How the postgraduate deanery can help doctors with disabilitiesBMJ 2004; 329 doi: https://doi.org/10.1136/bmj.329.7468.s132 (Published 25 September 2004) Cite this as: BMJ 2004;329:s132
- Heather Payne, associate dean for educational support
Heather Payne outlines what the innovative Welsh deanery has been up to
The effects of disability are very varied (see box for some of the conditions constituting a disability under the Disability Discrimination Act) and the degree of functional disability will vary with the job. For example, it is easy to imagine each of these disabilities would affect the work of a psychiatrist, a pathologist, a surgeon, a general practitioner or a public health doctor differently.
The Wales Postgraduate Deanery aims to give the right help and support to meet the training needs of doctors with disabilities and illnesses and keep their career progress on schedule.
Ability, disability, and vulnerability
Doctors with a disability have already shown considerable ability in knowledge, skills, and determination. They have passed exams, completed their training this far, and already possess many of the desired competencies. However, their disability will give rise to certain vulnerabilities, from both within and outside themselves.
Time lost from training because of sickness absence may lead to a deficiency in some key knowledge or skill areas (such as surgical techniques). Doctors may be unable to display some competencies in adverse circumstances (for example, in excess background noise for doctors with hearing impairments), they may have limited insight into their own situation (particularly when an alcohol problem exists and is combined with mental illness).
The attitude of colleagues is vitally important. We seem very bad as a profession at recognising and dealing with disability, chronic illness, and mental distress in colleagues. Organisational sympathy lasts for a while but then evaporates as the heat on service needs is turned up by a longer absence. This can lead to “sickness presence,” where a doctor with severe health problems carries on at work. The inquiry into the death of Daksha Emson (a 34 year old psychiatrist who killed herself and her 3 month old daughter last year) recommended that the NHS move towards a supportive and non-stigmatising attitude towards mental illness. In practical terms, this means that consultants must take a lead in safeguarding the mental wellbeing of their trainees.⇓
Training issues for doctors with disabilities
My job as one of a team of associate deans, is to identify the issues relevant to the doctor, the disability, and the job, and to help solve problems interfering with the doctor's training. In reality this means lots of liaison and negotiation with trusts, as the employers, to ensure that they make the right sort of adjustments to the workplace so the doctor can get the right training experiences. I use a typically “medical model” for this.⇓
Identifying problems, risks, and deficits
Agreeing the desired outcome (and how it will be measured)
Developing a management plan with a timescale
Making sure all the above happens.
Ensuring patients' safety
Training is a fundamental aim for the doctor, but the bottom line must always be patients' safety. The deanery ensures that a risk management strategy is in place that documents any areas where patients' safety might be a concern (for example, a doctor with a hearing impairment detecting a murmur), and how the risk will be managed (for example, ensuring that any patients at risk are examined by another doctor).⇓
Examples of illnesses and conditions
The following are some of the conditions and illnesses likely to fall under the remit of the Disability Discrimination Act 1995.
Post-traumatic stress disorder
This requires the agreement and support of the consultant who is ultimately accountable for patients' care. In practice, a clinical risk assessment document usually contains a long list of things the doctor can do perfectly well, followed by a very short list of potential problem areas that need cover.
Modifications to the training programme
Depending on the disability, we may call on the help of assessments from specialists including occupational health, psychiatry, occupational psychology, management, human resources, and speech and language therapists.
The modification is usually common sense. For example, if shift work precipitates mental illness in a trainee, then the trainee will need a supernumerary post with no on-call for a period. Someone with severe asthma might not be able to work in pathology (all the chemical fumes). A doctor with epilepsy who cannot drive would require a taxi to outlying clinics.
The experts at “Access to Work” will perform a site assessment, and recommend and pay for suitable workplace modifications. This may include computer software, lighting, and visual or mobility aids. They are always up to date with the latest ingenious disability aids and are a great source of support.
The following hypothetical examples of Dr X, Dr Y, and Dr Z illustrate the ways in which the deanery tries to support trainees with a disability.
Hypothetical case study—Dr X
A year 4 specialist registrar in orthopaedics with great difficulty in teamworking, empathy with patients and colleagues, and communication with nursing staff, leading to a record of in-training assessment (RITA) E
Great strength in attention to operative detail, research, audit, computing skills
Psychiatric assessment confirms a diagnosis of Asperger's syndrome
Remediation for RITA E offered via independently commissioned individual support programme, using personality inventory (Myers-Briggs), team work, and communication skills coaching, and occupational psychology input
Hypothetical case study—Dr Y
Acute onset of severe mental illness during preregistration house officer year, requiring hospital admission
Acute episode followed a week on night duty
Bipolar illness diagnosed by psychiatrist. Occupational health advice sought
Three months off work, followed by graduated return to work with daytime working only for three to six months in a supernumerary post (temporary funding from deanery) before returning to full duties to complete registration requirements, to be eligible to apply for a foundation programme 2 post
Information provided about Doctors Support Network, career options, flexible training, BMJ Careers health matching scheme (see further information box).
Hypothetical case study—Dr Z
Wheelchair user after a sporting accident causing paraplegia, during foundation programme 2 year, returning to rotation after a period off sick⇓
Risk assessment performed regarding patients' care (crash bleep, practical procedures), doctor (self catheterisation facilities, pressure care on shifts), and environment (access, health and safety issues) to produce documentation of foreseeable risks and management strategy
Access to Work visit to assess workplace, make recommendations about, and provide funding for, reasonable adjustments. Palm Pilot provided for ready access to procedures and formularies
Information given about career options, Association of Disabled Professionals, BMJ Careers chronic illness matching scheme.
See the table for some more examples.
The educational support plan
All trainees should already have regular help and advice from their educational supervisor. We encourage trainees to find a mentor. The royal colleges are very helpful in identifying suitable mentors to support and advise doctors with disabilities.
The educational plan may contain solutions to current problems or may aim to anticipate and avoid them. If an illness has interfered with training progression or exam success, then the RITA panel should have set the significant educational objectives. The deanery educational support plan must then help the doctor achieve these as a priority. We encourage all trainees to engage in reflective note keeping, as it represents effective learning and is a good lifelong learning habit. Some of the reflections are about aspects of their own situation, and show high levels of insight and clinical maturity.
Association of Disabled Professionals—www.adp.org.uk/MS/index.html
Access to Work—www.ucl.ac.uk/hr/docs/access_to_work.php
Disability Rights Commission helpline—08457 622 633—www.drc-gb.org
Doctors Support Network (peer support group for Doctors with mental health problems): tel 0870 321 0 642—www.dsn.org.uk
British Doctors and Dentists Group (peer support group for Doctors and Dentists with alcohol problems): tel 020 7487 4445
Medical Council on Alcohol—www.medicouncilalcol.demon.co.uk/
BMA website (links to funding charities and support organisations)—bma.org.uk
BMJ Careers chronic illness matching scheme—http://bmjcareers.com/chill)
We are currently developing our deanery website to provide links to many self help, support and lobbying organisations as a way of empowering doctors to choose their own preferred supports.
Helping trusts support disabled employees
The trust's disability coordinator (although there may not be such a person in all trusts) is a valuable aide to troubleshoot the million and one logistic problems that arise when trying to coordinate workplace modifications. The whole process can be stressful—even when things go well there are myriad irritations from bureaucracy, petty rules, and NIMBs (“not in my budget”) claims, and so a source of friendly psychological support is always important.
Remediation from the individual support programme
The communication skills unit at the Cardiff Academic Unit of General Practice offers this individual support programme for doctors who have difficulties with communication skills, personal interactions, team working, leadership skills, or other problems. The programme offers specifically tailored intervention to help the doctor overcome problems identified at assessment and is independent and confidential. It has been a very successful service, much valued by its clients, and we hope to see more widespread use of the model.