The pressure point

MPS has launched a worldwide counselling service for members, to provide support in times of work-related stress. Gareth Gillespie and Sara Williams look at the possible causes of stress and the potential consequences for doctors and patients

Stress has become an acceptable cliché, ignored by most and discarded as normal by many

Modern society is becoming increasingly frantic. If we are not rushing to get somewhere, we are reading headline news or replying to text messages, in between preparing our next tweet and Facebook post, while planning how we can afford an iPad, get fit, feed the family, advance our careers and see our friends; we could go on. Stress has become an acceptable cliché, ignored by most and discarded as normal by many.

In this all-action world, patience is not often regarded as a virtue; it is a hindrance. This modern attitude is becoming increasingly evident in medicine, where the business of running a successful and profitable hospital or surgery increasingly becomes the focus.

Doctors are under increasing pressure, with increasing demands on their time. Doctors are no strangers to stress, but these attitudes certainly do not make their jobs easier: stress needs to be tackled effectively or it will lead to burn-out. Not only can stress eat away at a doctor’s physical and emotional health, also adding strain to relatives or colleagues close by, but the impact on patient safety is potentially severe.

The association between stress levels and clinical negligence claims has been demonstrated in studies in the US, while the intervention of stress prevention programmes has also been shown to reduce the likelihood of errors and ensuing clinical negligence claims.^1,2

Prevalence

In the United Kingdom, studies have determined that the proportion of medical professionals demonstrating above-threshold levels of stress is around 28%, compared to around 18% in the general working population.³ The British Medical Association (BMA) has estimated that one doctor in 15 could develop a dependency on alcohol or drugs at some point in their career.⁴

Rates of suicidal thoughts and suicides, and those of substance misuse, are considerably higher among health professionals than in any other group of workers

The most disturbing statistics, however, come from the Working Group on the Health of Health Professionals, who prepared a report in 2010 for the UK Department of Health – these statistics showed that rates of suicidal thoughts and suicides, and those of substance misuse, are considerably higher among health professionals than in any other group of workers.⁵

Similarly, in New Zealand, studies of stress among doctors in 2000 and 2001 revealed that 30% of doctors had significant psychological symptoms, and around 10% of GPs, physicians and surgeons had symptoms of significant psychological distress.^6,7

In Hong Kong, stress in doctors is such a prevailing issue that the Hospital Authority set up Oasis in 2002, a “Centre for Personal Growth and Crisis Intervention”, which, among other services, provides treatment by clinical psychologists for healthcare workers in situations including the occurrence of a medical error.^8,9

Cause and effect

There are many causes of stress in doctors, and not all of them are work-related. A study of the usage of the MPS counselling service in New Zealand – which is jointly-funded by the Medical Assurance Society and has been in existence since 2006 – revealed that many doctors had “home-based” issues related to their spouse or alcohol use, or problems adapting to new cultures.¹⁰ For the workplace, the New Zealand study highlighted the following causes of stress:

• Perceptions of inadequacy and not performing to potential
• Staff shortages and working conditions
• Difficult dynamics within workplace relationships
• Bullying
• Poor management support
• Idiosyncratic reactions to patient deaths.

A complaint that causes stress may go on to cause another adverse event, which will bring about either another complaint or a claim – a vicious circle

In the UK, the BMA runs a support service called Doctors for Doctors. The service takes more than 2,000 calls a year and lists career issues and being the subject of a complaint to the General Medical Council (GMC) as the two most common sources of problems affecting callers.

A complaint that causes stress may go on to cause another adverse event, which will bring about either another complaint or a claim – a vicious circle that might be broken if a doctor is willing to be open about their stress. Depression, bullying and clinical competence are the other most common problems discussed with Doctors for Doctors.

Firth-Cozens identified compelling evidence that high levels of stress impair a doctor’s performance, by affecting memory, concentration and attention, and decision-making ability.¹¹ Firth-Cozens’ view was that individual and organisational factors are involved in the potential compromising of patient care, which can create a vicious circle.

Evidence of this process exists in a review carried out in the US of a large number of claims reported to a leading malpractice insurer.¹² These claims were analysed to ascertain the period between the notification date of a first claim and the incident date of a second claim against the same doctor.

The most frequent calls come from GPs, followed by those working in psychiatry, general medicine, surgery and anaesthetics

The results showed that in any given quarter, a doctor’s average risk of being named in a clinical negligence claim was 5% – but during the three months following notification of a first claim, the likelihood of a doctor being involved in an adverse incident leading to a second claim increased to 14.4%.

An increased risk of being involved in a successive clinical negligence claim was found to remain so for a two-year period. It is also interesting to look at which specialties are worst affected by stress. According to the BMA’s Doctors for Doctors, the most frequent calls come from GPs, followed by those working in psychiatry, general medicine, surgery and anaesthetics.

Users of the MPS/MAS counselling service in New Zealand were, again, predominantly GPs.¹³ Dr Mike Peters, who is the head of Doctors for Doctors and also a GP, said that GPs work in a unique set of circumstances.

He said: “General practice is demand led: it is difficult to say that, within a day, ‘I am going to be free for myself’. The stresses may not be patients, as practice staff are used to dealing with them, it might be that a GP has put half an hour aside to perform personal tasks, and the nurse tells them there’s an urgent visit required – that would be the stress of the day. The other thing is that if you are continually over-running surgeries this can become a real problem.

“I think one of the main problems is that there often isn’t compassion from colleagues because they are working at the ‘coal face’ and it’s difficult: everyone is under stress. Organising time for reflection with colleagues is really important.”

A professional view

MPS has launched its new counselling service worldwide after similar services in New Zealand¹⁴ and South Africa¹⁵ received positive feedback from those who used them. The current service in South Africa will be staying the same.

Counselling is a ‘stress-busting’ activity. Talking to a neutral but caring person allows clients to be open about the stressful situation, without losing face

Professional help with stress and anxiety is often the best way of rooting out the issues that are at the core of the problem. Jenny Lanyon is Head of Clinical and Service Development at PPC Worldwide, who are facilitating the counselling service for MPS. Ms Lanyon says that counselling can be an “enormously liberating” experience.

She said: “Counselling is a ‘stress-busting’ activity. Talking to a neutral but caring person allows clients to be open about the stressful situation, without losing face. Also, as counselling services are available on both a telephone and a face-to-face basis, it is possible to speak to a counsellor at the time which is most convenient.

"Telephone counselling is a 24/7 service, and it fits particularly well into busy lives. Online counselling – a real-time, ‘chat’-based service – is an alternative way of seeking help and support at any time, day or night.

“PPC’s counselling focuses on seeking practical solutions to issues, rather than unravelling the past. It is helpful to look at the reasons for the development of the stressful situation, but always with a view to replacing a ‘vicious’ with a ‘virtuous’ circle. In practice, this takes the form of replacing emotional symptoms with behavioural tasks.

It is helpful to look at the reasons for the development of the stressful situation, but always with a view to replacing a ‘vicious’ with a ‘virtuous’ circle

So, for a client who feels tired and anxious 80% of the time, the aim would be to begin to reduce – rather than eliminate – that high percentage. Monitoring stress symptoms on a daily basis would therefore be an important part of the process, so that even small changes can be registered as progress.

“The counselling process might continue to look at sleep patterns and, particularly, sleep deficit – a very common cause of stress. The counselling would then focus on putting in place a plan to remedy the poor sleep pattern. This would need to be realistic and gradual - behavioural change takes time.

It might begin with the client setting an alarm to remind him/herself to go to bed at an agreed time every night. The following week might introduce a period of relaxation before bed – a walk with the dog, a conversation with a partner, reading a book, or use of a relaxation tape.

“Depending on the client’s needs, the counselling might then look at exercise patterns and increasing the time spent on enjoyable leisure pursuits. Scales of 0-10 are used to assess progress at every stage, and counsellors will always discuss with clients how they will handle setbacks. It is normal for progress to be ‘stop-start’, and it is important not to become demoralised, so that the whole project is abandoned.”

Dr Fiona Donnelly is the chairman of the Doctors Support Network in the UK, an online forum that acts as a peer support group for doctors.

Dr Donnelly established the service after suffering stress and depression in her own life. While her story demonstrates how a problem like stress can be turned into a positive action, it showcases the perils of leaving stress unchecked.

I had no idea how ill I was. I felt very guilty, as there was a perception that people made things like this up to get out of work. I could do the job fine, but when I got home I wouldn’t leave the sofa or speak to my husband

Dr Donnelly said: “I got involved in this group because I experienced stress and depression in my own life. It was brought on by a series of events that occurred in a short period of time. I got married, bought my first house, started my first psychiatry post doing the job of a higher level trainee as my consultant was off sick, and then I was assaulted by a patient.

“I left my illness for a very long time. I had no idea how ill I was. I felt very guilty, as there was a perception that people made things like this up to get out of work. I could do the job fine, but when I got home I wouldn’t leave the sofa or speak to my husband.

“How effective stress management is depends on the local culture of where someone is working: some areas take a hard line on illness, and offer support and encourage staff to take time off. However, I know of other areas where the attitude is old-fashioned – if you can’t take the stress you shouldn’t be doing the job.

“GPs struggle because in comparison to a hospital, it is harder for a GP to go off sick as they feel they are letting their business down. So their stress builds up. Also it is harder for them to access occupational health facilities compared to hospitals, which have designated departments.”

Dr Donnelly was an in-patient for six months. Following this, she resumed her career and has since had two children – successes that she puts down to sharing her feelings and dealing with them.

Accessing the MPS counselling service

If you feel you might benefit from accessing the counselling service, simply contact your medicolegal case handler

The MPS counselling service is available to members who have experienced an adverse incident or medicolegal issue and are experiencing emotional or psychological difficulties. If you feel you might benefit from accessing the counselling service, simply contact your medicolegal case handler, who will provide you with the appropriate contact details. If you have not reported a medicolegal matter to MPS, but are suffering from stress due to an adverse incident or medicolegal issue, contact MPS and ask to speak with a medicolegal adviser.

PPC Worldwide offers a service tailored to the individual’s requirements and it is delivered by fully trained, qualified and registered psychologists and  counsellors. PPC’s in-house telephone counselling provides immediate access to support 24 hours a day, seven days a week, and face-to-face counselling sessions can be arranged near to you and at your convenience, all funded by MPS. The service provided by PPC is entirely independent and confidential – MPS will not be informed of any contact with PPC.

With thanks to Dr Tony Behrman and Mr Al Neaber for their help with this article

References

1. West CP, Tan AD, Habermann TM, Sloan JA, Shanafelt TD, Association of Resident Fatigue and Distress with Perceived Medical Errors, JAMA 302(12):1294-1300 (2009)
2. Jones JW, Barge BN, Steffy BD, Fay LM, Kunz LK, et al, Stress and Medical Malpractice: Organizational Risk Assessment and Intervention, J Applied Psychol 4:727-735 (1988)
3. Firth-Cozens J, Doctors, their Wellbeing and their Stress, BMJ 326:670-1 (2003)
4. British Medical Association, Report of the Working Group on the Misuse of Alcohol and Other Drugs by Doctors, London: British Medical Association (2000)
5. Department of Health, Invisible Patients. Report of the Working Group on the Health of Health Professionals, Crown (2010)
6. Dowell AC, Hamilton S, McLeod DK, Job Satisfaction, Psychological Morbidity and Job Stress among New Zealand General Practitioners, NZ Med J 113(1113):269-72 (2000)
7. Dowell AC, Westcott , McLeod DK, Hamilton S, A Survey of Job Satisfaction, Sources of Stress, and Psychological Symptoms among New Zealand Health Professionals, NZ Med J 114:540-3 (2001)
8. Oasis - Centre for Personal Growth and Crisis Intervention
9. Wong J, Doctors and Stress, Hong Kong Medical Diary 13(6):4-7 (2008)
10. Cunningham W, Cookson T, Addressing Stress Related Impairment in Doctors. A Survey of Providers’ and Doctors’ Experience of a Funded Counselling Service in New Zealand, NZMJ 122(1300):19-28 (2009)
11. Firth-Cozens J, Interventions to Improve Physicians’ Well-being and Patient Care, Social Science and Medicine 52(2):215-22 (2001)
12. Passineau TL, The Effects of Medical Malpractice Litigation on Subsequent Physician Performance, Presentation at the International Conference on Physician Health (September 1994)
13. Ibid 10
14. Cookson T, A Problem Shared, Casebook New Zealand 18(1):7 (2010)
15. Gillespie G, Putting the Stress on Anxiety, Casebook Africa 17(2):7 (2009)