1. The Doctor in Difficulty 28th March 2014, Dr Peter Noone MPH(Glas),LLM(Sal),FFOM(I),MFOM(UK),FFTM Consultant in Occupational Medicine, .

2. Why is it important? Doctors are not immune from becoming unwell! Rates of work-related mental illness amongst doctors are x 15 times higher than the national average (UK Health and Safety Executive 2005) 3. Patients are complaining all the time because expectations are being raised despite less and less resources. There is [sic] more complaints to deal with and less time for clinical work!! The quasi-legal systems the NHS has adopted that cast a reductionist veneer on issues that are more systemic and difficult to resolve. For patient or relative with an issue they want to redress, targeting an individual doctor can seem like the 'only' way to deal with wider systemic issues. Doctors are just one part of the system, certainly not the key movers and shakers, and The NHS 'knows' this, but has 'due process' in place to obfuscate the underlying problems within the system. 4. Professionalism is to be visible and to inspire trust 5. The Doctors Leadership Paradox A physician does not really need a boss at all If there should happen to be a boss anyhow, it must be another physician Bosses only do un-important, administrative things Colleagues who become bosses are no longer real physicians However, all physicians want to be bosses and have a highly developed sense of hierarchy. Source: Chief Physician Carola Lemne MD Hospital Manager of Danderyds University Hospital Karolinska Institutet, Stockholm 6. The Staff Governance Standard well informed; appropriately trained and developed; involved in decisions; treated fairly and consistently, with dignity and respect, in an environment where diversity is valued; provided with a continuously improving and safe working environment, promoting the health and wellbeing of staff, patients and the wider community. http://www.staffgovernance.scot.nhs.uk/what-is-staff-governance/staff-governance-standard/ 7. Heron & Teasdale An holistic approach to managing an individual 8. Effects of Work on Health Effects of Health on Work Managed Employee Wellbeing & Organisational Health Management What is Occupational Health? Safeguarding and enhancing employee health 9. Counselling Services 10. The Performance Triangle Work Context Clinical Capability BehaviourHealth 11. Work Stress "Physical and mental strain resulting from the mismatch between an individual and their environment", resulting from demands on a person, their ability to cope with those demands. Stress is most likely to occur in situations where: demands are high; the amount of control an individual has is low; and, there is limited support or help available for the individual. Bynoe G. Stress in women doctors. Br J Hosp Med 1994; 51(6): 267-8 12. Good and Bad Stress 13. HSE UK Management Standards Demands: workload, work patterns, and the work environment Control: How much say the person has in the way they do their work Support: encouragement, sponsorship and resources provided by the organisation, line management and colleagues Relationships: promoting positive working to avoid conflict and dealing with unacceptable behaviour Role: Whether people understand their role within the organisation and whether the organisation ensures that they do not have conflicting roles Change: How organisational change (large or small) is managed and communicated in the organisation. 14. Conceptualising Work Stress Job strain (Demand-Control) model Effort-Reward Imbalance model Organisational Justice model (fair treatment) Major work stress models (questionnaire based measures) 15. Organisational-level impact studies; Donald et al., (2005) 23% of variance in employee productivity (n= 16,000 UK employees) is explained by - Psychological well-being - Perceived commitment of organisation to employee - Resources and communications Cropanzano and Wright (1999) Five year longitudinal study of psychological well-being and performance. Strong correlation between well-being and work performance Harter, Schmidt and Keyes (2003) Nearly 8,000 separate business units in 36 companies engagement/well-being correlated with business unit performance (sickness-absence, customer satisfaction, productivity, employee turnover, etc) Boorman review NHS (2009) Health & well-being related to: MRSA, Patient satisfaction, NHS spend. 16. http://occmed.oxfordjournals.org/content/63/5/335.short?rss=1 http://occmed.oxfordjournals.org/content/early/2013/07/11/occmed.kqt078.full.pdf+ht ml http://oem.bmj.com/content/60/1/3.full.pdf+html http://www.hse.gov.uk/stress/management-standards.pdf http://occmed.oxfordjournals.org/content/59/8/574 http://occmed.oxfordjournals.org/content/62/3/203.full http://occmed.oxfordjournals.org/content/62/4/288.full http://occmed.oxfordjournals.org/content/60/4/277.full Evidence base for the Management Standards 17. Case Law Johnstone v Bloomsbury Health Authority 1992 Junior hospital doctor brought a claim for work stress suffered because of long working hours 18. HSE DNE Stress & Quality of Work Life Audit (2005) 19. HSE DNE Stress & Quality of Work Life Audit (2005) 20. EARLY WARNING SIGNS The disappearing act Rigidity in thinking Very slow Inappropriate emotional outbursts Failing to gain the trust of others Colleagues dont want to call on them Lack of insight Problems with probity Paice & Orton (2004) . 21. Key Pointers for Employers Watch out for signs of stress Report to someone senior Once employers representative knows of the problem employer will be liable for breach of duty Safe systems of work are essential Employers must adjust for people with disabilities 22. Why doctors health services? UK Common mental disorder 28% Depression (major) 10% Newcastle junior doctors: -60% exceed safe limits of alcohol intake -36% males, 20% females use cannabis -13% males, 10% females other illicit drugs Estimated 1:15 doctors dependent on drugs. 23. Why doctors health services? Australia 30% of GPs had mild psychiatric symptoms. 13% severe psychiatric symptoms. Suicide rate for female doctors x 6 general female population 24. Why Doctors Health Services? Canada One in 10 physicians will become dependent on psychoactive drugs or alcohol sufficient to impair their practice at some time during their careers. One in every 100 physicians will become a narcotics addict at some time during their career Saskatchewan Physicians at Risk Committee, Canada 25. CMA 2003 Physician Resource Questionnaire: 46% of respondents (n = 2,251) reported symptoms suggesting advanced stages of burnout. Canadian Physician Health Program 26. Physician Health Programmes in the United States About 10-12% of physicians in the US develop a substance use disorder, BMJ2008;337:a2038 About three quarters of US physicians with substance use disorders managed in this subset of physician health programmes had favourable outcomes at five years. 27. Why doctors health services? -a unique group Often dont have a GP, Corridor consultations Self prescribe Denial Access Trust and confidentiality Stigma, guilt, shame and remorse BUT highly motivated to recover! 28. ASSESSMENT DOMAINS Health and home Personality and behaviour Organisational issues Clinical capability 29. HEALTH & HOME High workloads and time pressures lead to depression and anxiety Firth-Cozens (2003) found significant levels of stress among junior doctors 28% above threshold levels of stress v 18% of the general population Like anyone else, doctors experience life events family, relationships, finance, etc. 30. PERSONALITY & BEHAVIOUR Personality types and learning styles are associated with different responses to working conditions , McManus et al. (2004), Personality strengths under pressure may become problematic, e.g. enthusiastic volatile , Hogan & Hogan (1997) , Isaksson R K -185 doctors at counselling centre in Norway , (doi:10.1136/bmj.a2004). Burnout, traits that make doctors vulnerable to depression are those for a capacity for empathy. 31. ORGANISATIONAL ISSUES Poor educational infrastructure, e.g. poor induction, rotation, staffing/workload issues, training and support of supervisors Bullying, harassment Service reconfiguration 32. CLINICAL COMPETENCE Lack of specific practical skills or knowledge, attitudes Capability Limited experience in a specific clinical area 33. KEY Support Points Causes of poor performance usually multifactorial Poor performance often has early warning signs Educational supervisor makes informed judgements about necessary steps once poor performance is identified Thoughtful support will help most individuals to improve performance 34. Issues Several periods or extended sick leave Isolated, worried about training and finances Limited sick pay Junior doctors have small savings and large debts Difficult to be resourceful while unwell! 35. The Role of Medical Leadership Strengthen line managers role, appropriate management styles and skills, Increase understanding of how management style and practices help promote employee mental wellbeing and keep stress to a minimum. Ensure that managers can identify and respond to employees emotional concerns, and symptoms of mental health problems. We are particularly concerned at the high levels of psychological and mental health problems that NHS staff suffer from, not least because management attitudes and practices may contribute to this NHS Health and Well-being Review, Interim Report, August 2009 36. Changes for Staff Support Strong leadership ; An evidence-based Health & Wellbeing Improvement Plan; Build management capability & capacity at all levels; Engage staff at all levels with health education, encouragement & support; HSE OHS that offers targeted, proactive & SEQOHS accredited support systems for staff & organisations. 37. Jones, CP, Jones Cy, Perry GS, the Cliff Analogy, Journal of Health Care for the Poor and Underserved 20 (2009): 112 38. What would you want? Work should be comfortable when we are well and accommodating when we are ill Nortin Hadler Professor Medicine, University of NC (1997)