. 4. Leicester University Student Psychological Health Project (2002). http://www.le.ac.uk/edsc/sphp 5. Goldberg DP, Williams P (1988): A User's Guide to the General Health Questionnaire. Windsor: NFER-Nelson. Competing interests: None declared |
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Woody Caan, Professor of public health Anglia Ruskin University, Cambridge CB1 1PT, UK.
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I wish Helen Macdonald and her senior colleagues every success with their medical school study, due to take place across London in 2009.[1] In 2008, Cheryl Haslam is a distinguished Professor of Health Psychology, whose fine work on occupational well-being is cited by many (including myself). Exactly 20 years ago this month, she had to endure appalling treatment by a hypocritical medical "establishment" for daring to discuss openly the mental health and substance use of medical students in London.[2] It is a tribute to her courage and to the tenacity of other young researchers in this politically-charged field, that research into medical student well-being is now progressing. [1] Macdonald H and colleagues. Research into medical student well- being. BMJ Rapid Response, 26 November 2008. [2] Haslam CO, Ghodse H, Agombar A, Harrison P. The Health and Substance Use of Medical Students. British Journal of Addiction 1988; 83: 1474-1475. Competing interests: Was rather peripherally involved in the St. George's Hospital student study 1988-1991. |
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