Over recent months I have repeated the phrase ‘pull your own oxygen mask down first’, not I hasten to add be-cause I am now moonlighting as an airline stewardess, but because it’s a phrase I use when talking to doctors about how to stay mentally and physically healthy in these troubled times within the NHS.
Doctors not immune to mental illness
Doctors are not immune to mental illness; in fact, doctors have high rates of depression and anxiety, and female doctors in particular have significantly higher suicide rates than the general population. Since 2008, I have run a confidential NHS service for doctors with mental health and addiction problems. Our experience at the Practitioner Health Programme is that, by and large, most doctors have months of distress and disability until they present as unwell after a work or home crisis. Many doctors who come to our service often talk about the shame associated with not ‘coping’ or becoming unwell, and of their fear that disclosure of their mental illness would lead to ‘career suicide’. They worry about confidentiality and about being referred to the regulator if they admit to having a mental illness.
The NHS is depressed
There are other deep-rooted problems. I have written recently that if the NHS were a patient, it would be depressed and in need of psychological treatment. The NHS is troubled for many reasons, but predominantly due to increasing workload and decreasing support systems. Also, constant reorganisation is creating a culture of fear: fear of exposure, fear of being shamed, named and blamed. This working environment is undermining the development of resilience. In recent years, a culture of increasing blame, bullying, and retribution has developed in medicine.
The General Medical Council estimates that one in eight doctors in training has suffered bullying. Constant reorganisations destabilise relationships, and coupled with early retirements and the moving of older and more established doctors, this removes the continuity and corporate memory that builds resilience in institutions. Paradoxically, shorter working hours may also be a contributory factor. Working time rules mean doctors work shifts, which further fractures the relationships between staff and patients that provide support and feedback to build resilience for trainees. Changes to working hours also erode continuity of care, which is valued by healthcare workers and patients alike.
The relationship between doctors and patients rests on the unconscious assumption that patients embody illness and, in contrast, doctors stand for health and immortality; if doctors are ill, they ‘have only themselves to blame’. When consulted in an independent survey to evaluate the need for a confidential, stand-alone mental health service for doctors, the public admitted to regarding doctors and dentists as ‘super-human’ rather than ‘normal people’. On further reflection they were aware of, and empathetic towards, the health impacts of such a stressful job. So … maybe we need to admit to our vulnerability more often … perhaps we do only have ourselves to blame ….
Health professionals rightly have a strong sense of vocation to ‘help people’, but sometimes it is done to divert the helper from their own psychic pain and vulnerability, and leads to the denigration of their own needs. This means that when unwell, rather than seeking help or taking time out from the work space, doctors merely work harder, in the assumption that this will ‘make things better’. Not surprisingly, this approach rarely helps, and a study has shown that when doctors finally allow themselves to take time off for ill health, they tend to be off work for longer periods because they consult so late.
Look after ourselves first
The General Medical Council exhorts us to ‘make our patients our first concern’. So does this run counter to the advice that I gave at the start? I don’t think so. Putting patients first means recognizing where we cannot deliver care to the standard that our patients warrant – for example, when we are exhausted or suffering from physical or mental illness. This isn’t to promote taking sick leave for any minor problem – but just being mindful of our own health needs and how they might impact on the patients we treat.
The GMC advises that doctors should be ‘alive to mental health problems, depression, and alcohol and drug dependence [in colleagues]’ and should ‘act without delay if you have good reason to believe that you or a colleague may be putting patients at risk.’ In most circumstances, this means advising that they take time out, removing themselves from the work-place and seeking appropriate help.
The good news is that it is still unusual for doctors to become mentally unwell, and most pass through training with few problems. Predictors of good psychological wellbeing are the same in doctors as in the rest of society: stable relationships and a high level of support from family members. Doctors tend to have many of these positive protective factors, being highly educated and having good friendship networks. However, we must not be complacent.
Doctors are an important and expensive resource for society, and loss of this workforce due to avoidable ill health is a waste to the health service, a loss to patients, a stress on colleagues, and a disruption to individual careers. Avoidable causes of ill health in the system that doctors work must be dealt with, and doctors must have timely access to confidential help.
Pull down your own oxygen mask first
Perhaps it is time to be honest with our patients and accept that a good and safe doctor means replacing the exclusive and somewhat over idealised medical role that dictates we serve patients come rain or shine. Instead, we should adopt a more mature role that ex-tends to self-care and putting the needs of doctors alongside the demands of patients – indeed, pulling one’s own oxygen mask down first is better for doctors and better for the patients they serve.