ASMOF (1998-2003)

NSW Doctors’ Mental Health Implementation Committee (Since 1998; Author of Literature Review 1999; First author of revised version)

Dissertation (RANZCP): “Developing a Doctors’ Mental Health Web Site Resource” (1999)

Medical Benevolent Association of NSW (since 1998)

3rd National Doctors' Health Conference 2003 Sydney NSW (Conference organising committee)

Distress is caused by an identifiable external stressor

Disorders result from an interaction b/w personal vulnerabilities and external triggers

are overlapping concepts

When a disorder (be it physical or mental) interferes with a doctor’s capacity to practice medicine with safety

Adverse effects if untreated

Consider referral to IRP if pose risk

Intervention is likely to reduce any risk

96% of 265 impaired doctors referred to NSW MB b/w 1981-2001 had a mental disorder (incl. D&A) (Petherbridge et al, 2002)

Harmful behaviours towards patients that are conscious or wilful 

Boundary violations (sexual & non-sexual), assault, fraud

Behaviour causing workplace difficulties, decreased morale in staff & decline in patient care

Sexual harassment, racial slurs, intimidation, abusive language, persistent lateness in responding to calls

Impairment due to a mental disorder found in ½ the complaints to US medical boards

Large random study of NSW medical practitioners (n=1,125) by questionnaire:

	19% marital disturbance
	18% "emotional disorders“
	3% alcohol problems
	1% drug abuse

Study design: inconsistent sample groups, uncontrolled, small numbers, retrospective, rating scales of psychological distress rather than structured diagnostic instruments

Focus on depression & drug use

Most studies European & North American

Neglect of changes in demographics

Neglect of GPs, private specialists & rural doctors

Terminology describing dysfunctional doctors used synonymously 

Large Canadian study of interns, RMOs and specialists (n=1,805): 

	23% had significant depressive symptoms on self-rated questionnaire (c/w 15% in community studies)
	Female doctors 2x as likely to be depressed
	Highest rates in: O&G RMOs > interns, psychiatry RMOs, radiology, anaesthetics, surgery & paediatrics

Multiple overseas studies (esp N American) have found significant rates of depression (& marital problems) in ~ 30% of interns

Prospective 1-year study on NSW interns (n=130) with GHQ & BDI: 

	Found similar scores at start & end of year, few episodes of mood disorder when asked at end
	However: 72% reported "often" experiencing significant episodes of anger through the year

Drs more prone to suicide than gen pop 

>3/4 of doctors who suicide are depressed & D&A probs often significant 

Men: meta-analysis indicated odds ratio of 1.41 compared with general population 
(Schernhammer 2004)

Women: meta-analysis indicated odds ratio of 2.27 compared with general population 
(Schernhammer 2004)

Over-represented specialties: anaesthetics, GP, psychiatry & emergency medicine

Also: young doctors, rural doctors & doctors on conditional registration

Higher in the medical profession than the gen pop, esp UK studies (Rucinski & Cybulska, 1985)

3½ x greater death rate from cirrhosis than gen pop

Alcoholism is the major cause of impairment in doctors >50 yo 

Older doctors more likely to have marital problems before & after alcohol misuse 

Assoc with: adverse childhood experiences, older age, career dissatisfaction, high stress, smoking & benzo use 

0.5-1.3% of the medical community in Australia (Cadman, 1995; Lonie et al, 1994)

Higher rates of drug dependency than pharmacists, dentists & veterinary surgeons in the international literature

Family background, personality traits & stress of practice argued to be the major factors

Trainee anaesthetists a particularly at-risk subgroup 

Retrospective r/v of file notes of 79 NSW doctors who had access to prescribe opiates revoked (1985-94) for self-administering opiates:

	Most abused pethidine
	Over-representation of rural GPs & ED doctors
	Majority in 30s
	Those >45 yo had medical conditions & were depressed
	>15% said depression was a factor in their drug use
	3/10 deaths were suicides (3.8% of total)
	>20% consulted a psychiatrist for non-drug problems prior to ID

PTSD - burnout & vicarious traumatisation

Panic disorder

High anxiety traits

Difficult childhoods, such as exposure to family members with mental disorder, may attract study in medicine (Vaillant, 1972)

Half of doctors in a longitudinal study had unsatisfactory marriages c/w one third of controls (Vaillant, 1972)

…due to personality factors & communication styles (Gabbard, 1987) 

Intellectual challenge (91.3%)

Altruism (85%)

Earn others’ approval (38.6%) 

Parental pressure (33%)  

Social status

Job security

Obsessionality / Perfectionism / Rigidity

Poor emotional expression

Poor coping skills to deal with stress

Self-sacrificing

High expectations of selves

Replace own needs with those of their patients

Ambitious

Low tolerance for uncertainty

There is a considerable body of opinion which suggests that doctors & their spouses:

	make difficult patients
	have complicated stormy illness courses
	poorer outcomes
	receive less than ideal treatment from their colleagues

Doctors avoid entering the patient role 

Prefer self-diagnosis & treatment 

Collective denial & resistance within the medical community

Fear exposure, stigmatisation & loss of credibility

Fear loss of control 

Fear hospitalisation

Fear loss of medical registration

Avoid expending time obtaining formal consultation

Overconfidence in their ability to remain objective

Acceptance of using drugs to combat distress & a ‘physician heal thyself’ mentality within the medical subculture

Guilt & shame 

Collective denial of medical community

Stigma of mental illness /psychiatry

Helplessness & loss of control is particularly threatening to doctors accustomed to power, authority and control

Narcissism

Society’s fantasy of doctors as omnipotent & invulnerable 

Unwillingness to give up on ‘illusions’ of grandiosity & indispensability

Negative stereotypes may adversely influence likelihood of referral to a psychiatrist, doctor proceeding with a referral, rates of dropout & compliance

Medical students attitudes: 

	To psychiatry:  lower prestige unscientific imprecise outside mainstream
	To psychiatrists:  fuzzy thinkers aloof self-centred poor communicators lost general medical skills
	To psychiatric patients:  hard to like/ identify with/ develop therapeutic alliance/ treat

Avoidance & denial 

Self treatment

Corridor consultations

Identification as ‘special patients’

Doctors prefer to avoid treating colleagues

Doctors don’t manage doctors well: 

	under-treatment
	mistreatment occurs

There are pitfalls & difficulties: 

	privacy
	confidentiality
	denial
	boundary setting
	control issues

The most difficult problem for the treater is over-identification with the doctor-patient

Treating doctors might feel intimidated, embarrassed or anxious treating fellow doctors

They might respond by rescuing: 

	being overindulgent
	overanxious
	overprotective

They might respond by being defensive & denying: 

	avoiding
	rationalising
	minimising the severity of the illness due to denial and discomfort

MVA mortality = 2x gen pop … related to long & disruptive work hours?

Impact of shift work & extended hours on sleep patterns & personal life of JMOs in hospitals

‘Job burnout’ associated with: high workload, accumulated amount of face to face clinical work, inadequate resources, treatment failures, diagnostic difficulties

Doctors experience continuous exposure to traumatic stimuli, in the face of clinical responsibility to relieve suffering

Frequent confrontation with ethical dilemmas

Competing needs of patients Vs family

Young doctors

	Overwork
	Sleep deprivation
	Dealing with death & suffering
	Unreasonably demanding consultants
	Concerns about competence
	Talking to psychiatric patients
	Presenting cases

Specialists working in acute medical settings

	HIV medicine
	Oncology
	ED
	ICU

Isolation

	Professionally
	Geographically

Industrial climate of economic rationing & waning resources

Consumerist movement of increasing demands for accountability … legislative & medicolegal

Rising tide of public mistrust & negative public depictions of the medical profession

Increased levels of external control & scrutiny: managed care, Govt control, HCCC, Med Board

Distress described in the literature as countertransference,  burnout and vicarious traumatisation, which are overlapping concepts

The activation of the therapist's unresolved or unconscious conflicts or concerns.

“The therapist's old scars and injuries are constantly rubbed anew" (Freudenberger & Robbins 1979)

Identification with & transference of feelings from patient

Symptoms include nightmares, intrusive images, reenactments, amnesia, estrangement, alienation, irritability, psychophysiologic reactions and survivor guilt 

The result of psychological strain from working with difficult populations. 
Symptoms include:

	Depression
	Cynicism & discouragement
	Boredom & loss of compassion (Freudenberger & Robbins 1979).
	Feelings of inadequacy or incompetence (Deutsch 1984)

Contributing factors:

	High workload
	Accumulated amt face-to-face clinical work
	Professional isolation
	Emotional drain of always being empathetic
	Non-reciprocated giving & attentiveness (Farber & Heifetz 1982)
	Failure to live up to one's own (perhaps unrealistic) expectations
	Diagnostic difficulties
	Treatment failures / ambiguous therapeutic successes (Bermak 1977)
	Inadequate resources

Doctor's unique responses to patient material shaped by both characteristics of the situation & doctor’s unique psychological needs & cognitive schemas (McCann & Pearlman 1990)

Just as PTSD is viewed as a normal reaction to an abnormal event, VT is a normal (inescapable?) reaction to working with highly traumatised patients/families.

Signs of VT:

	Damage to hope, idealism & optimisim
	Cynicism / withdrawal
	Depersonalisation of patient
	Sleep problems / fatigue
	Resistance going to work / sick leave
	Feeling like a failure
	Increased consumption of D&A

Give or receive supervision/consultation/support

Exert control where possible over your client load and distribution

Find a good balance and variety of tasks

Give or receive education or training

Make your work space a comfortable, nurturing place for you

Seek collegial support

Find/create forums to address VT

Ask that supervision/consultation be available in the workplace

Demonstrate respect for helpers and their clients

Ask for more resources (e.g., mental health benefits, space, time)

Make your personal life a priority

Seek personal psychotherapy

Enjoy leisure activities: physical, creative, spontaneous, relaxing

Attend to your spiritual well-being, whatever that means for you

Nurture all aspects of yourself: emotional, physical (diet, exercise,
sleep), spiritual (e.g., religion, time in nature, etc.), interpersonal,
creative, artistic

Pay attention to your physical health

Practice mindfulness and self-awareness: be aware of the potential for
VT, your own personal risk factors, and what you need

Nurture yourself

Seek balance between work, rest, and play

Re-establish meaning and connection (with yourself, with your work,
with others)

DHAS for medical assistance, advice, referral www.doctorshealth.org.au 

MBA for social worker support, counselling, financial advice, financial assistance & support for doctor & their family www.mbansw.org.au 

Also: ASMOF, MDO, Medical Boards