Helping sick doctors

Fix the job, not the doctors

Practising medicine can seriously damage your health. But despite mounting recognition of this fact,1 2 3 4 5 help for sick doctors in Britain remains inadequate and patchy.1 Other countries do better. Canada was among the first to acknowledge the constraints that stop doctors from seeking help for themselves, setting up a confidential help service in 1987,2 and in 1994 Norway invested $1.3 million in programmes to improve physicians' health and working conditions.6 Is Britain now ready to show a reciprocal duty of care to those who care for its members?

The National Counselling Service for Sick Doctors in Britain (national contact phone number 0171 935 5982) has greatly raised awareness of the problems of sick doctors, but the impact of the service, manned by volunteer physician counsellors and advisers, has been limited by a lack of adequate funds and specific training. Other schemes include the Staffordshire support scheme, which since 1994 has provided general practitioners with face to face counselling from psychologists, support from other doctors, and stress management workshops.7 Companies who run employee assistance programmes also offer help and support from teams of counsellors. In some areas hospital based occupational health departments actively promote their services to medical staff and general practitioners (V Ford, Leicester Royal Infirmary, personal communication). Few sick doctors (about 3% a year) use support schemes (personal communications from V Ford and Staffordshire scheme), although about 10% have availed themselves of the preventive help from stress management workshops.7

Sutherland and Cooper have shown a rise in mental illness among general practitioners during the past decade.3 Caplan confirmed that both hospital consultants and general practitioners have high levels of anxiety and depression: about a quarter of the doctors studied scored as cases of anxiety and a tenth scored as cases of depression.4 Some attribute doctors' widespread distress to the complex psychodynamics of doctor-patient relationships. Others take a more pragmatic approach, identifying specific stress inducing factors in doctors' workloads.3 5 8 Whatever the cause, the seeds of pathological behaviour are probably sown during the vulnerable years of being a medical student.9 10 The brutalising experience of working as a preregistration house officer also provides fertile ground for the development of maladaptive coping mechanisms such as substance abuse.9 The Nuffield Provincial Hospital Trust's recently published report concludes that doctors have special healthcare needs.11 Cultural and organisational barriers may prevent them from using services in the same way as lay people do. Doctors do not seek help because of the stigma of illness, attitudes of denial learned in medical training, and a lack of insight into personal illness.1 11 A dangerous result is that doctors can end up treating themselves in isolation or, after a delay, referring themselves to hospital consultants who may collude with this irregular procedure.11 12 13

Well intentioned plans are in the pipeline. The BMA will provide a 24 hour telephone counselling service for doctors from April 1996. The Department of Health has conferred with representatives of the royal colleges to stimulate activities and ideas to prevent and reduce doctors' stress, including setting up the stress fellowship posts held by the authors. Educational initiatives are being developed to help doctors at all stages of their careers to combat stress by mentoring, co-tutoring, and other personal development programmes. The BMA is continuing its efforts to negotiate improved working conditions for doctors in all specialties. Most recently, a working party of the Nuffield Provincial Hospital Trust has proposed the setting up of independent regional bodies that would offer their own system of comprehensive, accessible, and available healthcare for individual doctors, funded and promoted by the NHS Executive.14 However, doctors would need to have absolute trust in the effectiveness and confidentiality of any system, and organisers would therefore need to introduce watertight procedures to safeguard doctors' personal interests. The current crisis in recruitment and retention in medicine adds to the urgent humanitarian need to provide appropriate help for sick doctors. Equally important are the unquantified effects of doctors' stress on care of patients. The potential expense of new initiatives should be more than outweighed by the opportunity costs of failing to address these issues, losing practising doctors from the profession, and putting doctors and patients at risk. Such initiatives will need proper evaluation, which has so far been conspicuously lacking. But the real question remains. If the job is making the doctors sick, why not fix the job rather than the doctors?