Healing our healers
Scrutiny of doctors' mental health is taboo. Hard-wired for perfection and dependability, the psychological well-being of physicians has traditionally been neglected, to the detriment of practitioners and patients alike. Recent news of an obstetrician being banned from one of Hong Kong's private hospitals, for an alleged assault on another staff member, provided a salutary reminder. In a collective bent to avoid ownership of the problem, the Medical Council, the Private Hospitals' Association and the Department of Health all denied jurisdiction. Conspicuous only by its absence was any rational attempt to examine the likely underlying cause of such uncharacteristic behaviour: prevalent levels of stress at work.
Stress in this context means an imbalance between work demands and perceived ability to cope. Workplace stress levels for doctors are almost double those of the general working population (30 per cent compared with 18 per cent). Stress is unhealthy because it impairs physical and mental well-being, disrupts family life and relationships, and compromises the ability to provide high-quality care. Occupational sources of stress include excessive workload, inadequate sleep, poor teamwork, bullying/harassment and complaints or litigation. Susceptibility is influenced by personal factors such as experience, coping mechanisms and personality type. The comorbidities of unremitting stress are the three Ds: disaffection, dependence and depression.
Prolonged exposure to high stress levels commonly leads to disaffection and professional burnout. This is characterised by diminished value of work, emotional exhaustion and depersonalisation. The prevalence of burnout in doctors can be as high as 50 per cent to 75 per cent, and correlates with suboptimal patient care and higher rates of malpractice litigation.
Dissatisfied doctors can become troubled doctors. In a recent British Medical Association survey of how clinicians cope with work and ill health, more than one-third admitted to self-prescribing; one in 10 used alcohol or drugs to help and 25 per cent were aware of colleagues doing so. International studies show that some 10 per cent of physicians develop a substance dependence.
Depression appears to be more common in doctors than the general population. This has important implications for manpower (40 per cent of doctors who retire early do so because of psychiatric problems) and for patient safety. Male physicians have double the societal rate of suicide, and alarmingly, female doctors have suicide rates up to four times that of the populace. Fearing loss of status, embarrassment and discrimination, doctors in difficulty typically seek help late. The culture of medicine is such that many doctors go to work when unwell, often concealing or denying their problems. Overall, doctors average less than three sick days per year, compared with eight days for the general population.
Doctors' welfare should be a priority for any health care system, and can be promoted by preventive and remedial strategies to combat stress. Periodic health assessments and mentoring by colleagues provide for early identification and help.
Like many other health care systems, resources for doctors in Hong Kong are inadequate and fragmented. While the Oasis project at the Hospital Authority provides useful stress management programmes, there are few avenues available to the 5,000 or so doctors working independently in the private sector. The fitness-to-practice rationale of the Medical Council Health Committee militates against this route except as a last resort. Health programmes and sick-doctor support networks have been successful elsewhere, and would be a welcome addition locally.
Psychological ill health does not inevitably lead to permanent professional impairment. When treated adequately, doctors with mental health difficulties can often return to work safely. It is time to acknowledge that doctors can have stress problems but need not necessarily become distressed problem-doctors.
Darren Mann is a clinical associate professor (honorary) at the Chinese University of Hong Kong and examiner in surgery of the Royal College of Surgeons of Edinburgh