Doctors at breaking point

Doctors at breaking point

In hospital medicine the stakes are high, the workload demanding and the pressure unrelenting. Some doctors thrive but others burn out. Susan Field explores the causes and consequences of burnout and asks what can be done to help.

Eighty per cent of 1,000 respondents to a recent BMA survey rated the pressure they are under at work as high or very high. Their top three workplace stresses were meeting patients' demands, lack of time and excessive bureaucracy.

Of course, it is impossible to entirely remove the stress from medicine and many doctors flourish despite or even because of it. But surveys in the UK and the USA reveal the extent of the burnout issue. For example, in a 2012 poll of 7,288 US doctors, 45.8% reported at least one symptom, including 'extreme emotional exhaustion' and 'depersonalisation'. Those in the front line of care access, such as emergency medicine, were found to be at greatest risk.

Dr Mike Peters, head of the BMA's support service, Doctors for Doctors, believes that it's a growing problem in the UK too. He says: "One big factor is the fragmentation in the way care is delivered. Doctors are working different shifts so there is not the same camaraderie. At the same time, less invasive techniques and shorter hospital stays mean the turnover of beds in hospital departments is higher and there is a limited opportunity to establish a rewarding relationship with patients."

Then there is the sheer volume of information that doctors are expected to absorb, says Dr Sunil Raheja, a consultant psychiatrist and author of a Royal College of Psychiatrists learning module on managing stress. He observes: "It's the nature of modern life that we are all trying to work through more tasks in the limited time available while work, family and friends compete for our attention. We rely on technology to help but it can also be a hindrance because it is difficult to focus on one thing in the huge volume of information we need to process."

Studies of shift workers have shown that disrupted circadian rhythms can cause health problems but it may also be true that doctors are not always the best guardians of their own health.

In the foreword to his 2009 report into health and well-being in the NHS, Dr Steve Boorman notes a culture in which 'highly motivated staff do not always recognise the impact of their own health needs, and where early access to care is erroneously considered to risk disadvantaging patients.' The latest NHS sickness statistics for England show that NHS hospital doctors took an average of just 2.8 sick days in 2012-13, against a national average of 4.5 days, according to Office for National Statistics figures. Just 1.25% of hospital doctors were ill on an average day in 2012-13, the lowest rate of any staff group.

I wanted colleagues and patients to be able to depend on me so I kept up my usual routine, despite being in poor health. I thought I was heroically struggling by on one hour's sleep and painkillers but I didn't recognise how ill I was.

One consultant with first-hand experience of burnout recalls: "Working in a busy, under-resourced department, I wanted colleagues and patients to be able to depend on me so I kept up my usual routine, despite being in poor health. I thought I was heroically struggling by on one hour's sleep and painkillers but I didn't recognise how ill I was. I didn't consult a GP because I wasn't registered with one. I didn't even allow myself time to recuperate following surgery so it wasn't long before I relapsed. In short, I simply stopped thinking properly and didn't see that I was becoming a danger to others."

Compassion fatigue

The intense emotional engagement doctors have with their work is another important factor in susceptibility to burnout. Dr Emma Sedgwick, director of professional development at coaching specialists Healthcare Performance, estimates that burnout is a factor for 15-20% of doctors who seek her help with problems at work. She says: "Tragedies such as the death of a young patient invariably hit hard. Doctors can experience a sense of hopelessness, or even failure, when they have exhausted the treatment options for a patient. They are also often acutely conscious of the need to meet the expectations of patients, colleagues, employers and the GMC, and worry about letting others down."

Studies have shown that burnout is particularly associated with the caring professions. The author of a 1998 US report reflected: "Medicine attracts idealists who want to help others, but as professional demands increasingly impose on their available time and energy, more is crowded into the limited work day. The support which (was) granted to physicians in the past is not at hand [...] for many of the practitioners are far from their families and home towns, a great number settling in the area of their education and training. Their interactions are with patients who are in pain, sick or frightened. Rarely is a thank you proffered from a patient, practice is competitive, and the emphasis is on achievement, and the threat of a malpractice suit… constantly hovers over the physician."

Dr Sedgwick believes that doctors who suffer from burnout are often victims of circumstance. "They are usually undone by a malign alignment of several factors – a dysfunctional department, lack of support outside work, ill health, their own personality traits or a particularly traumatic adverse incident."

End of the line

Doctors who are on the verge of burnout will, according to Dr Sedgwick, typically experience symptoms such as loss of emotional response, short-temper leading to fractured relationships at work and at home, and what she calls 'Sunday night syndrome', an overwhelming dread of going into work the next day. She stresses, "This is not just an off-day. Burnout is a crushing emotional and physical exhaustion which leaves you unable to cope at work and at home."

Dr Peters reveals that those who contacted the Doctors for Doctors service experiencing burnout spoke of feeling isolated and ashamed that they are unable to cope. He adds: "It's not uncommon for them to distance themselves from patients as a survival strategy."

Indeed, the most disturbing consequence of burnout is that it can turn a good, caring doctor into a patient safety risk. The doctor may no longer be able to communicate effectively and sensitively with patients and may develop mental health difficulties, alcohol/substance abuse or musculo-skeletal problems, which affect their clinical judgment.

Sadly, as the consultant quoted earlier found, this can easily result in a serious untoward incident. "A number of things went wrong simultaneously, including a bad error of judgment on my part, and a patient was harmed," he says. "I was suspended and ultimately lost my job. Those were the worst times when everything seemed to spiral out of control. I was stressed about the way my case was being investigated, lonely because I missed the social aspects of work and felt I was falling apart."

Surviving burnout

Burnout is a real concern because doctors with the symptoms are often unable to admit they have a problem, says Dr Sedgwick. "While some might not recognise they are ill because their judgment is impaired, others might fear letting colleagues and patients down, or that the stigma of not being able cope will follow them throughout their career."

There is no doubt that admitting there is a problem can be difficult but doctors who do so can hope to recover from burnout and get back to work with appropriate practical support. For example, occupational health units can arrange phased returns to work and even make recommendations about adjustments to the working environment to help returning doctors. Doctors can also seek advice and support from their own GP or through services such as the Practitioners Health Programme (London and south east England) and the Doctors for Doctors 24-hour helpline. This service offers professional counselling or the opportunity to speak in confidence to a volunteer doctor adviser.

But while it is up to individuals to take the first step, it's also incumbent on employers and colleagues to respond sympathetically and appropriately. In helping burnt-out doctors to return to safe clinical practice they can encourage others to seek help and safeguard the best interests of patients.

For Dr Mike Peters, the issue of burnout requires both an internal and external response. "It requires doctors themselves to recognise that their condition is a risk to patient safety and not be too proud to ask for help. There also needs to be a cultural change so that 'presenteeism' is discouraged and doctors are encouraged to seek effective support at an early stage."

It has taken several years but the consultant has now got his career back on track at another hospital and is grateful to his new employers for giving him the opportunity and support he needed. He reflects: "Looking back, I feel I have learnt a major lesson the hard way. No one is indispensable. Taking time off when you're not fit to work is actually the professional thing to do and means you won't let colleagues and patients down."

A medico-legal view

Dr Catherine Wills, the MDU's deputy head of advisory services, offers medico-legal advice – and reassurance – for doctors affected by burnout.

  • You have an ethical duty to register with a GP outside your own family (paragraph 30, GMC Good Medical Practice). If you are unwell, it's important to get an objective assessment and not rely on your own assessment of your health or 'corridor consultations' with colleagues.
  • The GMC's online guide Your Health Matters advises doctors to 'note early warning signs of illness and take them seriously', suggesting that 'feeling low or irritable, or having poor concentration and low energy may be signs of burnout'.
  • If you know or suspect your judgment or performance could be affected by burnout, you must consult a suitably-qualified colleague (such as your GP, occupational health doctor or psychiatrist) and make any changes to your practice they advise.
  • Don't be tempted to self-prescribe to alleviate symptoms such as exhaustion or anxiety as this could leave you vulnerable to a GMC complaint. The GMC says cases involving self-prescribing or informal treatment of family and colleagues have increased from 36 in 2010, to 98 in 2012. In a review of the MDU's own files, some of the most common drugs involved in such allegations were benzodiazepines and opiates, suggesting the doctors involved were addicted or struggling to cope.
  • Contact the MDU for help if you are referred to the GMC with health concerns such as burnout. In many cases, we have helped members agree undertakings with the GMC at an early stage which minimises the strain involved and means they are able to carry on working.
  • In the MDU's experience, the GMC is sympathetic towards doctors with health problems if they co-operate with health assessments and show insight. The GMC's own indicative sanctions guidance states, 'Erasure is not available in cases where the only issue relates to the doctor's health'. However, MPTS panels can suspend doctors indefinitely if there is a risk to patients. Most commonly, the doctor will be asked to make undertakings or will be able to continue working with conditions (such as regular contact with a GP or attending AA meetings).
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