Young female doctors, mental health, and the NHS working environment

Over the past five years an increasing number of patients have presented to the Practitioner Health Programme, a confidential service providing treatment to doctors and dentists in the London area who have mental health or addiction problems.

What has also changed considerably is the age of the patients presenting for care. Since 2009, a decreasing proportion of older doctors and an increasing proportion of young doctors have presented.

In 2008 and 2009, 42% of the 195 patients presenting to the service were aged 46 years or over, and a quarter were aged 25-35. In 2012 and 2013, conversely, just over half (55%) of the 242 patients presenting to the service were 25-35 years old, and 22% were 46 or over (table⇓). To put these figures into perspective, under 35 year olds represent 28% of those on the General Medical Council register. Similar high rates of mental health problems have been found among those attending MedNet, the confidential service for doctors and dentists in London. The largest age group attending that service is doctors aged 30-39 years.

Over the five years that the Practitioner Health Programme has been running, and averaged for all age groups, the number of men and women presenting to the service is roughly equal. However, women make up more of the younger doctors treated by the service, and this pattern has not changed as the service has expanded. In 2013, female doctors made up around three quarters of those under 35 years old and only a fifth of those aged over 55 years.

Around two thirds of the doctors presenting to the Practitioner Health Programme do so because of mental health problems, such as depression, anxiety, and burn-out, and around a third present with addiction problems. However, the majority of younger doctors present with mental health problems, rather than because of difficulties with addiction.

There are likely to be a variety of reasons why increasing numbers of young doctors are presenting to the Practitioner Health Programme. One may be that there is increased awareness in the profession of mental health issues among doctors and an increased willingness to seek help for these problems.

Better training and more empathetic attitudes to mental health may have helped to reduce the stigma and shame that doctors can feel when admitting that they may have mental health problems. This may mean doctors feel more comfortable presenting for help. The Practitioner Health Programme is seeing some doctors who present early before their issues have become entrenched.

However, this is not the whole story. Our experience at the Practitioner Health Programme is that, by and large, most doctors do not present at an earlier stage in the progression of their illness. Many have months of distress and disability until their condition is noticed by friends and family or often by employers after a crisis at work.

The characteristics of good doctors, such as perfectionism and altruism, can make them vulnerable to mental illness. A change in these characteristics could explain increasing presentations to the Practitioner Health Programme among young doctors. However, the evidence does not suggest that there has been any change in the population of students choosing, or being selected, to study medicine. Instead, it may be that job stress, rather than personality, pre-existing mental health problems, or factors at medical school, is behind the mental health problems seen in newly qualified doctors.

One way in which the group of younger doctors presenting to the Practitioner Health Programme differs from the profession overall is in the larger proportion of female doctors. Since 2008, the number of young women under 35 years old presenting has increased fivefold, from 21 patients in 2008-09 to over 100 in 2012-13. Women represented 59% of all new patients in 2012-13, over represented, even given the high numbers of women entering medicine.

Research has shown that young female doctors are more likely to develop mental health problems. In a large Australian survey of medical students and doctors, female doctors reported higher rates than male doctors of current psychological distress (4.1% v 2.8%), likelihood of minor psychiatric disorders (33.5% v 23.2%), and current diagnoses of specific mental health disorders (8.1% v 5.0% for depression; 5.1% v 2.9% for anxiety).1

Young female doctors were also more likely to have had thoughts of suicide in the previous 12 months (11.0% v 10.0%) and in the period before the previous 12 months (28.5% v 22.3%), and to have attempted suicide (3.3% v 1.6%). In addition, they reported greater work stress (37.4% v 19.8% for conflict between career and family or personal responsibilities) and were more likely to report having stressful life events in the past year compared with male doctors (20.4% v 17.2% regarding caring for a family member).1

One way in which women in medicine differ from those in other professions is that, compared with their counterparts in other careers, female doctors are more likely to be in a training grade post in their early 30s. This can create tensions with the wish to settle down and start a family.

The most common age at which women present to the Practitioner Health Programme is 29-30 years, and it may be that women entering their fourth decade wonder whether they are achieving goals they set themselves before entering medical school. After caring for their patients during the day, female doctors who have family responsibilities have the additional demands of caring for their families in the evening and at night.

Doctors in training have always worked alongside death, distress, and disability. They are used to hard work and long, unsocial hours, and this has not changed in recent years. What has changed over the past decade is the working environment in which they are carrying out their roles, and this might undermine the development of resilience. In recent years, a culture of increasing blame, bullying, and retribution has developed in medicine—the General Medical Council estimates that one in eight doctors in training has suffered bullying—and this culture undermines the development of resilience among doctors.

Doctors’ shorter working hours are also a barrier to developing resilience. Working time rules mean doctors work shifts, and this fractures the team working structures and relationships that provide support and feedback and build resilience for trainees.

Changes to working hours also erode continuity of care. Continuity of care is valued by healthcare workers as well as by patients. That includes continuity in terms of looking after their patients from admission to discharge, and also continuity of space (in wards, hospitals, and homes) and colleagues (peers, trainers, and nurses). Continuity is now largely absent in many of these areas.

Complex systems, such as hospitals, can develop social resilience that allows doctors to cope with external stresses and disturbance as a result of change. However, recent changes in routines, customs, practices, and ways of working have destabilised the complex ecosystems in the health service. The result of this is that the older generation of doctors are now less able to support their younger colleagues.

Changes to the training environment also mean that there has been a fracture in the compact whereby the NHS provides sustenance, refuge, and support, and the doctor in training works as hard as possible for patients. Trainees are expected to move, sometimes every three months, with no security that accommodation will be found. They have little control over their working hours, space, days off, or job security, and no guarantee of support from superiors when things go wrong.

For staff, fear is becoming the prevailing culture within the NHS, juxtaposed with the culture of kindness and compassion that doctors are meant to espouse. The new inspection regimen is creating a culture of fear in those being inspected, and “name, blame, and shame” policies mean that doctors face humiliation and shame for any transgression.

Despite the figures shown, it is still unusual for doctors to become mentally unwell, and most pass through training with few problems. Predictors of good psychological wellbeing are the same in doctors as in the rest of society: stable relationships and a high level of support from family members. Other factors that help are involvement in reflective practice, such as Balint groups, and a good work-life balance, including taking holidays and breaks.

However, we must not be complacent. Doctors are an important and expensive resource for society and loss of this workforce due to avoidable ill health is a waste to the health service, a loss to patients, a stress on colleagues, and a disruption to doctors’ own careers. Avoidable causes of ill health in the system within which doctors work must be dealt with and doctors must have timely access to confidential help.

The experience of the Practitioner Health Programme has shown us that, when doctors in difficulty access services, they make a good recovery. They return to their previous levels of functioning with an increased awareness of how to avoid a relapse. However, this is not enough and we must help to ensure doctors work in a respectful, safe, and supportive environment.

Good Medical Practice (2013) sets out the duties of a doctor in four domains: knowledge, skills, and performance; safety and quality; communication, partnership, and teamwork; and maintaining trust. To these duties should be added an expectation that the NHS provides an environment that puts support in place for staff to provide the best care they can. Doctors are asked to make care of the patient their primary concern, but we must ensure that while we give doctors enormous responsibilities, with those responsibilities comes the right to be protected in their working environment.