KIERAN LE PLASTRIER: Health is not the absence of disease. Health is not the absence of troubles or worries. It's not the presence of this thing called "work-life balance.”
Health can be established even when there's a whole bunch of things going on that could be problematic: disability, fatigue, troubles with marriage, financial troubles—your performance is impacted by all of these things. Your health is impacted by all of these things. But you can remain healthy, despite these assaults.
CAMILLE MERCEP: This is Pomegranate, the CPD podcast of the Royal Australian College of Physicians.
In the past 4 weeks, how often did you feel hopeless? Did it ever feel like everything was an effort? Or you were tired out for no good reason?
You may recognise these questions from the K10 Scale, a measure of psychological distress. Many health professionals use it with patients—but how would you answer those questions for yourself?
This month we're looking at the issues surrounding doctors’ own health, both mental and physical. Using the K10, a recent Australian study found that doctors report substantially higher rates of distress than the general population. Those in the most distress also reported hazardous use of alcohol—which, along with drug problems, is the top cause of referral to medical boards.
The Doctors’ Health Advisory Service was created in 1981 to offer confidential help to practitioners in both Australia and New Zealand. In this episode Dr Jill Gordon, President of DHAS NSW; Dr Roger Sexton, Medical Director of the South Australia office; and Dr Edwin Whiteside, Director of the New Zealand office, discuss why doctors may experience higher rates of depression and anxiety, and common fears around mandatory reporting.
The conversation also includes Dr Kieran Le Plastrier, who is currently completing a PhD at Western Sydney University on “the fit professional.”
JILL GORDON: I think the specific aspects that contribute to difficulties for physicians, in relation to their mental health, are those that we frequently completely fail to acknowledge. And that is that from an existential point of view, we literally do deal with life and death.
While that might sound a little dramatic, every illness has the potential to be quite serious.
Most of the time we reassure patients that in fact it's not serious, or that it can be well-managed. But unlike other professions, we deal daily with a great deal of human misery. We have to talk not only to patients but to their families to explain what's happening, and that's often quite difficult to translate.
So all of those things like long work hours, lack of resources, increased bureaucracy, too much paperwork—we typically complain about all those things, but I think underlying it is the very real burden of the importance of the actual type of work that we do.
My name is Jill Gordon, and I come from a background of general practice. But I now work exclusively in the area of psychological medicine. I have a long background history of working in medical education, so it's been a good opportunity to observe evolving doctors and the kinds of stresses and pressures that medical students, and junior doctors, and older and retired doctors experience.
ROGER SEXTON: We have reports of suicide, of course, and all jurisdictions and states have those issues. I think they must be regarded as a sentinel event which triggers real change, and not just collateral damage or people falling by the wayside. We just can't let those things go by without looking at the root causes, and taking steps to realise that medicine is not easy. People come into medicine with many qualities, but it can certainly do good and bad things to us and we need to respond.
My name is Roger Sexton; my background is as a rural general practitioner. I’ve been a past chair of the Medical Board of South Australia, and I'm currently serving on a claims committee and as a board director of MIGA, the medical indemnity provider. And I'm currently Medical Director of Doctors’ Health SA.
EDWIN WHITESIDE: This is Dr Edwin Whiteside. I'm an occupational physician based in Wellington New Zealand. I've been the director of the New Zealand Doctors’ Health Advisory Service for the last 20 years.
I think doctors are now rushing around and getting increasingly busy—the demands of their work, demands of the home. There needs to be a much more organised system of caring for our colleagues, rather than just saying one colleague should care for another. Because there are those time constraints, among other reasons why it's more difficult.
KIERAN LE PLASTRIER: So my name is Kieran Le Plastrier and I’m currently training with the College of Psychiatrists, and a few years back started a PhD with the University of Western Sydney—where I'm more and more interested in what the clinical encounter between a patient and a doctor might tell us about how the health system is operating at large.
A “fit doctor” is, to some degree, a doctor who has taken onboard a whole range of advice that a college or a colleague or their medical training may have given them: “get a GP, manage your stress appropriately, learn to plan effectively, always maintain good clinical professional development.” All these things are actually important, but in and of themselves don’t motivate people to do anything—because it's not coming from within. It's not the level at which meaning-making is made in that doctor. They see it as important, but it's got to mean something to them in order for behaviour to change.
If your health is linked to your performance, and there's something satisfying in the work that you're doing which is materially linked to patient outcomes, we're starting to see the link-up between what might be considered some ephemera on the edges of, you know, “Who cares whether a doctor's really satisfied or not?” We actually see this has an impact in the health system that's really important, because it may actually be adversely affecting patients’ health.
JILL GORDON: The old saying that “The doctor who cares for himself has a fool for a physician” is actually very true. Because you never know what another person is going to pick up until you present, and actually place in front of a trusted colleague, your own medical history—and see what kind of advice comes from that.
ROGER SEXTON: Most doctors have a financial advisor of some sort, an accountant. They might have a number of other supports. But generally they may not have a medical advisor, a GP, a doctor who they can bounce ideas off—someone who says, “Look, you're overdue for this, you're overdue for that.” So they're quite receptive to the idea of having a medical advisor as part of their team. That's a very strong message that resonates with them.
We did a survey in South Australia, and we had about 2800 doctors respond to this survey. We said, “Look, how's your current heath and what sort of things would you like to help assist your health in the future?” And they said, “We'd like a clinic, we'd like after-hours services, we're very fond of check-ups, we want a website, and we want trained doctors to be able to go to.” So that's exactly what we've done—and they’ve been coming in the door.
So we're providing a range of services here: we might see doctors in acute situations, or we might see them for a comprehensive two-step check-up—and of course that's a health horizons scan, it's an opportunity to write down their medical history for the first time and look at the risks. We look at cardiovascular risk, cancer risk, medico-legal risk, mental health risk, look at immunisations and health screening, and offer an evidence-based check-up. It is really popular and it's of course what executives in other organisations have been doing for a long, long time—having this comprehensive assessment of your health.
KIERAN LE PLASTRIER: The “fit professional” is not just physically, emotionally, and mentally “fit enough.” The fit professional fundamentally understands the complexity of the environment in which they're operating, and is prepared to be open to the possibility that the way they see the world right in that moment is not a true and accurate representation of what's actually going on. And so they become aware that there are opportunities that the environment presents them: through the patient, through a nurse, through a colleague, through a paper that they've just read—all opportunities there to present them with new information which gives them an even finer-detailed map of the landscape in which they're operating.
It's probably also true that you have taken on some of these important aspects of your own care which is: having your own doctor, and exercise, and all these things. But you haven't done it because it's been given to you and told to you by somebody else. You're doing it because you understand in your own sense of self as an actor on this landscape that it's important in order for you to be able to read that landscape effectively, and therefore potentially be more satisfied and hence, less likely to make mistakes. And that becomes a recursive exercise: going to work, being satisfied, feeling effective; seeing patients get better and knowing that they're happy with what's happened—that feeds back to you and it feeds into and reinforces those opportunities and behaviours.
EDWIN WHITESIDE: Sometimes somebody will ring up our doctors’ health service and say, “Well, if I tell you what my problem is, am I going to be reported to the Medical Council?” And we say, “Well, we would like to assess you and we then will talk to you about what we think would be the best strategy here.”
In fact, we haven't had to refer a large number of people to the Medical Council for its mandatory monitoring system. But having said that, we do recognise that even doctors who support colleagues are under an obligation—once they know about a colleague who may be impaired—to ask that question.
In the past, I've had a memorandum of understanding between the Doctors’ Health Advisory Service and the Medical Board or the Medical Council so there will be a clear indication as to what type of problems should be referred to the board: significant psychiatric illness requiring medication, significant addiction disorders. These are the type of things that are likely to cause impairment.
ROGER SEXTON: Our experience here in South Australia is, and our surveys of the profession are, that certainly 30% of doctors regard being reported as the end of their career. In other words, they have a catastrophic view of being reported. It is the medico-legal experience as well of that of the medical defence organisations—because my background is also with MIGA—is that it is not a catastrophic event. But it takes resilience and a lot of support to get through it. Doctors who do undergo some sort of notification need good legal support, good medical support, they need colleague support, and they may need psychological support.
JILL GORDON: By and large there isn't any evidence that mandatory reporting has had a negative affect on doctors being able to help their colleagues. I don’t think any sane physician would object to a careful reading of the mandatory reporting requirements. We tend, I think, to overstate what they are and sometimes even to misinterpret them. But if there is any possibility that a doctor could actually be bringing harm to a patient I think everyone, I would hope that 100% of physicians, would say something must be done about that. But normally the number of situations in which this actually occurs, and in which mandatory reporting is relevant, is quite tiny. It's a very, very rare event. But it’s one for which we should always be prepared to act.
One thing I would really like to see is that the physician in a hospital department, or within a specialty practice, makes a special effort to follow the very basic rule that we've put on a website that we created for junior doctors, called the “Are You OK?” website. And it’s been demonstrated that that simple question can make a big difference.
I had recently a call from a specialty supervisor worried about a registrar who I was able to contact, and when I found out from the registrar some of the pressures that he was under—that was personal pressures and some tragedies in his life. With his permission I relayed them back to his supervisor—who was astounded, and ashamed and embarrassed, that he himself hadn't actually found out what was happening in that young person's life.
If he had asked "Are you OK?" and really genuinely asked that question, I'm sure that young man would have told him just as easily as he told me. It made a dramatic difference to the relationship—not only between the supervisor and the registrar, but in the registrar's ability to cope with the rest of that term.
ROGER SEXTON: I think a change of attitude is required by individuals in the workplace—we need to be realistic that some people are more adept to cope with pressure than others. We need to be able to work with others, whereas traditionally doctors have been loners. And maybe we need to take time out to learn stress management strategies. At the end of the day, a doctor has to be prepared to commit time and energy to improving their health—whether it's in the mental health field or through regular physical exercise, for example.
EDWIN WHITESIDE: I think it's observing people over time, having contact with colleagues and making sure you just ask after them to take notice of the subtle signs: the absenteeism, presenteeism, the risk-taking, the withdrawal, the lack of attention to detail, lack of thoroughness, lack of caring. If those symptoms are persistent, then clearly a problem is developing.
JILL GORDON: It has been demonstrated that there are five important steps that everybody should commit to memory and know about helping a friend. And if you're worried, the first rule is that you must not ignore the situation—you should actively approach the person and ask if you can help them. The second thing to remember is that you should be listening non-judgementally to what they say, so that they know that they've been heard.
You should then provide emotional support and any information that you think might be of help to them in whatever that problem might be, and you should always encourage them to seek professional help. That will often be from a psychiatrist or a drug and alcohol expert, but from whatever quarter seems appropriate. Sometimes it might be from their medical defence union, or from the Medical Board. And you should encourage them to enlist any other supports that they have, because people in difficulties often isolate themselves.
So those are five steps that have actually been empirically tested and shown to be related to more positive outcomes.
CAMILLE MERCEP: Approach, ask, listen, encourage and support. The links for the five steps that Dr Gordon outlines are on our website, along with the other tools mentioned in this episode. If you'd like to start a conversation with a colleague, visit racp.edu.au/pomcast for more resources. That's P-O-M-C-A-S-T.
If you're in a crisis and need immediate support, help is available 24 hours a day on Lifeline—in Australia just call 13 11 14, or in New Zealand, 0800 543 354.
We'd like to thank Kieran Le Plastrier, Jill Gordon, Roger Sexton and Edwin Whiteside for appearing on this episode. The views expressed are their own and may not represent the views of the Royal Australian College of Physicians. Let us know your thoughts about the program by e-mailing email@example.com.You can also subscribe to Pomegranate on iTunes, or wherever you listen to podcasts.
Pomegranate comes to you from the Learning Support Unit at the Royal Australasian College of Physicians. The program is presented by Camille Mercep. This episode was produced by Alastair Wilson, with editing from Anne Fredrickson.
Next month we’ll be partnering with IMJ to bring you a conversation with Dr Peter Collignon, author of an upcoming article on antibiotic resistance.
PETER COLLIGNON: A prevailing view of a lot in the profession is: “Well, unless we get new antibiotics, we’re all doomed.” I don’t actually share that same pessimistic view, because my view is that if we can do the two fundamental things that drive antibiotic resistance, we can make a difference with what we’ve got now.
CAMILLE MERCEP: We hope you can join us.