Risk Factors for Ill-Health in Doctors Jenny Firth-Cozens London Deanery of Postgraduate Medical...

Risk Factors for Ill-Health in Risk Factors for Ill-Health in DoctorsDoctors

Jenny Firth-Cozens

London Deanery of Postgraduate Medical Education, University of London

• Resources • Government control • Professional status • Patient expectations

- Litigation , illegal drug use , elderly • Media highlight the bad, never the good

The issues facing doctors today

The emotional context of riskThe emotional context of risk

‘Patients and physicians … live and interact in a culture characterized by anger, blame, guilt, fear, frustration, and distrust regarding healthcare errors. The public has responded by escalating the punishment for error. Clinicians and some healthcare organisations generally have responded by suppression, stonewalling, and cover-up.’

Leape et al., 1998

Clinical Governance

Stress of HealthService Staff

Quality of Patient Care

Clinical Governance, Staff Stress and Quality

The studies involvedThe studies involved Longitudinal study of 318 4th year medical students from

1983, followed up in 1985, 1993, and 1999 looking at long-term predictors of stress, depression, alcohol use and speciality

Longitudinal study of 126 pre-registration house officers with different types of rotations, 2000

Study of all general practitioners over 45 in north-east England, looking at predictors of early retirement, 2001

Study of all senior registrars in north-east England, looking at training, stress and gender/specialty differences, 2000

Jenny Firth-CozensJenny Firth-Cozens

Aims of this series of studiesAims of this series of studies

To look at individual and organisational predictors of stress, depression, alcohol use and early retirement in the workplace

To relate this to performance/error

To look at individual and organisational interventions

Jenny Firth-Jenny Firth-CozensCozens

18

30

26

32.4

42.7

29.4 2929.2

17.9 16.8

0

5

10

15

20

25

30

35

40

45

BritishWorkers(1993)

Mental HealthWorkers

Anaesthetists MedicalStudents

Junior HouseOfficers

Junior Doctorsand GPs

SeniorDoctors

% a

bo

veth

resh

old

GHQ above 3

Depression (SCL-90)

Stress (GHQ) and depression (SCL-90): Stress (GHQ) and depression (SCL-90): Proportions above thresholdProportions above threshold

Jenny Firth-CozensJenny Firth-Cozens

Consistency of stress levelsConsistency of stress levels

GHQ1 GHQ2 GHQ3

GHQ2 .25**

GHQ3 .11 .20*

GHQ4 .08 .34** .27*

Jenny Firth-CozensJenny Firth-Cozens

High alcohol use over timeHigh alcohol use over time

% scoring 4:A lot on occasions

% scoring 5:A lot most of the time

Students 17% 4%

PRHOs 14% 5%

SpRs/GPs 6% 5%

Senior doctors 10% 4%

Jenny Firth-CozensJenny Firth-Cozens

Consistency of alcohol use Consistency of alcohol use in senior doctorsin senior doctors

All Men Women

Since students .25** .20* .31**

Since PRHOs .27** .27* .30*

Since SpRs .34*** .44**

.28*

Jenny Firth-CozensJenny Firth-Cozens

Alcohol use and copingAlcohol use and coping

“I sometimes have an alcoholic binge after the death of an ITU patient which hurts particularly”“I think there is a general trend in juniors to do little exercise, even when they have time off, as they are so tired, so socialising with alcohol is much easier’

Time pressures in medicine were such that young doctors may not have had a chance to develop other ways of coping.

Alcohol useAlcohol use Women doctors have greater problems than

other women professionals Hospital doctors are using alcohol more to

cope, especially women hospital doctors The more complaints against you, the more

you use alcohol to cope

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Ideal age for GP retirementIdeal age for GP retirement

0

10

20

30

40

50

55 orbefore

56-59 60 61 or later

Ideal retirement age

Pe

rce

nt

A. Luce, J. Firth-Cozens, T. van ZwanenbergA. Luce, J. Firth-Cozens, T. van Zwanenberg

Predictors of desire to retire earlyPredictors of desire to retire early

• Role Satisfaction – predicted by:– Teamwork (.4)– Stress (.5)– Physical health (.2)

• Younger Age• Shorter consulting times

And doctor satisfaction predicts patient satisfaction, no-show rates, compliance etc.

Effects of Stress, depression, etc. Effects of Stress, depression, etc. on patient careon patient care

Cognitive function – decision-making and concentration – are affected for more than half the working day during depression.

Raised psychological symptoms of stress and depression are linked to reporting making more errors. But highly stressed are also more self-critical.

Mental “resilience” and adaptability of surgeons lead to better outcomes (Carthey et al, 2002).

So, what are the predictors so that we can intervene early?

Jenny Firth-CozensJenny Firth-Cozens

Individual predictorsIndividual predictors

GenderFamilyCopingPersonalityCareer choice

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Gender DifferencesGender Differences

Women are not significantly more stressed, but they are:

Significantly more depressed (p<.05) with an increased risk of suicide compared to the general population

Drinking the same as men Using alcohol more to cope (p<.05) especially if

they have children

Gender differences and Gender differences and depression (mean SCL scores)depression (mean SCL scores)

Men Women

General Practitioners .80 .83

Hospital doctors .62 1.12

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0

2

4

6

8

10

12

14

16

18

1

% above GHQ threshold

Fathers

Not fathers

Mothers F/T

Mothers P/T

Not mothers

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Proportions scoring above threshold on the Proportions scoring above threshold on the GHQ for male/females with and without children, GHQ for male/females with and without children,

working full-time and part-timeworking full-time and part-time

Personality and stressPersonality and stress

Self-criticism – high and low Very high self-esteem – grandiosity Rigidity Perfectionism: OCD, anxiety,

depression

DEPRESSION IN SENIOR DOCTORS

Factors as students: ALL MEN WOMEN

Self Criticism .21* .21 .17

Uncomfortable with Father -.25** -.16 - .35**

Uncomfortable with Mother -.10 -.25* - .02

Father’s age .28*** .40*** .20

PRHO Depression .20* .42*** .08

Clinical difficulty as students .15* 17 .13

Academic difficulty as students .17* .14 .20

Current factors as senior doctors:

Sleep -.17* -.25* -.15

Hours of work .06 .20* .04

Feeling part of a team .33*** - .35*** -.33**

Bed responsibility .03 .01 .27*

Individual & Work Factors andRelationship to Depression

Coping StyleCoping Style

Resilience to stress has been shown related to:

Tackling the problem (control) Low avoidance or denial Positive comparisons Less venting

Depression & Stress in Different Depression & Stress in Different SpecialitiesSpecialities

Speciality N Depression (Time 4)

Stress (Time4)

Depression (Time 1)

Stress (Time1))

PRHO Depression

PRHO Stress

GenPractice 10 0.79 12.9 4.5 11.5 1.1 12.3 Psychiatry 10 1.16 16.0 6.1 13.4 1.6 14.3 General Medical

24 0.84 11.9 4.0 11.5 1.1 12.7

Surgery 9 0.73 10.6 3.9 10.5 0.8 9.5 Anaesthetics/ radiology

12 0.78 11.57 4.8 13.0 1.1 13.3

Laboratory & PHM

11 1.07 11.89 6.1 12.7 1.4 15.5

Mean GHQ scores in 1987, Mean GHQ scores in 1987, by choice of future career in 1996by choice of future career in 1996

0

1

2

3

4

5

6

7

General Medicine General Practice Paediatrics

Psychiatry Surgery Anaesthetics

PJ Baldwin, M Dodd, RW Wrate, Young doctors: work, health and welfare (1997)

The role of the organisation in The role of the organisation in creating stress and dissatisfactioncreating stress and dissatisfaction

Managerial/organisational factorsManagerial/organisational factors

Borell et al (1996): Significant differences in stress levels between Trusts (17% - 33%). Large Trusts worse than small ones:

“The mental health of staff is better in Trusts characterised by greater co-operation, better communication, a stronger emphasis on training, and greater discretion for staff”

Stress levels of the PRHOs in July Stress levels of the PRHOs in July at individual hospitalsat individual hospitals

Hospital N Mean GHQ

A 6 15.33

B 10 12.90

C 21 11.95

D 14 11.57

E 11 11.45

F 8 11.00

G 3 10.67

H 16 10.38

I 19 9.89

J 12 9.83

K 6 9.67

L 10 9.10

M 7 8.14

Jenny Firth-Jenny Firth-CozensCozens

Work factors creating stress:Work factors creating stress:

Senior DoctorsDealing with complaints against meFear of making mistakesFear of litigationThreat of violenceOverwork/Lack of sleepConflicts between career and personal life

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0

2

4

6

8

10

12

14

16

18

20

Mean GHQ Score

GHQ Score 17.23 10.04

Poor Team Membership Strong Team Membership

Quality of team and stress levelsQuality of team and stress levels

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Multi-disciplinary teamwork for Multi-disciplinary teamwork for PRHOsPRHOs

Less stressed*

And significantly more positive about: Skill use*** Support** Workload*

Jenny Firth-CozensJenny Firth-Cozens

Only 42% (n=59) said they were part of a

multi-disciplinary team. They were significantly:

Differences in stress for two Differences in stress for two different HO rotationsdifferent HO rotations

2 x 6-month rotations in different organisations 3 x 4-month rotations in single organisation (the

12-month rotation)

By end of year only 10.3% (n=3) of 12-month HOs were scoring above threshold on the GHQ compared to 25.4% (n=29) of those on 6-month rotations.

Jenny Firth-Jenny Firth-CozensCozens

The risk factors in summary:

Individual risk factors for Individual risk factors for stress & depressionstress & depression

Depression as students (especially males) High alcohol use as students (especially females) Female hospital doctors with children Older fathers (especially males) High self-criticism and/or perfectionism Wanting to be a psychiatrist/pathologist Coping by denial or avoidance Complaints or litigation

Organisational risk factorsOrganisational risk factors

Poor leadershipPoor teamwork (not recognising multi-

disciplinary support etc.)? Larger trusts and teaching hospitalsSleep loss/hours of workPoor job design – (peripatetic, consulting

times, roles for older doctors, paperwork)Bullying punitive culture – from the top

Sleep Relationships Support Mistakes Litigation

Personality Coping Competence

Unclear goals Communication Supervision Teamworking Information Systems Blame culture Resources

Latent Organizational Failures

Stressors Doctor Impairment

Stress Depression Alcohol Drug Abuse

Poor Patient Care

Litigation Complaints TEAM

Management Prevention & Intervention

Team leadership training Data

Individual preventive work Training & development Own Doctor Career Clg Selection Student mood

Assessment Centres Counselling Psychotherapy AA Medication Suspension

Better Communication

A systems approach to the causes of poor patient careA systems approach to the causes of poor patient care

Jenny Firth-Jenny Firth-CozensCozens

ConclusionsConclusions High stress levels in doctors affect:

The doctor Other staff Resources – through recruitment and retention Their patients

There is reasonable evidence for some individual and organisational predictors of stress and depression

Early interventions at the individual and organisational levels are a cost-effective way to better patient care through healthier staff

Interventions for stressInterventions for stress

At the professional level At the organisational level At the teams level At the individual level

Professional levelProfessional level

Pre-entry information

Provision of mentoring and personal coaching

Helpline

Doctors with children

Addressing the length of the consultant’s career

SelectionJenny Firth-CozensJenny Firth-Cozens

Organisational level (1)Organisational level (1)

Better leadership* Good communication* Increasing participation in decision-making* Providing child care for parents Creating a fair culture* Clarity of organisational aims and

expectations* Reasonable hours and sleep* Systems for early recognition of problems

Jenny Firth-CozensJenny Firth-Cozens

Organisational level (2)Organisational level (2)

Provision of training for:– Team leadership *– Stress management *– Doctors treating doctors– Good supervision and appraisal with training*

Counselling/Psychotherapy services*

Resources

Jenny Firth-CozensJenny Firth-Cozens

Individual clinician level (1)Individual clinician level (1)

Throughout training:

Having own doctor – no self-prescribing Recognition of stress, depression and PTSD in

yourself/by others* Recognition of alcohol abuse in yourself/by others* Changing self-criticism* Teaching successful coping * Stress management* Career counselling

Jenny Firth-CozensJenny Firth-Cozens

Individual clinician level (2)Individual clinician level (2)

Throughout career:

Mentoring, personal coaching, counselling,

psychotherapy * Support at times of complaints, litigation,

suspension Advertised access to external agencies (AA, Relate, etc.) The National Clinical Assessment Authority

Jenny Firth-CozensJenny Firth-Cozens

ConclusionsConclusions High stress levels in doctors affect:

The doctor Other staff Resources – through recruitment and retention Their patients

There is reasonable evidence for some individual and organisational predictors of stress and depression

Early interventions at the individual and organisational levels are a cost-effective way to better patient care through healthier staff