Marie McInerney writes:
Rates of depression, anxiety and suicide among doctors have made headlines in recent years, underscored by high profile campaigns like #crazysocks4docs, but in ways that might be alarmist and counterproductive, according to a leading mental health researcher.
Importantly, despite the publicity, there is no available evidence on what hospitals and training colleges can and should do at an organisational level to address key risk factors like high workloads, long working hours and fatigue, Associate Professor Sam Harvey told the recent RANZCP Congress in Cairns.
Harvey, who is chief psychiatrist and head of the Workplace Mental Health Research Program at the Black Dog Institute in Sydney, steered a recent systematic review and meta-analysis of interventions to reduce symptoms of common mental disorders and suicidal ideation in doctors – thought to be the first such study in the world.
Published in February in Lancet Psychiatry, the study found “remarkably little” has been published (in English at least) on the efficacy of potential solutions, apart from a handful of studies that found benefits in individual interventions based around cognitive behaviour therapy and mindfulness.
“Stunningly,” Harvey told delegates to the Royal Australian and New Zealand College of Psychiatrists (RANZCP) summit, there were “absolutely no published controlled studies” that looked at organisational-level interventions around workplace issues like working hours.
This was despite evidence captured in a yet-to-be-published study by the Black Dog Institute that “once you had junior doctors working more than 50 hours a week they had more than double the odds of reporting depression and anxiety; and once that is over 55 hours you’ve doubled the odds of suicide ideation”.
In their Lancet review, Harvey and co-authors say their findings should “serve as a call to action” on effective interventions — both at an individual and organisational level — to improve doctors’ mental health, with more rigorous, comprehensive research required to establish an evidence base.
Speaking ahead of Saturday’s federal election, when Australians voted to return the Liberal-National coalition for a third term, Harvey said government leadership may be required on the issue.
The mental health of medical practitioners was on the COAG agenda in 2018, with a push to end mandatory reporting of doctors ultimately falling short with the passage of Queensland legislation in February.
Watch our interview with Harvey below:
What happens in the darkness
Harvey’s was one of a number of packed sessions over the four-day RANZCP congress that explored wellbeing issues, including bullying and burnout, for junior doctors and other at-risk occupation groups like first responders, military personnel and military veterans.
One session, titled ‘Telling Our Stories’, heard a graphic account of systematic bullying by a senior registrar when the presenter was in his first year of training.
“I felt my heart start to race when I entered the building. My confidence was being eroded, and I was being paralysed by my doubt and fear,” he told the session.
He went on:
I never pursued a formal complaint, I couldn’t tolerate sitting in a room with him and listing all the micro incidents that were making me feel stupid and afraid – I didn’t think people would believe me.
Each interaction seemed like nothing, but when taken as a whole this man was bullying me, he was systematically undermining and intimidating me.
This ‘telling’ is exactly what is needed to shed light on these shadows in our profession and to process what happens in the darkness.”
Bullying and burnout in medicine has come under increasing scrutiny in recent years, with trainee doctors blowing the whistle on cultural issues within the profession, prompting internal reviews by groups including the Royal Australasian College of Surgeons and Australasian College for Emergency Medicine (ACEM).
An online movement, #MH4Docs, has gained momentum following several highly-publicised trainee suicides, spawning a popular awareness-raising campaign, #crazysocks4docs, that has gone global. This year, the event will be held on Friday, June 7.
Not without consequence
Harvey opened his keynote address by challenging the value of reports that young doctors in particular have much higher rates of anxiety and depression compared to the general population.
In Australia those figures largely come from the 2013 National Mental Health Survey of Doctors and Medical Students conducted by Beyond Blue, which found significantly higher levels of very high psychological distress in doctors aged 30 years and below compared with the general population – 5.9 percent versus 2.5 percent.
“The conclusion is: ‘Oh my God, doctors are more than double the rate of depression and anxiety than the rest of the population, what the hell is going on!’,” Harvey said.
But he pointed to UK research suggesting that occupational studies return higher reports of psychological symptoms compared with population-based research, with a possible “framing effect” from research questions exploring ‘work stress’ in the occupational setting.
The UK study also made some unexpected findings within occupational groups: among professions predicted to have a higher level of trauma, such as the military and police, common mental disorders were not more prevalent compared to academia, teaching, white collar employment and the social services sector.
Questioning the statistics was not just “academic navel gazing”, Harvey said.
“I think it is a risk to us as an industry, going out and telling medical students that they’re at increased risk and perhaps should have chosen another occupation,” he said.
“Those messages are not without consequence,” he added. “It’s anxiety-provoking for them and has an impact on their perception of their symptoms and their resilience, which has knock-on consequences that may not be helpful.”
Describing doctors as being at substantially increased risk of mental health issues compared to other occupational groups “may not be accurate”, though they are by no means immune to the kinds of mental health problems seen in other populations.
What is clear, however, is that doctors are at increased risk of suicide, with Harvey nominating two key factors.
First, doctors often find it “very difficult” to seek help – for a range of reasons including the threat of mandatory reporting and loss of their medical licence. Secondly, they have access to and knowledge of highly lethal means.
“This points to one of the key issues in rates of doctor suicide, and why you don’t need to have doctors have higher rates of depression and anxiety than other occupations to explain high rates of suicide,” Harvey said.
Sleep deprivation and work-life balance
Beyond Blue has kindly given the Black Dog Institute access to its raw data from the 2013 survey, allowing Harvey and his colleagues to crunch the numbers on work-related risk factors for about 3,000 interns, junior doctors and registrars, across all specialties.
The original survey asked respondents how stressed they felt by a variety of workplace factors.
While the stress impact of some factors like bullying were lower than expected, two stood out in terms of frequency and impact: the conflict between work and personal life, and sleep deprivation.
Both will require rigorously researched organisational and individual interventions to address, Harvey said.
“And this is not just an Australian problem, this is an issue for health services around the world. It seems to me unimaginable that we can’t find the resources to actually study some of these things and to know which things work and which don’t,” he said.
In the absence of health sector-specific responses, other occupations are showing the way.
The Black Dog Institute has been working with Fire and Rescue New South Wales on training managers to better respond to mental health issues experienced by fire fighters and other emergency employees that it says has led to a significant reduction in sickness absence.
The Institute is now working with the Royal Australasian College of Physicians on modifying the training for doctors, with plans to conduct a randomised control trial.
It’s an approach that was welcomed at congress by public health physician and health lawyer, Dr Marie Bismark, who told Croakey that other industries have addressed issues like safe working hours and shift work much better than the health sector.
Bismark highlighted research by her colleague Associate Professor Allison Milner that found elevated rates of suicide among those employed in male-dominated professions such as construction compared to other occupational groups.
“It’s easy for doctors to feel that their workplace stressors are unique,” she told Croakey.
“What I really like about Sam (Harvey) and Allison Milner’s work is that they also work with other occupations and remind us that many of the problems – and solutions – to workplace stress are not unique to medicine,” Bismark said.
Andy Teodorczuk, Associate Professor in Medical Education at Griffith University, agreed it was “refreshing to have a psychiatry perspective on the wider wellbeing and resilience discourse that is one of medical education’s current hot topics”.
“I think that in medical education we often focus on burnout and distress. However, considering wellbeing in terms of depression and suicide lends itself to more holistic broader approaches in line with how we manage psychiatry disorders.
“For me Sam’s take-home was that it’s not system OR individual interventions that will make a difference but the need to focus on the system AND individual to tackle the complexity of the issue. Also there are some exciting studies in the pipeline…” he told Croakey.
Systemic risks and the administrative burden
The Black Dog Institute research says it is “incumbent” on colleges and hospitals to lead the way in addressing systemic risk factors, including work hours, workplace culture, regulatory requirements, ongoing training and the delivery of care to patients.
Organisational-level interventions also need to consider how recent trends in health care such as increasing administrative burden “might have affected the values, work-life balance, spirit and dignity of doctors”, it said.
The spirit-sapping toll of “paperwork load and clunky systems” was highlighted in another session on managing burnout, which psychiatrist Tessa Cookson from the RANZCP’s Member Welfare Committee said is expected to affect up to 50 percent of doctors through their careers – at “great cost” to themselves, patients and services.
Cookson said burnout was defined as a syndrome comprising emotional exhaustion, depersonalisation and reduced personal accomplishment in response to chronic stress in the workplace, much of which is seen in medicine as “rites of passage” – whether punishing exam schedules, exhausting patient loads and shift work, or instruction by humiliation.
While the impact of burnout on doctor welfare and performance had won increasing attention in recent years, evidence for practical strategies that can be taken up by individuals, in supervision, and by organisations, “is less clear”, she said, echoing Harvey’s sentiments.
One interesting insight for health services was to “get to know your doctor”, said Cookson, citing evidence showing that “if you give a doctor one day of work that holds intrinsic value they will work the other four days in something they do not particularly like, and do it happily.”
It was also vital to recognise that there was no point reducing work hours without a commensurate reduction in workload, said Cookson, with every one point increase on a ‘burnout scale’ generating a 30-40 percent likelihood that the person would reduce working hours over the next two years.
Though it “is a system issue”, Shanfelt warns that “most institutions operate under the erroneous framework that burnout and professional satisfaction are solely the responsibility of the individual physician.”
He and his team have come up with nine strategies to help.
We’ve captured some of the Twitter discussion below:
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