Risk Factors for Ill-Health in Doctors Jenny Firth-Cozens London Deanery of Postgraduate Medical Education, University of London

Resources  Government control  Professional status  Patient expectations  - Litigation , illegal drug use , elderly  Media highlight the bad, never the good The issues facing doctors today

The emotional context of risk ‘Patients and physicians … live and interact in a culture characterized by anger, blame, guilt, fear, frustration, and distrust regarding healthcare errors. The public has responded by escalating the punishment for error. Clinicians and some healthcare organisations generally have responded by suppression, stonewalling, and cover-up.’ Leape et al., 1998

Clinical Governance Stress of Health Service Staff Quality of Patient Care Clinical Governance, Staff Stress and Quality

The studies involved  Longitudinal study of 318 4th year medical students from 1983, followed up in 1985, 1993, and 1999 looking at long-term predictors of stress, depression, alcohol use and speciality  Longitudinal study of 126 pre-registration house officers with different types of rotations, 2000  Study of all general practitioners over 45 in north-east England, looking at predictors of early retirement, 2001  Study of all senior registrars in north-east England, looking at training, stress and gender/specialty differences, 2000 Jenny Firth-Cozens

Aims of this series of studies  To look at individual and organisational predictors of stress, depression, alcohol use and early retirement in the workplace  To relate this to performance/error  To look at individual and organisational interventions Jenny Firth-Cozens

Stress (GHQ) and depression (SCL-90): Proportions above threshold Jenny Firth-Cozens

Consistency of stress levels GHQ1 GHQ2 GHQ3 GHQ2.25** GHQ * GHQ **.27* Jenny Firth-Cozens

High alcohol use over time % scoring 4: A lot on occasions % scoring 5: A lot most of the time Students 17% 4% PRHOs 14% 5% SpRs/GPs 6% 5% Senior doctors 10% 4% Jenny Firth-Cozens

Consistency of alcohol use in senior doctors All Men Women Since students.25**.20*.31** Since PRHOs.27**.27*.30* Since SpRs.34***.44**.28* Jenny Firth-Cozens

Alcohol use and coping “I sometimes have an alcoholic binge after the death of an ITU patient which hurts particularly” “I think there is a general trend in juniors to do little exercise, even when they have time off, as they are so tired, so socialising with alcohol is much easier’ Time pressures in medicine were such that young doctors may not have had a chance to develop other ways of coping.

Alcohol use Women doctors have greater problems than other women professionals Hospital doctors are using alcohol more to cope, especially women hospital doctors The more complaints against you, the more you use alcohol to cope Jenny Firth-Cozens

Ideal age for GP retirement A. Luce, J. Firth-Cozens, T. van Zwanenberg

Predictors of desire to retire early Role Satisfaction – predicted by: – Teamwork (.4) – Stress (.5) – Physical health (.2) Younger Age Shorter consulting times And doctor satisfaction predicts patient satisfaction, no-show rates, compliance etc.

Effects of Stress, depression, etc. on patient care  Cognitive function – decision-making and concentration – are affected for more than half the working day during depression.  Raised psychological symptoms of stress and depression are linked to reporting making more errors. But highly stressed are also more self- critical.  Mental “resilience” and adaptability of surgeons lead to better outcomes (Carthey et al, 2002).

So, what are the predictors so that we can intervene early? Jenny Firth-Cozens

Individual predictors Gender Family Coping Personality Career choice Jenny Firth-Cozens

Gender Differences Women are not significantly more stressed, but they are:  Significantly more depressed (p<.05) with an increased risk of suicide compared to the general population  Drinking the same as men  Using alcohol more to cope (p<.05) especially if they have children

Gender differences and depression (mean SCL scores) Men Women General Practitioners Hospital doctors Jenny Firth-Cozens

Proportions scoring above threshold on the GHQ for male/females with and without children, working full-time and part-time

Personality and stress  Self-criticism – high and low  Very high self-esteem – grandiosity  Rigidity  Perfectionism: OCD, anxiety, depression

Individual & Work Factors and Relationship to Depression

Coping Style Resilience to stress has been shown related to:  Tackling the problem (control)  Low avoidance or denial  Positive comparisons  Less venting

Depression & Stress in Different Specialities

Mean GHQ scores in 1987, by choice of future career in 1996 PJ Baldwin, M Dodd, RW Wrate, Young doctors: work, health and welfare (1997)

The role of the organisation in creating stress and dissatisfaction

Managerial/organisational factors Borell et al (1996): Significant differences in stress levels between Trusts (17% - 33%). Large Trusts worse than small ones: “The mental health of staff is better in Trusts characterised by greater co-operation, better communication, a stronger emphasis on training, and greater discretion for staff”

Stress levels of the PRHOs in July at individual hospitals Hospital NMean GHQ A B C D E F G H I J K L M Jenny Firth-Cozens

Work factors creating stress: Senior Doctors Dealing with complaints against me Fear of making mistakes Fear of litigation Threat of violence Overwork/Lack of sleep Conflicts between career and personal life Jenny Firth-Cozens

Quality of team and stress levels Jenny Firth-Cozens

Multi-disciplinary teamwork for PRHOs Less stressed* And significantly more positive about: Skill use*** Support** Workload* Jenny Firth-Cozens Only 42% (n=59) said they were part of a multi-disciplinary team. They were significantly:

Differences in stress for two different HO rotations  2 x 6-month rotations in different organisations  3 x 4-month rotations in single organisation (the 12-month rotation) By end of year only 10.3% (n=3) of 12-month HOs were scoring above threshold on the GHQ compared to 25.4% (n=29) of those on 6-month rotations. Jenny Firth-Cozens

The risk factors in summary:

Individual risk factors for stress & depression Depression as students (especially males) High alcohol use as students (especially females) Female hospital doctors with children Older fathers (especially males) High self-criticism and/or perfectionism Wanting to be a psychiatrist/pathologist Coping by denial or avoidance Complaints or litigation

Organisational risk factors Poor leadership Poor teamwork (not recognising multi- disciplinary support etc.) ? Larger trusts and teaching hospitals Sleep loss/hours of work Poor job design – (peripatetic, consulting times, roles for older doctors, paperwork) Bullying punitive culture – from the top

A systems approach to the causes of poor patient care Jenny Firth-Cozens

Conclusions  High stress levels in doctors affect:  The doctor  Other staff  Resources – through recruitment and retention  Their patients  There is reasonable evidence for some individual and organisational predictors of stress and depression  Early interventions at the individual and organisational levels are a cost-effective way to better patient care through healthier staff

Interventions for stress  At the professional level  At the organisational level  At the teams level  At the individual level

Professional level Professional level  Pre-entry information  Provision of mentoring and personal coaching  Helpline  Doctors with children  Addressing the length of the consultant’s career  Selection Jenny Firth-Cozens

Organisational level (1)  Better leadership*  Good communication*  Increasing participation in decision-making*  Providing child care for parents  Creating a fair culture*  Clarity of organisational aims and expectations*  Reasonable hours and sleep*  Systems for early recognition of problems Jenny Firth-Cozens

Organisational level (2)  Provision of training for: –Team leadership * –Stress management * – Doctors treating doctors –Good supervision and appraisal with training*  Counselling/Psychotherapy services*  Resources Jenny Firth-Cozens

Individual clinician level (1)  Throughout training :  Having own doctor – no self-prescribing  Recognition of stress, depression and PTSD in yourself/by others*  Recognition of alcohol abuse in yourself/by others*  Changing self-criticism*  Teaching successful coping *  Stress management*  Career counselling Jenny Firth-Cozens

Individual clinician level (2)  Throughout career:  Mentoring, personal coaching, counselling, psychotherapy *  Support at times of complaints, litigation, suspension  Advertised access to external agencies (AA, Relate, etc.)  The National Clinical Assessment Authority Jenny Firth-Cozens

Conclusions  High stress levels in doctors affect:  The doctor  Other staff  Resources – through recruitment and retention  Their patients  There is reasonable evidence for some individual and organisational predictors of stress and depression  Early interventions at the individual and organisational levels are a cost-effective way to better patient care through healthier staff