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Pressure points

anxious woman

A new study highlights the risk factors to doctors’ mental health, as the BMA introduces a charter to help employers ease pressure on the profession. Keith Cooper reports

Doctors’ mental health is under attack on multiple fronts from staff shortages, poor basic amenities, and the target-chasing and bullying cultures in the NHS, a major new study reveals.

The report, Mental Health in the Medical Profession, the latest in a series of BMA-commissioned studies in 12 months, pinpoints the chief pressures from interviews with medical students and doctors.

In response to its alarming findings, the association has launched a mental wellbeing charter to help employers prevent further harm to the profession.

The first study, released earlier this year, found eight out of 10 doctors are at substantial risk of burnout.

‘We are running from one thing to the other all the time, firefighting’

The studies are part of a larger project led by the association’s immediate past president and consultant psychiatrist Dinesh Bhugra.

‘If in the NHS, we can’t look after the staff, then we are in really serious trouble,’ he says. ‘This report is important. It helps us to begin to understand what is going on. Doctors are professional and for professional reasons they want to do their best: they agree to provide cover, which becomes unmanageable. There are so many rota gaps and vacancies, and now uncertainty related to Brexit.’

This latest study pinpoints five groups of ‘risk factors’ flagged by doctors from interviews and focus groups: systemic; endemic; interpersonal; environmental; and socio-cultural (see below).

It suggests that doctors often attempt to manage their mental health by requesting more flexible working arrangements. When denied they are left ‘feeling their proactive attempts to help themselves are futile’.


Lack of flexibility

Doctors often feel unable to request time off or reduced hours for concern their posts won’t be filled.

‘Your colleagues have to pick up the slack and it just makes everyone else’s jobs even more difficult,’ one GP partner with a diagnosed mental illness told researchers. ‘People are just very busy. If you have to book a day off, who’s going to cover your work?’ a consultant said.

The report found that doctors returning to work after illness were frequently not offered ways to ease their transition, such as phased returns or reduced hours.

Even requests for flexible hours for childcare were ‘typically dismissed’, several female doctors told the researchers, ‘as though family life and caring for children are deemed less important than work’.

‘I got bullied by a registrar and there was some belittling going on and again just lack of support’

While many of the ‘risk factors’ isolated from the interviews are within the profession’s power to change, others are outside its control, such as ‘socio-cultural’ ones. They include the increased tendency of patients to ‘self-diagnose’ or request treatments they find on the internet, and the feeling that ‘public sentiment’ is turning against them.

‘Quite rightly, now you have to explain things to your patients and you have to give people choices,’ one salaried GP with diagnosed mental ill health said. ‘But the idea that you can do that in the same amount of time as when you would… say, “just take the pink tablet”, it is peculiar.’

Professor Bhugra believes the new mental health charter will be a major step forward if employers sign up. But more needs to be done to identify and ease pressure on stress points on the profession, he says. ‘We can do things differently.’

Find out more about the charter

Find out about the BMA's wellbeing support services


Five areas taking the greatest toll on doctors:

Systemic: what comes from above

This is the ‘backdrop’ to everything else in your working life – things coming down from above, such as restructures, changes to working practices, often as a result of cost cutting. They include: understaffing; rota gaps; consultation time slots of 10 minutes; and in general, less and less time to look after patients.

‘We are running from one thing to the other all the time, firefighting,’ said one consultant with symptoms of mental ill health but no formal diagnosis.

‘It just feels like we’re being stretched thinner and thinner. Patients are getting more and more of a poor service,’ said a junior doctor.

Such factors leave many feeling overwhelmed, anxious, and unable to perform at their best.

Respondents called for greater flexible working arrangements for a better work/life balance, longer appointment slots, and the ability to work shorter hours. All could reap rewards longer term by reducing resignations and early retirement.


Endemic: what comes with the job

Most doctors by definition are exposed to trauma. Over the course of careers such experiences build up and up.

Interviewees felt they had no one to offload to or ‘deconstruct’ them. The result can be anxiety, several doctors told researchers.

‘There was a child, a toddler who choked to death on his vomit in an afternoon nap and was found by a teenage sibling,’ said a consultant with symptoms of mental ill health but no formal diagnosis. ‘It was too overwhelming, too close to home.’

The pressure to keep up to date in an increasingly complex profession are also risk factors for mental health, the research says. ‘Scientific improvement in the management of patients is mushrooming,’ said one salaried GP.

‘There is patient pressure, scientific pressure and employment pressure.’ The report calls for more peer support, especially for junior doctors. Each hospital could build a peer support network.

‘Having a named doctor would be good or perhaps just be paired with another medical student from a [later] year,’ one medical student said.


Interpersonal: what comes from your colleagues

While many doctors think stigma around mental health is decreasing, it lingers still.

Junior doctors worry about being seen as ‘weak’ by superiors. Some older, male doctors remain dismissive of mental ill health, the researcher said.

‘In my time, I don’t think it was the right thing to do to talk about mental health issues,’ one consultant said. ‘People immediately think “oh dear, the poor chap is incapable” whereas that isn’t necessarily so.’

While doctors say some element of hierarchy is necessary in hospital, trainees feel unable to talk to senior colleagues for fear of a ‘judgement that they just aren’t up to the job’, researchers heard. In some cases, they felt ‘bullied’ and ‘belittled’ by seniors.

‘I got bullied by a registrar and there was some belittling going on and again just lack of support,’ said a salaried GP with a formal mental health diagnosis.

A more open attitude to mental ill health should be fostered at medical school, doctors told researchers. In the workplace, this could be done through inductions, workshops, and the appointment of a ‘mental health champion’.


Sociocultural: what comes from the world

These are significant stress points for doctors, albeit ones outside their sphere of influence.

Patients arrive more informed (or misinformed) about their condition.

More come armed to appointments with pages of downloads or ideas about what the ‘best possible treatment’ they found on the internet is.

GPs must spend time in short appointment slots explaining why treatments are not there in the NHS.

‘Patients expect us to be there all the time and get back to them straight away,’ one salaried GP said. ‘So there’s definitely a lot of pressure in terms of patient expectation.’ Some doctors said they felt undervalued by the public, prompting questions about their career.

‘We need a sense of being appreciated by physicians, surgeons, and hospital specialists as well as by our patients.’

The BMA has a role to continue to act as a voice for the profession, the report indicates. The Government could be more honest with the public about what services resources allow.


Environmental: what comes from your workplace

Doctors’ jobs have got harder as facilities and resources, such as mess rooms, are closed – and many have been.

All interviewees felt their workplaces lacked basic amenities. There is nowhere to cook or prepare food away from patients, no personal space, such as lockers. As a result, many are left feeling undervalued.

Lack of breaktime leaves little or no space for doctors to socialise and relax together, leading to feelings of loneliness and isolation. ‘Any break you get is the time to walk to the sandwich shop and back,’ one salaried GP said. ‘Some days you don’t even get that.’

Protected lunchtime and coffee breaks and dedicated socialising space could help reduce professional isolation, the report recommends.

Efforts to address poor facilities are already under way, of course, with the BMA Fatigue and Facilities Charter. Hospitals could also help by earmarking parking spaces close by and by providing showers.

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