Making doctors betterBMJ 2018; 363 doi: https://doi.org/10.1136/bmj.k4147 (Published 03 October 2018) Cite this as: BMJ 2018;363:k4147
- Clare Gerada, medical director1,
- Cat Chatfield, quality improvement editor2,
- Abi Rimmer, deputy editor, BMJ careers2,
- Fiona Godlee, editor in chief2
- Correspondence to: C Chatfield
More doctors than ever are in a state of distress.1 This is true regardless of age, specialty, gender, ethnicity, seniority, or whether their health system is publicly or privately funded. Does the solution lie with the individual clinician or the system within which they work?
Rates of mental illness, emotional exhaustion, and anxiety are increasing among health professionals.23 The causes are generally the same across the world and include a lack of time with patients, loss of continuity, erosion of amenities such as on-call rooms and doctors’ messes, shift systems that undermine traditional peer and senior support, unrealistic public expectations of medicine, the industrialisation of healthcare turning it into a production line, a growing burden of administrative tasks, and being expected to deliver more with fewer resources.
Doctors increasingly work within a culture of litigation and blame, carrying the full burden of accountability despite a loss of authority and autonomy. They suffer when they can’t provide the high value care patients deserve,4 and may feel they must always appear infallible. Commentators note that doctors often struggle to uphold the demands of their professional persona, demands that include self sacrifice and the denial of vulnerability.5
Many doctors feel defined by their role as a healthcare professional. The creation of this “medical self” is understood to be the merging of professional and personal identities during medical training.6 The medical self serves to mask suffering and protect doctors from feelings of guilt, fear, and hopelessness. If the professional side of the medical self dominates, however, doctors may neglect the personal roles essential for their wellbeing, including, when they become ill, the role of patient.
The medical self must be counterbalanced by a healthy working environment, personal support, and external interests. Too often, however, the effectiveness of initiatives that aim to improve clinician wellbeing is limited because they focus on support for the individual while neglecting the wider environment. Mindfulness, stress management, and discussion groups can reduce physician burnout, but their effect on clinicians with mental health problems is less clear.78 In the past, much was made of resilience training to help protect doctors from the stressors created by the systems in which they work. More recently, this approach has been questioned and even rejected by clinicians.910
Restructuring working patterns and shift lengths is important, but organisations could do much more to foster clinical teams, generate a sense of belonging, and balance the sometimes conflicting demands of evidence based practice and clinician autonomy.3711
Only a whole systems approach will enable an honest discussion between clinicians, patients, and the public about the limits of both medicine and its practitioners. Scotland’s Realistic Medicine, for example, aims to tackle expectations on a societal scale alongside an ambitious national improvement programme.12 The Changing Face of Medicine project encourages doctors to reflect on changes to their traditional role and considers how to redesign their roles and tasks to ensure maximum value for patients.13 But we must also tackle the persistent blame culture that is making doctors fearful and defensive, particularly, in light of the Bawa-Garba case.14
Finally, we need to create a new pact between medical professionals and patients that allows doctors to be flawed, to be human, and to be able to say, “enough is enough.” We need to restore team based training rather than continue in the belief that rota systems and individual reflection documented onto sterile e-portfolios can replace the camaraderie of learning together. Space must be created for team based reflection through tools such as Schwartz rounds and Balint groups. Dedicated places for meeting, thinking, and exchanging should be restored, but above all we must declutter the professional lives of doctors and give them the time and space to enjoy their jobs.
The BMJ champions the wellbeing of doctors. To coincide with the tenth annual conference of the Practitioner Health Programme, the wounded healer, on 4 and 5 October, we have curated an online collection of articles published in the past few years (www.bmj.com/wellbeing), including recent articles on the importance of staff engagement,15 how to deal with a bullying colleague,16 and optimising sleep for night shifts.17 We are also considering how best to redesign health systems18 to move away from a production line mentality towards co-production of services with patients.19
We see the need for fundamental changes in culture, systems, and practice that will help maintain and improve the wellbeing of all health professionals, and by extension, their patients. We have convened an expert advisory panel to establish a clear understanding of these issues and would like readers to tell us their most pressing concerns to inform our campaign priorities.
As populations age and expectations escalate, the pressure on healthcare systems will inevitably increase. Maintaining the physical, mental, and emotional wellbeing of clinicians is essential if they are to provide the safest and highest quality care for patients.
Competing interests: We have read and understood BMJ policy on declaration of interests and declare that CG is medical director of the practitioner health programme. CC and AR are The BMJ leads for the wellbeing campaign.
Provenance and peer review: Commissioned; not externally peer reviewed.
This article was updated on 4 October to correct errors with author names in the reference list.