It is no surprise that the current COVID-19 pandemic has had huge implications for mental wellbeing worldwide. Dr Sara Sreih, Medicolegal Consultant at Medical Protection, takes stock of the issue

COVID-19 isn’t going anywhere soon – maybe not ever – but the constant waves of infection that are affecting countries around the world are having a cumulatively damaging effect on people’s wellbeing. And this is no different for healthcare staff.

In a survey of our members based in Malaysia in March, Medical Protection found that the greatest impact on these doctors’ current mental wellbeing was their concern for the health of their family and friends. Just over half of respondents were concerned about their own health, and they were also experiencing concerns about finances or loss of income. All these concerns can be compounded in day-to-day practice if doctors are having to adapt to different ways of working.

Notably, a significant number of members reported being concerned or extremely concerned about facing an employer, regulatory or criminal investigation for circumstances related to the pandemic, for example, as a result of clinical decisions made whilst working outside of their usual scope of expertise (56%), whilst working in high-pressure environment (61%), missed or delayed non-COVID-19 diagnoses due to constraints (66%) and as a result of delayed referrals or limited/ unavailable services (62%). This adds increased stress on clinicians, many of whom may already be suffering from, or are at risk of, burnout.¹ We are concerned that working in the context of the ongoing pandemic, and the intensity of exposure to the human suffering that this can entail, is a huge emotional strain and may be devastating for some.

While there is no explicit mention in the Malaysian Medical Council’s (MMC) Code of Professional Conduct around the obligations placed on doctors who are suffering from ill health, section 2.2.5 states that if a medical practitioner is unable to perform their professional duties to the best level, they have an ethical obligation to inform their senior colleague and may voluntarily cease practising, thus protecting patients from potential harm.²

The MMC has also published guidance for practising doctors over 70 years old.³ It advises that all registered medical practitioners have an obligation to recognize the limits of their professional competence, and highlights the importance of doctors following advice and guidance from their own doctors. Indeed, it is difficult for doctors to effectively care for others if they are not taking care of themselves. There are many reasons why doctors may struggle to access mental healthcare for themselves; these include a lack of knowledge of possible sources of support, concerns around professional implications and confidentiality and intrinsic psychological barriers, such as shame.⁴ It is particularly important, therefore, that resources for mental wellbeing support for doctors are available, easily accessible, and doctors are encouraged to utilize the resources. It is better for doctors to seek the help they require at an early stage, rather than later, when they may be in a significantly worse position.

Malaysia has experienced waves of the pandemic interspersed with short periods of what may be called normality. As with managing the pandemic, we must think about the health of clinicians longitudinally, being alert to the present circumstances and planning for the future. The effects of the different phases should be considered, and support offered to the staff accordingly. During the acute phases, the stress tends to be related to planning, concerns over personal safety and exposure to suffering and distress. However, exhaustion may set in when the pressure starts to ease following the acute phase.⁵ If clinicians are expected to be able to continue working through these cycles, it is essential to consider additional support. Of course, even after the pandemic has eased, clinicians must be able to continue providing healthcare to the community.

Considerable research is being undertaken and some helpful guidance has been produced in support of healthcare workers during COVID-19.^6-8 Some steps doctors can take include the following:

1. Know that stress currently is normal and appreciate the importance of managing your health at this time.

    

2. Try to take care of yourself, consider using coping strategies that are healthy and helpful to you as an individual, and look out for each other.
   
   
3. Do not ignore basic needs, such as eating, drinking, and resting, when possible.
   
   
4. Try to maintain social connections and sources of social support; even though physical connectedness may be limited, it is important that social connectedness is not lost.
   
   
5. Support your colleagues and acknowledge their anxieties and concerns.

As well as providing medicolegal advice and support, Medical Protection has been offering members support for their wellbeing through podcasts, workshops and an online resilience hub. This support has been offered both before and during the onset of the pandemic. In response to the challenges of the pandemic, we have delivered webinars on self-care, and have extended our free and confidential counselling service to all members. However, support across the profession is required.

Patients and the wider public alike are grateful to the clinicians who are working so tirelessly during the pandemic. At the very least healthcare professionals should be able to access and receive the support that they require, so that they are able to maintain their own health and wellbeing, and in turn provide the best possible care for their patients.

Members of Medical Protection can seek confidential counselling support free of charge.

References: 1. BMJ 2017;358:j3360. 2. Malaysian Medical Council. Code of Professional Conduct 2019. Available at: CODE-OF-PROFESSIONAL-CONDUCT-2019-Amended-Version.pdf (mmc.gov.my). Accessed on 27 May 2021. 3. Malaysian Medical Council. Guidelines for Medical Practice for Doctors beyond the age of 70 years. Available at: (Microsoft Word - 20090414 Medical Practice for Doctors over the age of 70 y\205) (mmc.gov.my). Accessed on 27 May 2021. 4. J Ment Health 2011;20:146–156. 5. Royal College of Psychiatrists. The top ten messages for supporting healthcare staff during the COVID-19 pandemic. Available at: Microsoft Word - Top Ten Messages Williams et al.docx (rcpsych.ac.uk). Accessed on 27 May 2021. 6. BJPsych Advances 2020;26:116–128. 7. WHO. Mental health and psychosocial considerations during the COVID-19 outbreak. Available at: Mental health and psychosocial considerations during the COVID-19 outbreak (who.int). Accessed on 27 May 2021. 8. NHS Clinical Leaders Network. Enhancing mental health resilience and anticipating treatment provision of mental health conditions for frontline Healthcare workers involved in caring for patients during the COVID-19 pandemic – A call for action. Available at: CLN Paper V6.7. Accessed on 27 May 2021.