Work is central to doctors’ identity, and those unable to work need support
BMJ 2016; 353 doi: https://doi.org/10.1136/bmj.i2014 (Published 21 April 2016) Cite this as: BMJ 2016;353:i2014
- Clare Gerada, medical director of the Practitioner Health Programme
- clare.gerada{at}nhs.net
Abstract
Clare Gerada looks at the impact of being unable to work on doctors’ health and wellbeing
Work is central to individual identity, social role, and status,1 and this is particularly the case for doctors. Absence from work, especially for prolonged periods, has a negative effect on physical, mental, professional, and financial health.
Not working—especially if enforced—can lead to demoralisation, depression, and even suicide.2 Exclusion from work risks leaving doctors in a state of suspended animation: unable to revalidate, move jobs, progress their career, or make decisions that require financial certainty.
Unemployed and suspended doctors are among the most isolated doctors, and are at the most risk of developing serious mental health problems.3 Suspension or exclusion, though purportedly a neutral act, rarely feels so since NHS institutions often bar the suspended doctor from their premises. This increases the doctor’s sense of isolation, fear, and guilt. Even if doctors are still being paid, suspension can result in financial hardship, as many supplement their pay with income from other sources and suspension by one employer often leads to suspension by all. Doctors exclusively employed in private practice risk losing all their income overnight.
Doctors involved with regulatory processes because of mental health problems have a triple whammy of not working, being mentally ill, and being involved with regulatory processes. Not working means that doctors are isolated and, as said, often suffer serious financial and personal hardship; being mentally ill means that doctors often face the stigma and shame of their illness and of referral to the GMC; and being involved with regulatory processes creates fear and anxiety.
Self-stigmatisation among doctors who are not working is also common, with doctors describing themselves as failures and internalising the negative views of others.4 In addition, many medical royal colleges automatically revoke membership for doctors suspended by the GMC for three months or more.
Mental illness and exclusion
From 2008 to 2015, 1809 doctors were seen at the NHS Practitioner Health Programme (PHP), a confidential service for doctors with mental health or addiction problems. At presentation, 74% were in work or training. The 26% who were not working included those on short or long term sick leave (11%), those who were unemployed (5%), those who were suspended from work (2%), and those who were on parental leave, sabbatical, retired, or whose status was unknown (9%).
Doctors, mental illness, and regulator involvement
Between 2008 and 2015, 308 (17%) of those doctors seen at PHP were involved with regulatory processes (formal investigation, interim orders panels, suspended, undertakings, conditions, or undergoing fitness to practise hearings). For doctors not working at presentation, 29% (138 out of 472) were involved with regulatory procedures compared with 13% (170 out of 1337) for those working (see Table 1⇓).
Working status among PHP doctors and likelihood of regulatory involvement
Suspension or exclusion from work often goes hand in hand with GMC referral: 79% of doctors who presented at PHP and had been suspended by their employers had regulatory involvement (see Table 2⇓). Among those who defined themselves as unemployed, 47% were also involved in GMC procedures.
Doctors’ work status when presenting to Practitioner Health Programme
Impact of enforced unemployment or underemployment
Doctors who have been through disciplinary procedures are often unable to return to work due to high medical defence fees. Premiums rise considerably—sometimes over £20 000 for GPs who are not covered by their employer—after involvement with the regulator and it is not unusual for medical defence organisations to refuse to offer indemnity to a doctor, at any cost, meaning that doctor (especially if self employed) is essentially unemployable.5 Doctors may be unable to work due to specific GMC undertakings or conditions, or they may be unable to find a workplace supervisor or practice willing to employ them for the period required by the GMC.
Surviving worklessness
Out of work doctors should get help early. Local medical committees, the BMA, confidential support groups, the Royal Medical Benevolent Fund, the Cameron Fund, PHP, and other organisations can all provide support to doctors who are not working (see box).
Unemployment, especially if enforced, can be a lonely time and it is important that out of work doctors talk to colleagues, family, or friends, and make an appointment with their GP. Even if they are not depressed at the point of suspension or referral, the risk of becoming so is very high. At PHP we have a very low threshold for recommending enhanced services—such as antidepressants or talking therapies—for doctors who are suspended or referred to the GMC.
Doctors out of work also need the support of their peers. In today’s litigious, complex, fragmented, blaming, and risk adverse environment, the threat of a referral or being out of work hangs over all of us.
Sources of support
LMCs
General practitioners can access local medical committees’ pastoral services www.bma.org.uk/about-the-bma/how-we-work/local-representation/local-medical-committees
The BMA
The BMA provides free counselling www.bma.org.uk/doctorsfordoctors and a support service for doctors undergoing GMC investigation (Doctors Advisor Service)
British Doctors and Dentists Group
For doctors (and dentists) with addiction problems, the British Doctors and Dentists Group provide support through buddying and groups across the UK as well as support for families. www.bddg.org
Confidential support groups
Confidential support groups for out of work doctors exist. For example, the Doctors Support Group meet every two months and assist doctors and dentists who are facing suspension, exclusion, and investigation of complaints and/or allegations of professional misconduct. Their meetings are free and confidential, and provide opportunities to learn from others who have gone through similar experiences. Their web site also contains useful information gleaned from the experience of others. www.doctorssupportgroup.com
Financial support
Financial support can be provided through the Royal Medical Benevolent Fund (for all doctors) and the Cameron Fund for general practitioners.www.rmbf.org, www.cameronfund.org.uk
Practitioner Health Programme
The London based Practitioner Health Programme www.php.nhs.uk has been running a monthly group for suspended doctors for 5 years. Facilitated by a psychotherapist the group helps to reduce isolation and to sustain a sense of self despite not working.
Psychotherapy groups
Psychotherapy groups help address the loneliness of being out of work and provide a safe space to open up without fearing retribution or humiliation. Groups provide a sense of belonging at a time when many doctors feel isolated and excluded. The Institute of Group Analysis www.groupanalysis.org can provide advice about where to seek psychotherapy groups.
Footnotes
I have read and understood BMJ’s policy on declaration of interests and declare: I am a partner of the Hurley Group, an organisation that runs a number of practices and GP walk-in centres across London, and I am medical director of the Practitioner Health Programme.