INTERVENTIONS FOR DOCTORS IN DIFFICULTY Jenny Firth-Cozens London Deanery
Why interventions are necessary Doctors stress and depression levels are higher than the workforce as a whole Alcohol problems are high in some groups of doctors Doctors often do not have their own doctor Poor mental health of staff affects patient care.
Effects of stress, depression, and alcohol on patient care Cognitive function decision-making, memory and concentration are affected for more than half the working day during depression. Raised symptoms of stress and depression are linked to reporting making more errors (Firth-Cozens & Morrison, 1989). Effects of alcohol and drug abuse. Mental resilience and adaptability of surgeons lead to better outcomes (Carthey( et al, 2002).
Interventions for doctors in difficulty Interventions can be aimed at the individual, the team or the organisation. Interventions can be preventive or secondary.
Poor Latent Stressors Doctor Patient Litigation Hours Personality Care Complaints Organizational Sleep Coping Impairment Relationships Competence Stress Failures Support Early life Depression Death Alcohol Mistakes Drug Abuse Litigation Better Individual Communication Preventative Management Work Counselling Prevention & Psychotherapy Intervention AA Medication Suspension
Prevention for the Individual * An evidence base Having own doctor Career counselling Support groups (eg( eg,, Schwartz seminars) Mentor Stress management training* Teaching successful coping * Changing self-criticism* Recognition of stress, depression and PTSD in yourself/in others* Recognition of alcohol/drugs abuse in yourself/in others*
Recognising there s s a problem The first step for intervening is recognising there is a problem. Early recognition is imperative: - To the doctor - To patients How do colleagues recognise a doctor in difficulty?
How do people recognise a doctor in difficulty?* Rigidity: - Difficulty recognising when corners must be cut/unwillingness to compromise - Difficulty in prioritising - Problems in dealing with ambiguity and uncertainty *Paice E, Orton V. Early signs of the trainee in difficulty. Hospital Medicine 2004.
How do people recognise a doctor in difficulty? Rage: Ward Rage: - Flare-ups with colleagues - Rows with nurses - Inappropriate confrontations with patients - Complaints and counter-complaints complaints - Real rage
How do people recognise a doctor in difficulty? The Disappearing Act: - Arriving late, leaving early - Excessive casual sick leave - On-site but can t t be found - Bleep broken / lost - Asking colleagues to hold bleep for an hour - Not to be found in a crisis
How do people recognise a doctor in difficulty? The Bypass Syndrome: - Patients ask to see a different doctor - Nurses call senior colleagues first - Junior colleagues go over the head or behind the back of the doctor - Peers avoid being on duty with the doctor
How do people recognise a doctor in difficulty? Poor decision-making or poor judgment: - Lack of confidence in own judgment/decisions - Decisions made to avoid confrontations - Decisions made with no clear line of reasoning - Hasty judgments without considering all the facts - Not knowing when to take advice/unwilling to seek advice/failure to recognise limitations
Are they sad or bad? Sad Perfectionist, lack of compromise Irritable Often can t t be found By-passed as others recognise a problem Lack of confidence Alcohol/drug use
Sad or bad? Bad Arrogant Ward rage Bleep problems Taking decisions others are better placed to take. Don t t recognise their limitations Evidence/suspicions of alcohol, drugs or unethical practice
What do staff actually do when they see a doctor in difficulty? Answer: Very little!* * Firth-Cozens, Redfern & Moss, Confronting errors in patient care: the experiences of doctors and nurses, Clinical Risk,, 2004
What do staff do? They ignore: Minor rather than major problems One-off events rather than patterns of similar problems An occasion where the person was sorry or showed insight An otherwise good doctor
What do staff actually do? They find it easier to deal with problems in junior staff They find it easier to tackle clinical error than bad behaviour They intervene to help the patient where possible
Reporting Situations 70 60 Number of doctors/nurses 50 40 30 20 10 0 Nurses - Considered reporting (n=93) Nurses - Reporters (n=61) Nurses - Nonreporters (n=32) Doctors - Considered reporting (n=89) Doctors - Reporters (n=63) Doctors -Nonreporters (n=25) Bad clinical practice/error/incompetence Poor treatment/abuse of patients/staff Management problems/irregularities Colleagues mental health
We need early recognition: early intervention No blame Talk around possible organisational problems: Job re-design/hours/promotion? Team changes/team stress? Organisational changes?
Early recognition: Early intervention Talk around possible individual problems: Skills/CPD/supervision problem? Recent life events? Physical problems? Depression etc? A new problem or part of a pattern? Seek appropriate support/secondary care
Secondary interventions for the individual Counselling and psychotherapy brief and long- term* Medication* Interventions for alcohol and drug abuse* Out-patient and in-patient services as necessary * Evidence base
Poor Latent Stressors Doctor Patient Litigation Hours Personality Care Complaints Organizational Sleep Coping Impairment Relationships Competence Stress Failures Support Early life Depression Death Alcohol Mistakes Drug Abuse Litigation Better Individual Communication Preventative Management Work Counselling Prevention & Psychotherapy Intervention AA Medication Suspension
Organisations vary significantly in their levels of stress Mean stress levels of house officers at individual London hospitals varied from 8.1 to 15.3, measured on the General Health Questionnaire. In a large scale UK survey of all staff in 19 UK trusts, proportions above threshold on the GHQ varied from 17% to 33% So organisations and their management influence the stress levels of their staff.
And teams also affect the stress levels of their members.
Quality of team and stress levels 20 18 16 14 Mean GHQ Score 12 10 8 6 4 2 0 Poor Team Membership Strong Team Membership GHQ Score 17.23 10.04 Jenny Firth-Cozens
Primary interventions for the organisation Taking staff health seriously at management level Provision of stress management training Staff stress surveys Leadership training and team development Measures to increase staff retention
Primary interventions for the organisation Extra support for first-year doctors and new consultants Thorough orientation for all new doctors The hospital at night scheme Elimination of clinical responsibilities after nights on call Back-up coverage for sick doctors Support groups
Secondary interventions for organisations All secondary interventions require: Staff involvement Management commitment
Secondary interventions for organisations Access to counselling, occupational health and psychiatry/psychology services Provision of team interventions for troubled teams Job/service redesign where necessary A management culture that staff health is important
In conclusion Success depends on early recognition and reporting of problems. That depends upon a culture of trust and openness, where a clinician s s health is recognised as a key feature in patient safety.