versão On-line ISSN 2078-5135
SAMJ, S. Afr. med. j. vol.100 no.1 Cape Town Jan. 2010
Stressed doctors thrown an MPS lifeline
A little-known free counselling service used by stressed local doctors last year has been introduced in South Africa for members of the Medical Protection Society (MPS) following telling research in New Zealand and locally.
The service is highly confidential and not even MPS is aware of who is reporting a particular problem. Despite only 19 doctors using the service to date, many more have been referred by MPS but have yet to take up the offer.
Dr Tim Hegan, International Operations Director for MPS, told 600 doctors attending an ethics evening in Cape Town on 12 November that thoughts of suicide and quitting medicine had been discussed by some users of the service.
Referrals for psychiatric treatment and long-term counselling were also made. Others 'declined help owing to tight time constraints and feelings of inadequacy and pride' an alarmingly widespread malady.
Dr Hegan said that to monitor the wellbeing of those doctors who had declined counselling (for example, during professional conduct hearings), MPS made courtesy calls 'intermittently'.
All doctors presented with high levels of anxiety, depression and irritability, with one reporting feeling burnt out and others simply overwhelmed. Some presented with 'vegetative symptoms' like insomnia, poor concentration levels and a loss of appetite while two reported feeling 'harassed and victimised' because of pending law suits.
A rare 2006 study probing levels of occupational stress in doctors working in an unnamed South African public sector1 hospital revealed understaffing, inadequate resources, a lack of control and/or participation in planning, managing infectious patients and a lack of work security as major stressors.
Others were poor career advancement opportunities, difficult working schedules, salary structures and benefits and the negative and intrusive effect of work on their home life all cited as contributing factors to their strike by disillusioned public sector doctors during the Occupation Specific Dispensation wage talks in June last year.
The stress of taking a stand
A total of 252 public sector doctors have been asked by the Health Professions Council of South Africa (HPCSA) to provide written explanations on potential charges of dereliction of duty and 'refusing to attend to life-threatening emergencies' following the country-wide wildcat doctor strike last year. They will have to live with the unknown until the second half of next year, when case-by-case decisions are made on whether to progress to a preliminary hearing or not.
The 2006 local public sector study found that many doctors were using coping strategies significantly more than the standard population, yet their stress levels remained very high.
In New Zealand, where MPS co-introduced a similar counselling service in January 2006, an audit revealed that of all income security assurance payouts, a quarter were to doctors unable to work due to the stress caused by a patient complaint. The service was initially introduced for this reason but had since expanded.
A 2008 survey in New Zealand of 28 counsellors and their 39 clients revealed that those doctors who had more than 10 sessions suffered from depression, bipolar disorder, prior sexual abuse and personality disorders. Those with less than 10 sessions had pure work-related stress.
One doctor became psychotic and required immediate admission to psychiatric care. All reported benefit from counselling, the most valued aspects being confidentiality, provider independence and the service being offered for free.
Dr Hegan said private sector doctors were hardly immune to stress. The main stressors here were the lack of autonomy in managed care, high levels of patient demand on budget schemes, fear of being reported to authorities, poor take-home pay, draconian regulations, inability to access decision makers in their national health departments and the 'sheer load' of paperwork.
Complaint may be spurious but effect is not
A qualitative study of GPs against whom spurious complaints had been laid in New Zealand (i.e. complaints that did not proceed to a formal hearing) showed immediate intense negative emotional responses, including anxiety, anger and guilt. Respondents questioned their self-perceptions related to their functioning as a health care professional and experienced a reduced ability to consult with speed and confidence. They also suffered a debilitating loss of trust in the integrity of presenting patients.
Long-term effects included depression, anger, erosion of goodwill towards patients and the introduction of strategies to reduce the likelihood of further complaints (e.g. quicker or immediate referrals).
In a satirical but sobering analysis, Dr Hegan said stressors for doctors came from them being high achievers, perfectionists, strongly self-critical, 'five years of training in a booze-soaked student culture', regular exposure to death and human misfortune, never-ending exams/lifelong study and a strict hierarchal conservative training with a 'high degree of bullying and intimidation'. Doctors were also comparatively well paid, held in high regard by the public and had 'easy access to pharmaceuticals'.
They were faced with 'multiple jeopardy', where a single clinical incident could give rise to a complaint, claim, HPCSA enquiry, disciplinary action, hospital enquiry, inquest, criminal investigation and 'trial by media'.
The local counselling service is provided by Independent Counselling and Advisory Services (ICAS), a nation-wide body that specialises in providing support for professional organisations. MPS members can access it by contacting MPS's medico-legal consultants Dr Tony Behrman and Dr Liz Meyer; no details need to be provided in order to be referred. Dr Behrman (based in Cape Town) and Dr Meyer (Pretoria) are available 24 hours a day to offer advice and support to MPS members (contact details at the end of this article). Dr Hegan gave an undertaking that once referred, a member would be contacted within 24 hours to set up a consultation which would then occur within a week.
An Izindaba interview with an ICAS counsellor and his partner (chosen at random) revealed that 10% of their practice consisted of health care professionals, a third of whom were doctors referred by corporate and government bodies, not MPS.
The psychologists said they were most concerned about those health care professionals who did not seek help out of fear that they may be reported to the HPCSA or that their partners would 'find out that they were in therapy'.
'A huge percentage of doctors out there are in burnout that is associated with denial if they fail to get help they will inevitably reach a situation that they cannot handle,' one warned. Many doctors 'normalised' that they were OK in a situation that was anything but normal, an understandable trait if one remained in a situation long enough.
The take-home message to doctors was: 'Don't get complacent about the way you are feeling. If your heart sinks on your way to work on a Monday morning, listen to it. And if you feel you don't have empathy for your patients any more or that you're not gaining anything from you work, these are some of the danger signs,' she added.
The best way to avoid the 'blind spot of normalisation' was to ask close associates or family if they were noticing anything different about you.
A social worker and part-time lecturer at Stellenbosch University who offers 'self-care' workshops for health care professionals, Dr Mariette van der Merwe, said vital coping strategies included examining your case load, boundaries (including time), limit-setting and taking on manageable responsibilities.
Too many doctors 'bought' the mythical narrative of the knight in shining armour fighting dragons to save the lady in distress. However, the classic symptoms of burnout and vicarious trauma fatigue rendered their once shiny armour and sharp swords rusty and ineffective, 'often too late to prevent the armour from cracking'.
WMA President appeals for intervention
The president of the World Medical Association, Dr Dana Hanson, told the Global Forum of Health Leaders in Taiwan in November last year that the medical profession and governments should pay more attention to stress and burnout among physicians.
The medical profession 'must strive' to remove the stigma surrounding burn-out, while governments should address the problem, because healthy resilient physicians equalled longer professional lives and, more importantly, more accessible care for patients.
Hanson, a Canadian dermatologist, said that according to surveys in Canada and elsewhere, some 45% of physicians were in an advanced state of burnout, with an even higher figure in developing countries. He questioned why one physician thrived in their career while another experienced stress.
The answer seemed to lie in part in being able to manage and recover from adversity. Resilience meant rising to challenges, responding creatively, learning and growing. Physicians should not have to choose between saving themselves and serving their patients. Many physicians who were outwardly patient and enthusiastic were inwardly burning and finding their work less rewarding. The global shortage of physicians was also leading to chronic overwork and stress.
Hanson said that healthy physicians meant healthier patients, greater satisfaction, safer care and a sustainable workforce.
(To contact Dr Tony Behrman or Dr Liz Meyer of MPS, call 083 270 7439 or 082 653 5755, respectively.)
1. Thomas LS, Valli A. Levels of occupational stress in doctors working in a South African public sector hospital. S Afr Med J 2006, 96:1162-1168. [ Links ]