Over the weekend of April 22-23 at the Stanford Medicine X | ED 2017 conference, I had the honour and privilege of sharing the stage (at their invitation) with my friends at the @ALiEMteam at #MedX @StanfordMed. The session was on their successful Wellness Think Tank, which is aimed at supporting doctor wellbeing. They asked me to talk about an international perspective on this issue, and to also touch on organisational activity in this sphere.
Here’s a rough transcript of what I said, with some additional bits I left out in the interest of time. You can also watch the video.
My own journey in Wellness began 15 years ago, when as a second-year Registrar (or Resident in US), I experienced a version of burnout. It was my boss who rescued me at the time, most impactfully with the words: “I’ve been there”. He urged me to not diminish this episode, and at his behest I took three weeks off to recover.
At that time, the attitude held by the medical profession towards Wellness was that of course it was important. However it was, at best, an after thought or, at worst, an issue that was an indulgence, undertaken by those who were clearly not busy enough doing the legitimate work of being a clinician.
This attitude is changing, with significant progress in Australia over the last five years.
Beyond Blue is a national organisation which researches and supports people with anxiety and depression.
In 2012-2013, it conducted a large survey of the medical profession. The 25% response rate still included over 11,000 doctors and almost 1800 medical students (Beyond Blue, 2013).
One of its most profound findings was that not only do doctors and students experience psychological distress, but they experience it at a rate which is double that of the general population. There are similar comparative data for parameters of burnout and even more startling data for suicidal ideation.
The survey revealed that those most at risk tended to be those with type A personalities, those who were stressed and fatigued, and those who tend to be self-critical – in short, almost all of us.
In its final consideration, Beyond Blue urged the medical profession to address and resolve its stigmatising attitudes towards mental illness, stating that these attitudes may not only impact the way doctors deal with their own mental health issues, but may also impact their ability to provide the best care to their patients, including by perpetuating the stigma that exists within the community.
Over the last two years, we have experienced several clusters of doctor suicide in Australia, including four junior doctors in Victoria in 2015, of which three were Psychiatry trainees, and a further three young doctors between September 2016 and January 2017, this time Physician trainees.
These tragic events have attracted the attention of our community and the media, and our profession is now obliged to act in a substantial, effective and meaningful way (ABC News, 2017).
At national level, the Australian Medical Association (AMA) has reaffirmed Wellness as a priority in its vision (Australian Medical Association, 2011). The Medical Board of Australia has strengthened the Doctors’ Health Advisory Service, to enhance its accessibility and reach. In Queensland, a Resilience on the Run program can be purchased by hospitals whereby interns participate in a two-session workshop and develop skills required for transitioning into the medical workforce.
Importantly, the AMA is lobbying hard to change our mandatory reporting laws whereby a doctor disclosing a mental health issue and seeking help from a professional will not carry the current legal risk of compromising registration.
Our own Australasian College of Emergency Medicine (ACEM) conducted a workforce sustainability survey last year (Australasian College of Emergency Medicine, 2016). Its findings paralleled those of Beyond Blue and confirmed that Emergency Physicians and trainees are at significant risk of burnout. It identified sources of stress to include work environment: work load, access block and dynamics with inpatient teams. It also sought to understand how Emergency doctors seek balance and treatment, and discovered that they are generally adept at practices which promote resilience. ACEM has committed to its role of actively supporting its members and is working on a strategy and implementation plan to meet this commitment.
Around Australia, several hospitals have embarked upon their own initiatives. One that I particularly admire is at Monash Health. ‘Monash Care’ is a program built by the hospital’s executive medical team for all doctors, although it catch-phrase is “No junior doctor will struggle in silence”. It has several facets including a dedicated wellbeing officer, a mentorship program, and even a perinatal group which supports doctors, male and female, during early parenthood (MonashHealth, 2015).
At Gold Coast Health, where I work, we have put effort into embedding a Wellness program, oneED, into our Emergency Department. It also has several informal arms, but one focus is on Mindfulness practice.
Our approach is to be proactive rather than reactive.
We need to work to shift the frame away from ‘supporting those who are struggling’ and rather toward ‘a collective culture of positive growth’ – whereby we create an environment that nurtures our health practitioners so that everyone can thrive.
My observations of supporting junior doctors include the following:
We need to recognise that our junior doctors are not simply us ten or twenty years ago
The millenials have their own unique characteristics:
They tend to engage in group think and largely operate via a collective consciousness. Hence a model based on peer support – whereby doctors look after doctors – is likely to be most acceptable to them.
Many of their issues are related to injustice, whether real or perceived. Examples include workload and fatigue, assessments, and dynamics with other team members. By building trust and rapport between them and with them, we can address these issues – either fix them, or fix their ability to cope with them.
However, they also need a clear distinction between which of us is their mentor and which of us is their supervisor. The former is there for support and allows disclosure of vulnerability; the role of the latter is to objectively assess their ability to do the job. Clearly they need to trust that there is no conflict between the two.
In addition, this generation is completely connected with online platforms. The internet is their “go to” for all matters for which they seek input, be it a clinical issue or a personal one.
Hence a program like ALiEM is brilliantly positioned to make accessible to them resources on Wellness.
Whatever we build to support doctors must meet their needs as end-users
Traditional avenues e.g. Human Resources or the Employee Assistance Service tend not to be used unless one is directed there, or there is a specific issue. This is perhaps because of mistrust, again real or perceived, around links to employment and assessment.
The support system that is built for them must be actively and robustly informed by them.
However – and here is my call to action: It is incumbent upon senior clinicians to initiate, influence and sustain the discourse and action in this sphere.
We are people within the profession with the power and influence to fix this. And we are also without the risk faced by our junior counterparts: that if a concern is voiced, then career opportunities may be compromised.
After all, we are partly responsible for creating the current situation of Unwellness.
We aren’t necessarily well ourselves
Beyond Blue found that psychological distress, burnout and suicidal ideation steadily decrease (ie improve) as we get older and advance in our profession.
My view is that this is likely due to the fact that our level of control over our environment increases over this time, rather than any intrinsic improvement in Wellness. This is arguably evidenced by the Whitehall (Marmot et al., 1978) and Whitehall II (Marmot et al., 1991) studies.
As senior doctors, we can influence our job descriptions and even our daily schedules. If there is an unpleasant task to be conducted, we can defer it or we can even delegate it.
Furthermore, our colleagues become tolerant of our dysfunctional behaviours over time, attributing them to our quirks or idiosyncrasies: “Oh yeah, we all know Bob is aggressive and unapproachable, but that’s just Bob – he’s a great proceduralist”. This attitude not only dismisses the effect Bob might have on his colleagues, and particularly his juniors. It also disregards the prospect that Bob may have some serious struggles himself.
We almost wear our Unwellness as a badge of honour
We model to our juniors that Wellness is not a huge priority; that if you’re doing the job properly, then you are overworked and fatigued.
As such, we strongly influence the culture within our profession and our specialties.
Sure, we inherited this culture from the generations that preceded us. But we are now in the position to make a conscious decision regarding whether we are going to perpetuate that culture, or whether we are going to work to modify it into one where we support each other and our juniors.
We can do this by exerting our leadership in our immediate work environment and by simply inviting and encouraging the conversation on Wellness. Perhaps simply by saying the words “I’ve been there”.
My closing comments are that Physician Wellness is not an issue confined to one country or one specialty. It is a global issue – if it were infectious it could be considered a pandemic.
It is vital that the various groups around the world working on Wellness connect with each other. By doing so, we lend credibility to each other’s efforts and we convert the issue of Physician Wellness from one that may be considered indulgent into one that is not only legitimate, but is critical.
The ALiEM team generously asked me to provide the final closing comments for the Wellness Think Tank panel session. On our collective behalf, this is what was said. You can watch these closing comments here.
The time is now.
We recognise and understand more about Physician Wellness than we ever have before. The question is: What will we do about it.
Well, we can continue to do little, and to maintain the status quo. Or we, not only as a profession but as a community, can grasp the issue with both hands and determine to fix it.
Finding the solution will require intellect. But more than that, it will require heart.
The end-game is to normalise the conversation on Physician Wellness so effectively that if a doctor is noted to be struggling, anyone from hospital executive, to a medical colleague, to a nurse or allied health worker, even a non-clinical staff member, perhaps even – with some careful consideration – a patient may be comfortable to reach out a hand and ask, “Doctor, are you okay?”
ABC News (2017) – Doctor suicides prompt calls for overhaul of mandatory reporting laws
Australasian College of Emergency Medicine (2016) – ACEM Workforce Sustainability Survey
Australian Medical Association (2011) – Health and wellbeing of doctors and medical students
Beyond Blue (2013) – National Mental Health Survey of Doctors and Medical Students
Marmot, M. G., Rose, G., Shipley, M., & Hamilton, P. J. (1978) – Employment grade and coronary heart disease in British civil servants. Journal of epidemiology and community health, 32(4), 244-249.
Marmot, M. G., Stansfeld, S., Patel, C., North, F., Head, J., White, I., … & Smith, G. D. (1991) – Health inequalities among British civil servants: the Whitehall II study. The Lancet, 337(8754), 1387-1393.
MonashHealth (2015) – Monash Care – The Mental Health & Wellbeing Strategy for Monash Doctors!