Intended for healthcare professionals

Career Focus

Setting up and running a stress management service for doctors

BMJ 1997; 315 doi: (Published 30 August 1997) Cite this as: BMJ 1997;315:S2-7107
  1. Karen Appleby, Counsellor
  1. Contact, Firs Health Centre, Firs Lane, Smethwick, West Midlands B104 7YT.

    Karen Appleby, who runs Contact, a stress management service for doctors in the West Midlands, outlines the structure and function of the service

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    Doctors are exposed to stress. This reality is well documented,1,2 as are the high levels of some of the less adaptive coping strategies-for example, alcohol misuse.3 A survey of preregistration house officers in west Midlands found that two thirds of respondents thought an independent stress counselling service was needed and that crisis support and training should be included in this.4 The results helped bring Contact into being.

    Many accounts exist of how difficult it can be for doctors to request and obtain appropriate help.5 Having a choice between services helps protect professional boundaries.

    Most of the people we have seen were moderately to very distressed-their average scores on the General Health Questionaire were 21. For these doctors we were a last resort-often they had not been able to think of other sources of help. Some had lived with their problem for years.

    Our service was set up in 1995, initially just for doctors in training, and extended in 1996 to cover all grades of doctors and dentists. Doctors can bring either personal or work related problems, provided that there is a clear focus to work with, and we have seen doctors with their partners if relevant.

    Contact is staffed by two clinical psychologists and two counsellors working on a sessional basis with administrative support. The service is confidential, independent, free to the user, and accessed on a self referral basis. Often contact starts over the telephone, but usually a face to face appointment is booked. Clients attend an average of 4.9 sessions with a non-attendence rate of less than 2%. Around 83% of clients attend within 3 days of their first call.

    Around 52 of the 2600 junior doctors in the region made use of the service in the past 12 months, which represents about a 2% uptake of clinical use of the service: inquiries for advice were received from 78 (3%). Use by other doctors and dentists is gradually increasing as they learn about the service.

    We are careful to address our own limitations and consider accessing back up services such as psychiatric assessment or drug and alcohol services when it is appropriate. Sometimes assessment with the client indicates the need for longer term psychotherapy which is extremely difficult to find within the NHS. Clients then have to decide whether to wait or pay privately for sessions.

    We have had discussions about a mechanism through which we could request an extracontractual referral to help a doctor obtain services away from their professional life, though this has yet to be tested. The important principles are that the service needed can be accessed quickly and easily, and without the need for a doctor's name to be given to health trusts or authorities which could also be his or her employer.

    Customising for doctors

    The commonest question we answer is about confidentiality. Any perceived link with employers, referees, or colleagues means doctors don't use the service. Potential users need to know at the outset what professional code therapists adhere to and in what circumstances any information might be divulged and to whom. The experience and confidence of the therapeutic staff is crucial-asking the right questions and discussing the implications of what is presented. We occasionally have had to raise issues about fitness for work, and it has often come as a shock to a doctor to address the effects their problem might have on their professional skills. However, once that insight is there, clients can make a responsible decision about work themselves.

    An direct telephone line is essential, which should be staffed as much as possible. An answering machine can give information about the service and take brief messages but most clients are not keen to leave any personal information in this way and will not leave a call back number.

    Clients can struggle to meet agreed appointment times both because of work demands and because personal time and other boundaries collapse after years of “bleep control.” We have to work with this, and we also have systems to ensure work colleagues do not meet each other. We use different waiting areas, counselling rooms in different parts of the building, and staggered appointment times. Doctors often need to make and change appointments at short notice, and unlike other client groups who may settle on an appointment at a regular time, some doctors need to keep moving to a different day to fit in with on call arrangements-but would like to see the same therapist.

    Having a choice of early morning and evening appointments is important for doctors, as is the promptness with which an appointment can be offered.

    Contact's offices are centrally based and nearest to the largest conurbation in the west Midlands. Despite this, doctors from outlying parts of the region may have made a two hour journey to get to us. Some welcome the feeling of distance from the workplace, others find it impractical. A possible solution is to have links with therapists in these areas who can see doctors on an occasional basis.

    Just as doctors can become isolated, so can the staff supporting them. Our staff often deal with high levels of distress, and we believe it important to have good staff support and supervision, which are also confidentially run.

    Problems experienced by Contact clients

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    Promoting the service

    Doctors get a lot of junk mail and will not pick up leaflets just left out in a pile. Publicity material about the service is best posted in individually addressed envelopes, even if it is time consuming. We distribute a plastic card the size of a credit card with brief details of the service. Doctors are likely to keep these: we have had calls a year or more after cards were received.

    Information about the service is distributed every six months because junior doctors change jobs and locations frequently. We also distribute the information to new graduates from Birmingham Medical School as a large number stay in the area. A display describing the work of the service, left for a couple of weeks in a corner of a postgraduate centre which people can read discreetly, is also valuable.

    Postgraduate clinical tutors and administrators, occupational health departments, staff in human resources and in medical staffing, librarians, and local psychology departments can pass on details of the service, may invite you to speak to trainees about it, or will put up posters. We have found that general practitioners and consultants are less likely to know about the service and less comfortable about inviting us to talk about stress.

    Senior doctors can easily give negative messages about seeking help to improve coping skills-for example, “We all know medicine is stressful, but the best doctors don't get stressed.” Our experience accords with the research finding that the more conscientious and empathic doctors-including many high flyers-probably experience the most distress.6

    Who uses the service?

    A new service takes time to introduce-gradually people start to use it by recommendation and see it as trustworthy-but you (and especially your funding body) have to be patient about this. Most users are doctors, and there are peak times-between April and June and in October and November. More men than women sought help The commonest personal problems were depression, anxiety, and sleep difficulties. Major work related themes were career crises (including anxiety about exams, interviews, and presentations), work relationships, workload, and problems within the work organisation.

    Now that we see doctors further along the career path there are more family and relationship issues presenting. There may be regrets at having put career and work first and family second. There can also be problems of neglected and deteriorating health. A local survey found that the majority of doctors responding could envisage no provision for time off sick, declaring that there was simply no one to delegate work to. There was a negative attitude towards sick leave no matter how bad the circumstances.

    Avoiding stress

    An obvious way to stress proof doctors is by teaching stress management skills. A degree of resilience to stress was noted in medical students who completed stress management training.7

    Our experience is that stress workshops are only well attended if they fit in to an existing programme of meetings. A small group of doctors at about the same stage of their careers, could receive brief presentations from the research on doctors' stress, then launch a discussion on helpful and less helpful coping responses and attitudes.

    Little has been done in the way of formal evaluation of the effectiveness of stress management work in improving the coping strategies of doctors. Our clinical work suggests that medical environments don't always make it easy to use logical problem solving skills or good time management strategies. Stress management workshops probably need to be backed up by workplace systems that help to establish and maintain good strategies. Personal boundaries may be hard to find and maintain without external support because for many doctors ‘good = perfect' and ‘effective time management = meeting everyone's needs'.


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