Health of Physicians Statement from the Royal Australasian College of Physicians In a field that demands as much of us as medicine, anything less than (the) integration of person and professional may be unsupportable in the long run Inui 2003 Preamble Unhappy doctors are a worldwide phenomenon. 2, 3 The Canadian Medical Association 4, in its statement on physician health and well being stated: There are indications that physician stress is on the rise; increasingly, medical students, residents and practising physicians are voicing distress and seeking assistance in coping with stresses in their training, practice and personal lives. Australian physicians and trainees are part of the worldwide trend. The Australian Medical Association similarly stated: 5 Medical practitioners have an above average health status that is similar to others in advantaged socio economic groups. Some issues of concern, however, include higher than average rates of suicide, stress related problems and substance abuse. The health of some sub groups of medical practitioners may also be more at risk because of their professional circumstances. These include rural practitioners working in areas with scarce resources, some groups in training in hospitals with excessive work hours, female practitioners trying to balance competing professional and other obligations, practitioners from a non English speaking background and Indigenous practitioners. Explanations for the decline in the health and well being of physicians, and the documented increase in their work related stress include: 4 The rapid pace of change in the healthcare system; An unprecedented growth in medical knowledge and technology, and the accompanying ethical dilemmas; The political and economic uncertainty affecting practice location, remuneration, hospital closures and mergers; and The needs and expectations of an increasingly informed public. May, 2010 1
Health care practice generally has a large emotional component. There are the demands of working within the complex context of the family needs for the patient, and the physical demands of providing urgent/acute specialist care in many areas of practice. Responses to the inevitable stress experienced by physicians and trainees must combine personal action and responsibility, and actions by the RACP and employing authorities that support the practitioner. This statement on the Health of Physicians claims to contribute to the promotion of the health and well being of practitioners, their families and ultimately the people they serve. The RACP recognises that: 1. There is a relationship between the reduced health and wellbeing of the physician and a reduction in the quality of patient care. 6 2. There is a growing awareness within medicine that physicians and other health care professionals are at risk of burnout which threatens the sustainability of the healthcare enterprise. 3 A large percentage of dissatisfied physicians consider leaving the profession and feel that their occupation impacts adversely on their physical and mental health. 7,8 3. Work overload, excessive on call and high demand areas (eg regional practice, neonatology, emergency and intensive care) place individual practitioners at higher risk of burnout and thus contribute to the economic effects of a burnt out workforce. 4. A high proportion of physicians tend to aim for perfection, and are self sacrificing and self critical. 9 All of these factors may lead to professional success, but they also predispose to stress related symptoms. 5. The medical care system appears to encourage self sacrifice and driving yourself into the ground, and often seems to discourage time for self reflection and selfcare. 10 There is still a widespread belief that being a committed physician means working long hours and taking work home, despite increasing evidence that longer work hours do not equate to improved workplace efficiency. 6. Workplace bullying is still an unacceptable feature of the health industry. 7. Physicians tend to avoid seeking formal health care for themselves, to continue to work when unwell, and to self treat 11. Only a minority of physicians have their own General Practitioner 12. They have difficulty in not only adopting the patient role but in treating physicians as patients. Physicians are more likely to receive inferior health care and to have major concerns about confidentiality. 13 8. Patterns of inappropriate health care behaviour develop very early in physicians careers: trainee and young physicians give their own health a low priority. 14 May, 2010 2
9. In Australia, many physicians, practice in regional centres. Onerous on call obligations, difficulties in maintaining support from colleagues, poor access to continuing professional development, and difficulty in getting locum relief make regional practice additionally demanding. These additional stressors may also operate in high demand and underserviced areas of metropolitan Australia and New Zealand. The RACP further recognises that the majority of those now entering medicine are women, and: 10. Balancing the demands of work and home effectively are a high priority for most female and male physicians/trainees. 15 Female physicians/trainees are at particular risk of work related stress as many retain the primary role for managing the household. 11. Often the work environment offers few supports for women physicians. There can be harassment at work. Women experience inappropriate sexual comments and behaviour, which may not be overt or intentional, but which are still demeaning. Female physicians are vulnerable to high rates of verbal abuse and physical assault by male patients and other healthcare workers. 16 12. More women are having children during their medical training. This is because many students are entering medical school at an older age. There are now improved employee benefits, including parental leave and provision for part time training. Those exercising these benefits may feel guilty because their colleagues will have an increased workload in covering them (particularly as some hospitals do not employ locums for parental leave). Furthermore, these physicians/trainees may experience criticism and disapproval from colleagues, and even their supervisors. 13. The early years are recognised as being crucial to a child s development. It is vital that physicians/trainees are able to provide quality parenting to their own children through flexible workplace practices that support the work family balance. This is not only important for the children of physicians but also ensures that we are setting an example to the community. Accordingly the RACP encourages physicians and trainees to: 1. Establish and maintain regular contact (health care) with a General Practitioner (preferably outside of the family and practice setting). 2. Adopt a balanced lifestyle with time for self, family and friends, and for professional life (see the box below: Ten Tips for Healthier Physicians). 3. Establish and/or participate in local professional support networks. These might include any of: professional supervision, mentor programs, peer support networks, or formal professional groups. May, 2010 3
4. Recognise that both personal life and professional life will be affected by workrelated stress. Learn about the physical and emotional characteristics of excessive stress and burnout in oneself, and in colleagues. Find out about action you can take if professional impairment is recognised in a colleague (eg role of local Medical Board). 5. Incorporate health maintenance as part of professional life. 6. Act now. Would you recognise these signs of burnout in yourself? 1. Emotional exhaustion. 2. Cynicism. 3. Perceived clinical ineffectiveness. 4. Sense of depersonalisation in relationships with co workers, patients or both. Spickard et al 3 How would your health be affected? Accordingly the RACP will support the well being of physicians and trainees by: (Within the College) 1. Including sessions on physician wellbeing in the Annual Congress program. 2. Recognising that the participation of physicians in wellness educational activities, such as, supervision and mentor programs, is a component of Continuing Professional Development. 3. Investigating ways to reduce stress associated with the College examination and assessment processes. 4. Ensuring that during the accrediting of hospital/services for training positions, consideration is given to wellness issues for trainees. This includes on call requirements, flexible work hours, professional support, the availability of part time and job share options, and personal impacts such as accommodation. 5. Raising the profile of self care, wellness and lifestyle in training and continuing professional development documents. 6. Including material in Supervisor Workshops regarding trainees developing health maintenance activities/strategies. 7. Preparing a What comes First resources package for new Fellows entering practice. May, 2010 4
(Beyond the College) 8. Facilitating the availability of regional locum services. 9. Recognising and responding to the specific needs of overseas trained physicians, especially those working in regional settings and areas of need. 10. Supporting the development of professional networks, peer support activities, and mentoring and clinical supervision programs within the RACP. 1. Working with government health care agencies to establish healthy lifestyle practice standards for physicians and trainees, including work load, on call rosters, and continuing professional development time. 2. Collaborating with the Australian Council of Healthcare Standards and other similar bodies to incorporate practice standards for physicians in accreditation processes. 3. Supporting individuals and groups of physicians and/or trainees in the resolution of inappropriate or unsustainable working environments and expectations. 4. Promoting the message that Healthy Physicians promote Healthier Communities. Ten Tips for Healthier Physicians 1. Have your own GP. 2. Avoid taking work home. 3. Establish a buffer zone (time out) between work and home. 4. Take control of your work hours. The following are a few examples: Schedule breaks; Take days off; Strike a balance between the hours of paid work and the demand of your job; Put holidays in your diary months ahead. 5. Manage your time by making realistic schedules and not over committing yourself (at work or at home). 6. Manage your work environment. This may take time, new skills and lobbying for better work conditions. 7. Use your colleagues for support and maintain and work on relationships with partner/friends. 8. Take time out for your own needs through such activities as relaxation, enjoying personal interests or pursuits and maybe spending time alone. 9. Do not feel guilty or less of a doctor for demanding a work life balance. 10. Humour is therapeutic: surround yourself with fun and humour daily. May, 2010 5
References 1. Inui T (2003) A flag in the wind: Educating for professionalism in medicine. Assoc. Amer.Med.Coll. February. 2. Edwards N, Kornacki M, Silversin J. Unhappy Doctors: What are the causes and what can be done? BMJ 2002; 324:835 838. 3. Spickard A, Gabbe SG, Christensen JF. Mid career burnout in generalist and specialist physicians JAMA 2002; 288:1447 1450. 4. Canadian Medical Association. CMA Policy Statement: Physician Health and Well being. CMAJ 1998; 158 (9): 1191 1195. 5. Australian Medical Association (2001) AMA Position Statement: Health of Medical Practitioners AMA Ltd Publication. 6. Firth Cozens J, Howie et al. Work satisfaction of general practitioners and the quality of patient care. Family Practice. 1993; 2:128 135. 7. Schattner P, Goman G. The stress of metropolitan general practice MJA 1998; 168:133 137. 8. Appleton K, House A, Dowell A. A survey of job satisfaction, sources of stress and psychological symptoms among general practitioners in Leeds Br J General Practice 1998; 48:1059 1063. 9. Rucinski J, Cybulska E. Mentally Ill Doctors Br J Hosp Med 1985; 33(2):90 94. 10. Wilhelm K. The Student and Junior Doctor in Distress MJA Supplement 2002; 177 S5 S8. 11. Chambers RM. What should doctors do if they become sick? Family Practice 1993; 10(4):416 423. 12. McCall J, Maher T et al. Preventative health behaviour among general practitioners in Victoria Aust Family Physician 1999; 28:854 857. 13. Forsythe M, Cainan M et al. Doctors as patients: Postal survey examining consultants and general practitioners adherence to guidelines BMJ 1999; 319:388 395. 14. Shadbolt N. Attitudes to healthcare and self care among JMOs MJA Supplement S20. 2002 15. Gautam M. Women in medicine West J Med 2001; 174: 37 41 Additional reading: Western Journal of Medicine (2001) Vol 174 whole issue devoted to physician health. Medical Boards publications in Australia and New Zealand related to physician competence and impairment. Maslach C, Leither MP The Truth About Burnout San Francisco, Jossey Bass Publishers 1997. Clode D. (2004) The Conspiracy of Silence: Emotional health among medical practitioners, Royal Australian College of General Practitioners, South Melbourne. May, 2010 6