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Doctors' Mental Health Working Group Report and Recommendations

dated 29 May, 1997

TABLE OF CONTENTS

EXECUTIVE SUMMARY
TERMS OF REFERENCE
    Background
    Aims
    Strategies and Goals
MEMBERSHIP
PREAMBLE
    Extent of the problem
    Who is affected?
    What are the likely consequences of these problems?
    What are the impediments to addressing these problems?
    Who are these recommendations for?
    Overall Aims of the Recommendations
RECOMMENDATIONS
    One: Ongoing Review of Issues Affecting Doctors' Mental Health
    Two: Preventative Strategies
    Three: Early Intervention
    Four: Optimal Management of Mental Health Problems, Psychiatric Disorders, Inappropriate Behaviour and Associated Problems
    Five: Postvention
REFERENCES

EXECUTIVE SUMMARY

The Doctors' Mental Health Working Group was chaired by Prof Beverley Raphael, Director, Centre for Mental Health. The Working Group was a joint initiative of the NSW Health Department and the Australian Medical Association (NSW Branch), and met on seven occasions from June 1996 to February 1997.

The Working Group was convened in response to specific concern at the then recent suicides of a number of doctors, and more general concern about the levels of unrecognised and untreated stress and mental illness in doctors.

Although there is relatively little data available on the subject of Doctors' Mental Health, the existing data supports substantially higher suicide rates in doctors compared with other professional groups. Significant rates of substance abuse and dependence among doctors are also consistently reported, but very little information about other psychiatric illness in doctors is available.

Nonetheless the Working Group found that unrecognised and untreated stress and mental disorders in doctors have significant impacts on the doctor, his family, colleagues, patients and society as a whole. These impacts will at best impair the ability of the doctor to function optimally, and at worst have tragic consequences.

A range of impediments to addressing the problem of doctors' mental health were identified by the Working Group, ranging from difficulty in recognising that a doctor may be experiencing stress or mental problems through to the absence of readily identifiable pathways to appropriate treatment services.

The recommendations of the Working Group reflect both the identified problems and the impediments to addressing these problems. The Working Group has recognised that developing a comprehensive approach will necessitate an ongoing process. Consequently, central to the recommendations is the formation of a Standing Committee to oversee and promote developments in the sphere of doctors' mental health.

The major focus of the recommendations is on prevention and early intervention, and is aimed at encouraging doctors and medical students to develop strategies and work-practices that will ameliorate the stresses associated with medical practice. Emphasis is placed on doctors being aware that they are at risk from stress and mental problems, and that they have a responsibility to "look out" for both themselves and their colleagues, and to seek appropriate professional care as patients.

The Working Group has also recommended that it is crucial that clear systems of referral, treatment and rehabilitation for doctors with mental health problems or difficulties be developed, and acknowledges the importance of postvention programs to minimise the impact of a doctors' impairment.

It needs to be noted that the considerations and recommendations of the Doctors' Mental Health Working Group are part of a broader evolutionary process in which more attention is being given to doctors' mental health by a range of bodies, such as registration boards, health departments, employers and medical defence organisations. The Doctors' Mental Health Working Group wishes to ensure that this momentum is maintained, and that emphasis continues to be placed on achieving the best outcome for doctors in terms of minimising the deleterious impacts of stress and mental disorders on doctors and the community.

It is noted that there are also likely to be similar matters of relevance to other health professionals, and the Doctors' Mental Health Working Group would wish to see the similar staged development of processes to address issues with these groups as appropriate.

TERMS OF REFERENCE

Background

Recent suicides and the stresses faced by doctors in their professional and personal lives have lead to recognition of the need to address the mental health of doctors, and to develop prevention and care programs. The Impaired Registrant Program and the Doctors' Health Advisory Service both provide ample evidence of the frequency with which mental health problems and substance abuse affect doctors' personal lives and functioning.

Aims

To review available evidence and practice with respect to the mental health issues affecting the medical profession, the factors which contribute to these and the strategies for effective prevention and management.

Strategies and Goals

1. To review available scientific literature on mental health issues affecting medical professionals with particular emphasis on Australian doctors and including factors which increase risk of problems or offer protection.
2. To review reported and actual services and interventions offered to medical practitioners for mental health and related problems, and to examine evidence for their effectiveness.
3. To identify high quality and appropriate organisational, educational and specific intervention programs aimed at preventing mental health problems for doctors, providing early and effective intervention, and where necessary, ongoing care.
4. To specifically address suicide and suicidal behaviours amongst medical professionals and to recommend prevention strategies.
5. To examine and describe barriers to and resources required for, the most feasible and acceptable strategies.
6. To make specific recommendations and describe appropriate strategies for their implementation so as to achieve optimal mental health outcomes for medical professionals.
7. To consult widely during this process.
8. To provide through the above processes a model which may be extended to the development of strategies for other health professionals.

MEMBERSHIP

Chairperson:

Professor Beverley Raphael
Director, Centre for Mental Health
NSW Health Department

Representative Members / Organisations:

PREAMBLE

The Doctors' Mental Health Working Group arose out of increasing concern at the recent suicides of a number of doctors. While there has been no single causative factor identified, it was acknowledged that unrecognised and untreated stress and illness in doctors is likely to be contributing to these tragic incidents. Thus the brief of the working party was to examine mental health issues in doctors, and make recommendations about reducing the morbidity and mortality secondary to stress and mental illness.

Extent of the problem

There is a relative paucity of hard data on the extent of the problem. There is no means of identifying all deaths by suicide in NSW, and all interstate and overseas studies have the significant methodological limitations common to all attempts to identify the "true" suicide rate (it is commonly assumed that the "official" suicide rates identify only a proportion of actual suicides, and that other deaths such as single car accidents, accidental overdoses, death by misadventure etc may in fact contain suicide deaths). In doctors this may be compounded by misrepresentation on the death certificate to avoid embarrassment¹. Nonetheless some features of studies of suicide in doctors are common and concerning: all report a substantially higher rate of suicide for doctors compared to both the general population and to other professionals. This increase in relative risk is even more marked for female doctors, ranging from 2.5-5.7 times age-matched standards (relative risk for male doctors was 1.1-3.4)^1-3. Determining the rate of suicide in medical students is fraught with similar problems, with a tendency for universities to acknowledge only those suicides occurring on-campus or during the academic year⁴.

According to the NSW Medical Board there have been 21 known suicides of doctors since 1992, with three of these in the past few months⁵. Assuming 22,000 registered doctors, this very crudely equates to a rate of 19.1/100,000 p.a. (compared with a NSW community rate of 12/100,000)⁶. However anecdotal evidence supports a considerably higher rate of suicide, with at least nine Anaesthetic registrars and specialists thought to have suicided in the past 4 years (Australia wide)⁷.

Interestingly, data concerning other aspects of doctors' mental health are equally thin. The majority of studies has focused on rates of substance abuse, but are characterised by relatively low rates of response and self reporting. However trends emerge, the most significant of which is that benzodiazepine and opioid abuse and dependence are more prevalent than in non medical peers⁸. The extent of reported lifetime alcohol abuse or dependence varied from 2-13%^8-11. American studies support a considerable rate of alcohol and other substance abuse in doctors, with one study finding that 11 % used benzodiazepines and 17.6% minor opiates in the past year¹⁰. Of note is that a significant proportion of benzodiazepine and prescription opiate use was found to begin in residency, and was associated with self-prescription⁸.

In terms of psychiatric disorders very little information is available, but the rate reported by bodies such as impaired registrants panels of American Medical Boards (1-3% of registered doctors) is a fraction of the expected rates derived from epidemiological data¹⁰. The proportion is even less in NSW, with just over 100/22,000 (about 0.5%) of NSW doctors being on the NSW Medical Board's impaired registrants panel⁵. This would suggest either that doctors enjoy exceptional mental health or that substantial numbers of unwell doctors are unrecognised. In support of the latter are consistent reports of doctors experiencing one-year prevalence rates of depression in the order of 13-20%, and anxiety of up to 30%^11,14.

Who is affected?

All doctors are at risk of developing a stress-related disorder or psychiatric illness (as is the whole population). The grain of the existing studies is insufficiently fine to give detailed pictures of high risk predictors. However some trends have emerged, notably that the increase in the relative risk of suicide is greater for female doctors than for male doctors, such that the gender difference in actual suicide rates seen in the general population is not apparent in doctors^1,3,12. It has also been suggested that young doctors (particularly resident medical officers), anaesthetists, rural doctors and doctors placed on conditional registration by a Medical Board have a relatively higher risk of suicide, but there are very few studies to support this^1,2,13.

Factors which have been suggested to be associated with increased stress in doctors include sitting higher exams, involvement in emergency medicine and other acute medical environments (eg neonatal intensive care), juggling career and family commitments (especially for women), overwork and tiredness, having a non-English speaking background, physical illness, working in authoritarian hierarchies intolerant of perceived "weakness or failure" and "stress in the system" (eg shrinking funds, poor morale)¹⁴. Other factors contributing to high levels of stress in doctors may be the increasing emphasis on efficiency, increasing requirements for formalised accountability, increasing threats of litigation, decreasing cohesiveness (sense of guildship), decreased long term unhurried relationships with individual patients, perceptions of a decline in the status of medicine and increasing emphasis on patients "rights" and uncertainty about the future career options (eg restrictions on provider numbers). Pre-existing substance abuse or other psychiatric disorders are also considered to be risk factors^8,9.

Further contributors, which may also act as precipitants for acts of self-harm, include general life stressors such as marriage break-up or financial difficulties, and stressors peculiar to medicine such as failing exams or being involved in a medical catastrophe (such as the death of a patient under anaesthetic).

What are the likely consequences of these problems?

For the doctor

High levels of stress with inadequate means of coping will reduce the capacity of the doctor to enjoy his or her work and life. They are likely to lead to an increased risk of mental disorder, which if untreated or unrecognised, will at best impair the doctor's ability to function optimally, and at worst lead to suicide. Attempts at self diagnosis and self medication may further complicate matters.

For patients

The consequences can range from none, to mild (a lack of courtesy or poor communication from a stressed doctor), moderate (a decrease in the patient's faith and trust in the doctor) or severe (an error in diagnosis or treatment which could lead to the death of the patient). Changes in the doctor- patient relationship (such as the patient assuming a caring role for the doctor) may lead to boundary violations which will further impair the ability of the doctor to provide optimal care to his patients.

For colleagues

A doctor affected by stress or mental illness may lead to an increase in the levels of stress experienced by colleagues. While most doctors affected by stress will continue to function at a level sufficient not to impact on their professional duties, some will not be able to do so. At a minimum there may be an increased workload, as the affected doctor is unable to cope with his own work. There will be conflict between the requirement to ensure that patients are receiving safe, effective and accepted treatment and reluctance to address the problem of an unwell colleague. At worst there will be a need to attempt to rectify the errors of the affected doctor, either directly or through disciplinary or legal redress.

For family

The consequences for the family of a doctor affected by stress and mental disorder can range from mild to catastrophic, and involve a whole range of psychological, social, physical and financial sequelae, from abuse, through neglect, to penury.

For society

The failure to recognise and respond appropriately to impairment in doctors may lead to a decreased trust of doctors, a decline in the reputation of the medical profession, a decrease in the morale of the medical profession, an increasing cost of medical care, and a perpetuation of the stigma associated with mental illness as it is denied to be a problem by the very profession charged with treating it.

What are the impediments to addressing these problems?

Recognition

Doctors may be particularly at risk of not having a problem picked up early, through denial and concealment of the problem, self diagnosis and treatment, and the reluctance of colleagues to suggest one of their peers may be unwell. As Chambers and Belcher wrote: "[a doctor's] self image as a powerful, scientific and objective individual has worked strongly against the development of any truly effective peer support system"¹⁰. This may be particularly true of depression and substance abuse, in which diminished insight can be a feature of the disorders.

Personality factors

Personality characteristics of doctors which may be protective and advantageous under many conditions may also contribute to both a lack of recognition of problems, and difficulty in seeking and accepting treatment. Descriptors such as high achieving, driven, obsessional, competitive, seeking approval, deferring gratification and being self contained apply to many successful persons, but equally can lead to reluctance to accept personal difficulties. Doctors are also in a powerful position to routinely direct and exert control over their patients; it is difficult to shift from this position to one of realising and accepting that the impaired doctor needs direction and control from other doctors.

Professional Responsibilities

Admitting to the need for, and accepting help, may be seen as a failure of professional responsibilities towards patients. This in turn is likely to reduce the self-esteem of a doctor who may derive much of his self worth from his professional activities and status.

Treatment and Management

There are few formal pathways by which doctors can access help, and those that exist are little known by doctors. Furthermore, there is an absence of knowledge and expertise about how these problems in doctors are best managed, and treating doctors are often poorly skilled and uncomfortable in helping other doctors. This applies to all aspects of doctors' health, but is particularly true of mental health care^15,16.

Cost / Financial

As with the general community, loss of income and the cost of the long term treatments necessary are substantial disincentives to individual doctors seeking treatment. Particular concerns for doctors include the lack of ability of most medical practices to generate income without a functioning doctor seeing patients, the need to employ locums and the risk of absence resulting in a diminishing of practice goodwill. Institutions similarly will be concerned about the costs of extended sick and stress leave, and of providing locum services.

Lack of trust

Doctors may fear breaches of confidentiality, with a fear that dissemination of the fact they are suffering from mental illness or stress may result in automatic disqualification of their ability to practice, with a resulting loss of livelihood and dignity.

Stigma

Doctors are not immune from participating in society's stigmatisation, and indeed may be more stigmatising, of those with mental illness and towards mental health and psychiatric treatments. A lack of belief in, and knowledge about, effective psychiatric treatments contributes to this fear of personal stigmatisation should treatment for a mental disorder be sought. Ironically, delaying treatment of mental illness in doctors may reinforce this stigma, as the manifestations of the mental illness may become more severe the longer it is left untreated.

Who are these recommendations for?

While many of the following recommendations will be germane to all doctors, the main focus is the hospital doctor, as most of the deliberations of the Working Group have considered problems at an undergraduate and recent post-graduate level. Clearly other groups of doctors, such as career medical officers, isolated and solo practitioners and doctors from non-English speaking backgrounds, have stresses and constraints particular to their circumstances, and further consideration of these is warranted.

Overall Aims of the Recommendations

To promote and protect the mental health of all doctors and medical students, and at the same time ensure that optimal treatment is provided to the people of NSW, by ensuring that doctors' capacities are not impaired by mental health problems or disorders. It is recognised that there are two distinct but intertwined themes, which are that of preventing and ameliorating doctors' stress and mental disorders, and that of protecting patients, families and staff from the adverse impacts of unchecked mental illness in doctors.

RECOMMENDATIONS

One: Ongoing Review of Issues Affecting Doctors' Mental Health.

Background:

It is clear that the there are complex sets of factors which adversely impact on doctors' mental health, and that addressing these problems will require a sustained and concerted effort.

There is a paucity of factual information concerning the mental health of doctors, although notably Hume and Wilhelm¹⁷ have provided a useful base of knowledge concerning stress in NSW interns. If a sufficiently wide network of reporting is established, it should be possible to gather at least suicide statistics for doctors and medical students. Other data could usefully be gathered, such as the incidence of impaired registrants, the efficacy of current treatment programs for impaired registrants, the number of referrals to the Doctors' Health Advisory Service (DHAS), the numbers of staff not completing contracts, "exit polls" of staff to identify sources of stress, the rates of mental illness and non-completion of studies by medical students and, perhaps, the sponsoring of formal research in this area. An example is the comprehensive prospective study of stress in medical students and interns due to commence next year to be undertaken by Dr Simon Willcock and colleagues¹⁸.

At the very least there needs to be a body that can review and monitor the recommendations made by the Working Group. Membership should be as broad as possible, within the constraints of workability. Possible members could include representatives of the DHAS (NSW), Australian Medical Association (AMA), Postgraduate Medical Council, specialist colleges, Doctors' Reform Society, Medical Registration Board, Medical Benevolent Association, medical defence organisations, NSW Health Department, university medical schools, undergraduates and the Health Care Complaints Commission. Roles should include data gathering, reviewing recommendations, monitoring research and developments in this area, acting as a coordinating and information resource for professional bodies and individuals, and liaising with interstate and overseas professional bodies engaged in similar tasks. It is suggested that this committee would meet perhaps twice a year, and given the large number of members, have a smaller active executive body which would be responsible for carrying out the day to day activities of the committee. It is to be hoped that similar committees would be established in all Australian states, as many of the issues need addressing at a National rather than a State level, and a coordinated approach is desirable.

Recommendations:

Two: Preventative Strategies

Background:

The importance of preventative strategies as a cost-effective and humane approach to public health issues is now well recognised. In line with this the Doctors' Mental Health Working Group believes that the main emphasis should be on developing and implementing strategies that will promote the health and well-being of doctors and minimise the factors putatively thought to contribute to mental health problems and disorders.

Recommendations:

2.1    All professional doctors' groups should have documented policies which:

2.2    Specialty Colleges should:

2.3    Area Health Services should:

2.4    Undergraduate courses should:

2.5    Intern and resident programs.

The Area Health Service, through the Directors of Clinical Training and the Hospital Administration, should ensure compliance with these recommendations.

All Intern and resident programs should:

2.6    Registrars and specially trainee programs

The Director of Training is responsible for ensuring that registrars and specially trainees are provided with education programs, career guidance, financial guidance and effective complaint / arbitration mechanisms.

2.7    Career medical officers, unstreamed residents and other registrars

This group is likely to increase in size and complexity in the near future and is at risk of failing between existing training structures.

2.8    Fully qualified specialist and general practitioners not otherwise addressed

This group includes many isolated solo practitioners who may or may not belong to active professional doctors' groups

Three: Early Intervention

Background:

In order to maximise positive outcomes for doctors, their families and patients, it is vital that mental health issues are identified and treated at the earliest opportunity. It is hoped that by establishing a climate of openness, promoting discussion of doctors' mental health issues and developing known and accepted pathways for accessing mental health care, early detection and intervention will be facilitated. The importance of early intervention has been emphasised by Wilhelm et al., (1997) particularly in light of the NSW Medical Board's emphasis on support and rehabilitation of doctors^16,19.

Recommendations:

3.1    All professional doctors' groups should:

3.2    Specialty Colleges should:

3.3    Area Health Services should:

3.4    Undergraduate courses should:

3.5    Intern, RMO and Registrar programs should:

Four: Optimal Management of Mental Health Problems, Psychiatric Disorders, Inappropriate Behaviour and Associated Problems

Background:

Mental illness affects at least one in five of the population. Doctors are not immune from developing mental illness, or from the effects of stress. It is critically important that Professional bodies develop a culture of acceptance and recognition of mental health problems and disorders as they relate to doctors' lives. In order for optimal management to be ensured, four conditions are necessary:

1. That the problem is recognised;
2. That the doctor, his colleagues and his family be aware of, and have access to appropriate referral pathways;
3. That the doctor, his colleagues and his family be aware of, and have access to, appropriate treatment services;
4. That rehabilitation services are available.

All doctors should have the right to "patient-hood" and to receive appropriate up-to-date and skilled assessment and treatment, as well as family support. It is important that consultations between doctors be formalised, so that a doctor seeking help is treated as a patient in the framework of a traditional "doctor-patient" relationship, and "corridor consultations" are discouraged. It should be noted that it is often difficult for a doctor to assume the role of a patient, and similarly special skills are required to treat a colleague as a patient. The psychiatrists, and other specialised mental health professionals, have a particular responsibility to ensure that doctors who suffer from the effects of stress or mental illness are afforded the best possible care¹⁶.

Recommendations:

4.1    Recognition

4.3    Treatment Services

4.4    Rehabilitation

Five: Postvention

Stress and mental illness affecting doctors is likely to have adverse impacts for the families of the affected doctors. The critical importance of access to specialised and appropriate help for marital problems, parenting and family difficulties should be acknowledged.

REFERENCES

1. Pitts F, Schuller A, Rich percent, Pitts A.: Suicide among US Women Physicians, 1967-1972. Am J Psych 1979, 136, 694-696
2. Richings J, Khara G, McDowel M: Suicide in Young Doctors. Br J Psych 1986,149, 475-478,
3. Schlicht S, Gordon 1, Ball R, Christie D: Suicide and related deaths in Victorian doctors. Med J Aust. 1990, 153, 518-521.
4. Hays L, Cheever T, Patel P. Medical Student Suicide, 1989-1994. Am J Psychiatry 1996 153; 553-555
5. Johnson P, NSW Medical Board. Personal communication 1996
6. Stewart G, Chipps J, Sayer G. NSW Public Health Bulletin, 1995, 6, 49-52
7. Goulding G, "Welfare of Anaesthetists" group. Personal communication 1996
8. Hughes P, Conrad S, Baldwin D, Storr C, Sheehan D: Resident Physician Substance Use in the United States. JAMA. 1991,265, 16, 2069-2073.
9. Baldwin D, Hughes P, Conrad S, Storr C, Sheehan D: Substance Use Among Senior Medical Students. A Survey of 23 Medical Schools. JAMA. 1991, 265, 16, 2074-2078.
10. Hughes P, Brandenburg N, Baldwin D, Storr G, Williams K, Anthony J, Sheehan D: Prevalence of Substance Use among US Physicians. JAMA. 1992 267, 17, 2333-2339.
11. Chambers R, Belcher J: Comparison of the health and lifestyle of General Practitioners and teachers. Br J Gen Pract 1993; 43, 378-382
12. Seagroatt V, Rooney C: Suicide in doctors (letter) BMJ pp 447, 307, 14 Augustl993
13. Shore J: The Oregon Experience With Impaired Physicians on Probation. An eight year follow up. JAMA 1987, 257, 2931-2934.
14. Hsu K, Marshall V: Prevalence of Depression and Distress in a Large Sample of Canadian Residents, Interns and Fellows. Am J Psych 1987, 12, 1561 - 1566
15. Voelker R: Finding Effective Treatment for Impaired physicians. JAMA 1994 272,1238
16. Wilhelm K, Diamond M, Williams T: Roles for consultant psychiatrists in prevention and treatment of impaired doctors. Advances in Psychiatric Treatment, 1997 (in press)
17. Hume F, Wilhelm K: Career choice and experience of distress amongst interns: a survey of New South Wales internship 1987-90. Australian and New Zealand of Psychiatry 1994; 28: 319-327
18. Willcock S et a]., 1996 Personal communication
19. Williams T: "The Impaired Medical Practitioner - The NSW Medical Board's Response". Paper presented at the Royal Australian and New Zealand College of Psychiatrists Annual conference, 1995

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Medical Benevolent Association of New South Wales. All rights reserved.

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