Risk Factors for Ill-Health in Doctors
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Transcript of Risk Factors for Ill-Health in Doctors
Risk Factors for Ill-Health in Risk Factors for Ill-Health in DoctorsDoctors
Jenny Firth-Cozens
London Deanery of Postgraduate Medical Education, University of London
• Resources • Government control • Professional status • Patient expectations
- Litigation , illegal drug use , elderly • Media highlight the bad, never the good
The issues facing doctors today
The emotional context of riskThe emotional context of risk
‘Patients and physicians … live and interact in a culture characterized by anger, blame, guilt, fear, frustration, and distrust regarding healthcare errors. The public has responded by escalating the punishment for error. Clinicians and some healthcare organisations generally have responded by suppression, stonewalling, and cover-up.’
Leape et al., 1998
Clinical Governance
Stress of HealthService Staff
Quality of Patient Care
Clinical Governance, Staff Stress and Quality
The studies involvedThe studies involved Longitudinal study of 318 4th year medical students from
1983, followed up in 1985, 1993, and 1999 looking at long-term predictors of stress, depression, alcohol use and speciality
Longitudinal study of 126 pre-registration house officers with different types of rotations, 2000
Study of all general practitioners over 45 in north-east England, looking at predictors of early retirement, 2001
Study of all senior registrars in north-east England, looking at training, stress and gender/specialty differences, 2000
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Aims of this series of studiesAims of this series of studies
To look at individual and organisational predictors of stress, depression, alcohol use and early retirement in the workplace
To relate this to performance/error
To look at individual and organisational interventions
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42.7
29.4 2929.2
17.9 16.8
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BritishWorkers(1993)
Mental HealthWorkers
Anaesthetists MedicalStudents
Junior HouseOfficers
Junior Doctorsand GPs
SeniorDoctors
% a
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GHQ above 3
Depression (SCL-90)
Stress (GHQ) and depression (SCL-90): Stress (GHQ) and depression (SCL-90): Proportions above thresholdProportions above threshold
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Consistency of stress levelsConsistency of stress levels
GHQ1 GHQ2 GHQ3
GHQ2 .25**
GHQ3 .11 .20*
GHQ4 .08 .34** .27*
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High alcohol use over timeHigh alcohol use over time
% scoring 4:A lot on occasions
% scoring 5:A lot most of the time
Students 17% 4%
PRHOs 14% 5%
SpRs/GPs 6% 5%
Senior doctors 10% 4%
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Consistency of alcohol use Consistency of alcohol use in senior doctorsin senior doctors
All Men Women
Since students .25** .20* .31**
Since PRHOs .27** .27* .30*
Since SpRs .34*** .44**
.28*
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Alcohol use and copingAlcohol use and coping
“I sometimes have an alcoholic binge after the death of an ITU patient which hurts particularly”“I think there is a general trend in juniors to do little exercise, even when they have time off, as they are so tired, so socialising with alcohol is much easier’
Time pressures in medicine were such that young doctors may not have had a chance to develop other ways of coping.
Alcohol useAlcohol use Women doctors have greater problems than
other women professionals Hospital doctors are using alcohol more to
cope, especially women hospital doctors The more complaints against you, the more
you use alcohol to cope
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Ideal age for GP retirementIdeal age for GP retirement
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55 orbefore
56-59 60 61 or later
Ideal retirement age
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A. Luce, J. Firth-Cozens, T. van ZwanenbergA. Luce, J. Firth-Cozens, T. van Zwanenberg
Predictors of desire to retire earlyPredictors of desire to retire early
• Role Satisfaction – predicted by:– Teamwork (.4)– Stress (.5)– Physical health (.2)
• Younger Age• Shorter consulting times
And doctor satisfaction predicts patient satisfaction, no-show rates, compliance etc.
Effects of Stress, depression, etc. Effects of Stress, depression, etc. on patient careon patient care
Cognitive function – decision-making and concentration – are affected for more than half the working day during depression.
Raised psychological symptoms of stress and depression are linked to reporting making more errors. But highly stressed are also more self-critical.
Mental “resilience” and adaptability of surgeons lead to better outcomes (Carthey et al, 2002).
So, what are the predictors so that we can intervene early?
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Individual predictorsIndividual predictors
GenderFamilyCopingPersonalityCareer choice
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Gender DifferencesGender Differences
Women are not significantly more stressed, but they are:
Significantly more depressed (p<.05) with an increased risk of suicide compared to the general population
Drinking the same as men Using alcohol more to cope (p<.05) especially if
they have children
Gender differences and Gender differences and depression (mean SCL scores)depression (mean SCL scores)
Men Women
General Practitioners .80 .83
Hospital doctors .62 1.12
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% above GHQ threshold
Fathers
Not fathers
Mothers F/T
Mothers P/T
Not mothers
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Proportions scoring above threshold on the Proportions scoring above threshold on the GHQ for male/females with and without children, GHQ for male/females with and without children,
working full-time and part-timeworking full-time and part-time
Personality and stressPersonality and stress
Self-criticism – high and low Very high self-esteem – grandiosity Rigidity Perfectionism: OCD, anxiety,
depression
DEPRESSION IN SENIOR DOCTORS
Factors as students: ALL MEN WOMEN
Self Criticism .21* .21 .17
Uncomfortable with Father -.25** -.16 - .35**
Uncomfortable with Mother -.10 -.25* - .02
Father’s age .28*** .40*** .20
PRHO Depression .20* .42*** .08
Clinical difficulty as students .15* 17 .13
Academic difficulty as students .17* .14 .20
Current factors as senior doctors:
Sleep -.17* -.25* -.15
Hours of work .06 .20* .04
Feeling part of a team .33*** - .35*** -.33**
Bed responsibility .03 .01 .27*
Individual & Work Factors andRelationship to Depression
Coping StyleCoping Style
Resilience to stress has been shown related to:
Tackling the problem (control) Low avoidance or denial Positive comparisons Less venting
Depression & Stress in Different Depression & Stress in Different SpecialitiesSpecialities
Speciality N Depression (Time 4)
Stress (Time4)
Depression (Time 1)
Stress (Time1))
PRHO Depression
PRHO Stress
GenPractice 10 0.79 12.9 4.5 11.5 1.1 12.3 Psychiatry 10 1.16 16.0 6.1 13.4 1.6 14.3 General Medical
24 0.84 11.9 4.0 11.5 1.1 12.7
Surgery 9 0.73 10.6 3.9 10.5 0.8 9.5 Anaesthetics/ radiology
12 0.78 11.57 4.8 13.0 1.1 13.3
Laboratory & PHM
11 1.07 11.89 6.1 12.7 1.4 15.5
Mean GHQ scores in 1987, Mean GHQ scores in 1987, by choice of future career in 1996by choice of future career in 1996
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General Medicine General Practice Paediatrics
Psychiatry Surgery Anaesthetics
PJ Baldwin, M Dodd, RW Wrate, Young doctors: work, health and welfare (1997)
The role of the organisation in The role of the organisation in creating stress and dissatisfactioncreating stress and dissatisfaction
Managerial/organisational factorsManagerial/organisational factors
Borell et al (1996): Significant differences in stress levels between Trusts (17% - 33%). Large Trusts worse than small ones:
“The mental health of staff is better in Trusts characterised by greater co-operation, better communication, a stronger emphasis on training, and greater discretion for staff”
Stress levels of the PRHOs in July Stress levels of the PRHOs in July at individual hospitalsat individual hospitals
Hospital N Mean GHQ
A 6 15.33
B 10 12.90
C 21 11.95
D 14 11.57
E 11 11.45
F 8 11.00
G 3 10.67
H 16 10.38
I 19 9.89
J 12 9.83
K 6 9.67
L 10 9.10
M 7 8.14
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Work factors creating stress:Work factors creating stress:
Senior DoctorsDealing with complaints against meFear of making mistakesFear of litigationThreat of violenceOverwork/Lack of sleepConflicts between career and personal life
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Mean GHQ Score
GHQ Score 17.23 10.04
Poor Team Membership Strong Team Membership
Quality of team and stress levelsQuality of team and stress levels
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Multi-disciplinary teamwork for Multi-disciplinary teamwork for PRHOsPRHOs
Less stressed*
And significantly more positive about: Skill use*** Support** Workload*
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Only 42% (n=59) said they were part of a
multi-disciplinary team. They were significantly:
Differences in stress for two Differences in stress for two different HO rotationsdifferent HO rotations
2 x 6-month rotations in different organisations 3 x 4-month rotations in single organisation (the
12-month rotation)
By end of year only 10.3% (n=3) of 12-month HOs were scoring above threshold on the GHQ compared to 25.4% (n=29) of those on 6-month rotations.
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The risk factors in summary:
Individual risk factors for Individual risk factors for stress & depressionstress & depression
Depression as students (especially males) High alcohol use as students (especially females) Female hospital doctors with children Older fathers (especially males) High self-criticism and/or perfectionism Wanting to be a psychiatrist/pathologist Coping by denial or avoidance Complaints or litigation
Organisational risk factorsOrganisational risk factors
Poor leadershipPoor teamwork (not recognising multi-
disciplinary support etc.)? Larger trusts and teaching hospitalsSleep loss/hours of workPoor job design – (peripatetic, consulting
times, roles for older doctors, paperwork)Bullying punitive culture – from the top
Sleep Relationships Support Mistakes Litigation
Personality Coping Competence
Unclear goals Communication Supervision Teamworking Information Systems Blame culture Resources
Latent Organizational Failures
Stressors Doctor Impairment
Stress Depression Alcohol Drug Abuse
Poor Patient Care
Litigation Complaints TEAM
Management Prevention & Intervention
Team leadership training Data
Individual preventive work Training & development Own Doctor Career Clg Selection Student mood
Assessment Centres Counselling Psychotherapy AA Medication Suspension
Better Communication
A systems approach to the causes of poor patient careA systems approach to the causes of poor patient care
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ConclusionsConclusions High stress levels in doctors affect:
The doctor Other staff Resources – through recruitment and retention Their patients
There is reasonable evidence for some individual and organisational predictors of stress and depression
Early interventions at the individual and organisational levels are a cost-effective way to better patient care through healthier staff
Interventions for stressInterventions for stress
At the professional level At the organisational level At the teams level At the individual level
Professional levelProfessional level
Pre-entry information
Provision of mentoring and personal coaching
Helpline
Doctors with children
Addressing the length of the consultant’s career
SelectionJenny Firth-CozensJenny Firth-Cozens
Organisational level (1)Organisational level (1)
Better leadership* Good communication* Increasing participation in decision-making* Providing child care for parents Creating a fair culture* Clarity of organisational aims and
expectations* Reasonable hours and sleep* Systems for early recognition of problems
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Organisational level (2)Organisational level (2)
Provision of training for:– Team leadership *– Stress management *– Doctors treating doctors– Good supervision and appraisal with training*
Counselling/Psychotherapy services*
Resources
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Individual clinician level (1)Individual clinician level (1)
Throughout training:
Having own doctor – no self-prescribing Recognition of stress, depression and PTSD in
yourself/by others* Recognition of alcohol abuse in yourself/by others* Changing self-criticism* Teaching successful coping * Stress management* Career counselling
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Individual clinician level (2)Individual clinician level (2)
Throughout career:
Mentoring, personal coaching, counselling,
psychotherapy * Support at times of complaints, litigation,
suspension Advertised access to external agencies (AA, Relate, etc.) The National Clinical Assessment Authority
Jenny Firth-CozensJenny Firth-Cozens
ConclusionsConclusions High stress levels in doctors affect:
The doctor Other staff Resources – through recruitment and retention Their patients
There is reasonable evidence for some individual and organisational predictors of stress and depression
Early interventions at the individual and organisational levels are a cost-effective way to better patient care through healthier staff