Anaesthetists

not  magnify  mistakes  and  minimise  successes.  Avoid  emotional

reasoning  and  seeing  oneself  as  responsible  for  negative  external

events.  Try to learn from the bad experiences of yourself and others

to avoid similar problems in the future. Look at the bottom line and

know what is really important.

6.

Efficient Time Management

Efficient use of time conflicts with the  excessive  and  unreasonable

demands which are often part of the work place environment.  It is

fundamental not to take on more than can be realistically coped with

although most of us may be guilty in this respect. Demands, if not

realistic and legitimate, should be rejected.  

SECTION IV - STRESS MANAGEMENT

11

It is fundamental to establish priorities and to distinguish between the

urgent, the  important  and  the  unimportant.  It  is  important  to  be

selective in tasks to be done, to allocate appropriate time to them and

also to do things well but not obsessively. The most  difficult  tasks

should be undertaken  when  fresh  and  it  is  better  not  to  postpone

unpleasant matters.

It is useful to take a critical look at one’s use of time and to analyse

those factors which interrupt and steal time.  There is a tendency to

delay difficult tasks and it is usually better to do important projects as

early as possible.  There is also a responsibility to delegate to others

and so to increase the experience of the whole team thus adding to its

strength.

SECTION V - STRESS SUPPORT

12

SECTION V - STRESS SUPPORT

1.

Personal and Professional

When difficulties do occur there are many steps which can be taken

both to care for the affected doctor and at the same time to ensure

that the paramount concern for patient safety is preserved.

Recognition of stress in oneself or in a colleague and the acceptance

that there is a real problem is fundamental though it may be difficult

or unpalatable.  Discussion of the perceived situation with a friendly

but uninvolved colleague may be all that is required to  put  matters

right and return affairs  to  the  correct  perspective.    Such  informal

counselling or mentoring is often a valuable method of gaining insight.

There must be a follow up to confirm that the situation is resolved.  

When the symptoms are evidence of a more severe reaction to stress,

then access to training in relevant areas of stress management should

be sought.  The sources of the problem need to be identified and a

strategy constructed to counteract them.  Stress in medicine is very

common  but  good  relationships  within  directorates,  objective

friendships and an understanding general practitioner usually resolve

the majority of stress problems.  Their changing  role  has  perforce

brought Postgraduate Deans into a pivotal  position  in  dealing  with

problems affecting trainees and the Clinical Psychology Department

may  be  helpful.    Anaesthesia  Directorates  must  be  aware  of  the

support mechanisms which are available; they should be organised to

find and supply such support and training when needed.

Doctors in need of medical care have the same NHS services available

to them as do the rest of  the  population  but  may  have  particular

difficulties in the role of patient, the antithesis of the doctor’s normal

activity.  Doctors are often reluctant to accept the need for help and

may put off seeking it until their condition becomes too severe  to

ignore.  All doctors should be registered with a general  practitioner

with whom they have an easy professional relationship formed in an

atmosphere of mutual trust and respect. This is essential but is often

lacking.  Hospital  doctors  have  a  tendency  to  bypass  the  general

practitioner  and  to  think  they  know  best  while  the  general

practitioner is  often  wary  of  the  hospital  doctor’s  expertise.    All

doctors should be discouraged from self diagnosis and especially self

treatment.

SECTION V - STRESS SUPPORT

13

While there may be problems in helping doctors with physical illnesses

the real problems seem to arise with non physical problems such as the

effects of stress, possibly compounded by the misuse  of  alcohol  or

drugs.  At a local level, there may be a variety of initiatives offering

types of support ranging from the Director of Medical Administration

in some hospitals through the Occupational Health  Services  to  the

Three Wise Men procedure.  At national level the Association’s Sick

Doctor Scheme and the National Counselling Service for Sick Doctors

are confidential and have no immediate risk of any backlash.  The

Health Committee of the GMC can also be useful but while initially

confidential, it is perceived  as  close  to  statutory  restriction.    The

move to NHS Trusts and the organisation into clinical directorates is a

major shift in structure and climate of the workplace of the hospital

doctor.  The full effects of these changes still have to be assessed but

to date the fears of a less sympathetic  employer  for  doctors  have

proven groundless.

Unfortunately, all too often the first words which a doctor hears when

performance is suboptimal are those containing threats of discipline or

complaint.  This  can  occur  because  of  directorate  inexperience  or

because the  situation  has  been  allowed  to  develop  to  an  advanced

stage.  Directorates should therefore establish procedures to recognise

and  cope  with  stressed  members  at  an  early  stage  offering  them

realistic help and support to change both the job and the way they

cope.  Directorates are in a position to audit present working practices

and  to  press  for  and  contribute  to  more  efficient  management,

realistic work plans and constructive planning for the future.

In severe stress, often the most formidable step is to get the affected

person to admit that all is not well.  There has to be acceptance that

there is difficulty coping either at home, at work or often in  both

areas and the next step then involves admitting the problem to others.

There are now in existence completely confidential  advice  systems

which can be very efficacious (vide infra).

There is a clear methodology for approaching any of the schemes.

Remember it is important that the person in need realises that they

are not unique or alone, nor are they abnormal even if that is how

they may feel at that moment.  Many people have had difficulties at

some time in their lives and have found a way to cope with them.

These people and others are sympathetic and often have worked out

systems and strategies which others may find useful.

SECTION V - STRESS SUPPORT

14

When doctors, whether due to stress, illness or a combination of both,

prove  incapable  of  coping  with  their  work  and  when  the  general

measures so far outlined have proved unable to rectify the situation,

there is need for a more radical approach to the situation.  In extreme

cases the doctor may have adopted methodologies of self treatment

which could be detrimental to patient safety.

2.

Support Mechanisms

In a Trust, the clinical director is responsible for the management

of a department.  This,  together  with  other  changes  including  the

introduction  of  clinical  audit,  has  given  new  opportunities  for  a

medical manager to review the overall  performance  of  the  clinical

directorate and should result in the earlier recognition  of  individual

doctors having problems.

The mentor system is worthy of greater exploration.  This is a more

formal structuring of the general measures described earlier and may be

appropriate in large departments where it is easier for individuals to

become isolated either in work or in the social context.  It is possible

to make arrangements with neighbouring Trusts although the mentor

does not necessarily have to be someone from the same speciality.

It  is  paramount  that  members  of  all  grades  and  seniority  in  a

directorate  support  each  other  constructively.    Factions  within

departments are destructive.  The single-minded loner may accomplish

a lot but the price can be unreasonable.  No person has the right to

make life miserable for those around them.

SECTION V - STRESS SUPPORT

15

(a) Clinical Director

A clinical director takes responsibility for the whole directorate

in terms of process and outcome.  This includes the performance

of all staff within the directorate.   The  clinical  director  often

finds himself in an unenviable situation as the first person to hear

that a member of the directorate is having a problem in coping

with  work.    Finding  a  solution  to  such  problems  is  a  serious

responsibility and a ruling of the GMC has made it even  more

explicit.  As an arm of management, the clinical director may be

perceived as not necessarily the best person to make preliminary

enquiries though there may be no alternative.  It is worthwhile for

a directorate to give consideration to a structure to take this into

account.

Changes in working practice and requirements for flexibility may

provide stresses creating problems for everyone in an anaesthetic

department.    However  a  change  in  the  normal  habits  of  a

colleague may give a clue to problems they may be having at the

work  place.    If  such  behaviour  is  noted  or  is  the  subject  of

discussion between colleagues, then it is the responsibility of any

consultant or indeed of any individual within the directorate to

make sure that the clinical director is informed and measures for

patient safety put into place.

If a clinical director realises that a doctor is underperforming for

reasons  of  ill  health,  there  is  a  need  to  address  the  personal

problem  to  ensure  that  the  colleague  has  every  chance  of  a

complete recovery and so is enabled to resume full activity.  The

issues of cost and departmental performance standards must also

be considered.  Conflicts of interest and loyalty could begin  to

surface at this point and work against a  sympathetic,  informal

approach to the problems of the doctor concerned.  

The first action of the clinical director or his deputy must be to

discuss  the  problem  with  the  person  involved  and  attempt  to

arrive at an assessment of the situation.  If a difficulty is admitted

it may then be possible to seek a solution.  If a difficulty is not

admitted,  continued  review  of  the  individual’s  practice  should

occur whilst seeking advice from other consultant colleagues.

SECTION V - STRESS SUPPORT

16

It may be appropriate at this time to  discuss the matter with the

medical director who now takes ultimate responsibility for issues

which in the past were dealt with by the regional medical officer

or the director of public health.

While  it  may  be  an  acceptable  short  term  measure  it  is  not

appropriate in the long term to use trainees to bolster the service

and so attempt to decrease the stress on more senior colleagues.

It is important not to ignore the situation after the first steps

have been taken.  Good practice suggests that there should be a

revisitation of the colleague who is in difficulty, possibly with a

witness  who  may  be  either  another  anaesthetic  colleague  or

someone from the personnel department.   Emphasis  should  be

placed on the fact that discussion has arisen because of concerns

for  the  best  interest  of  the  doctor  and  their  patients.    The

opportunity may be taken to discuss possible options, either short

term  or  long  term,  such  as  a  review  of  the  job  plan  of  the

colleague, the dropping of a particular list for a time, having a

break either by annual leave or sick leave,  going  part  time  or

even taking early retirement if appropriate.

Other measures may be necessary such as retraining to cope with

changes  in  practice.    The  colleague  should  be  persuaded  that

discussing their difficulties with their general practitioner may be

useful  or  as  an  alternative,  the  personnel  officer  may  suggest

occupational health assistance.  In the case of a severely disturbed

doctor or in an instance where patient safety is deemed to be at

risk, suspension from duty may be the preferred option while an

investigation  into  the  circumstances  is  made.    This  then

introduces the use of more formal measures.

The occupational health service should have an important part to

play but unfortunately it is often perceived as too closely allied to

management to be accepted as neutral.

In a smaller hospital department some support functions may be

undertaken by the chairman of medical staff.  In all these general

measures  those  involved  must  remember  that  they  have  a

primary function to preserve patient safety at all costs.

By the measures so far outlined many problems can be resolved

rapidly.    If  a  problem  is  incapable  of  resolution  by  informal

SECTION V - STRESS SUPPORT

17

measures  then  it  will  be  necessary  to  move  to  formal

mechanisms.

(b) Mentor System

There are now several projects in the field of general practice,

some  offering  a  mentor/mentee  type  of  support  and  others

offering reciprocal co-mentoring or co-tutoring. These projects

are relatively new but they appear to be successful in providing

personal and professional support and diminishing levels of stress.

A mentor is usually assumed to be a more experienced colleague

who can be seen as offering support, advice and an opportunity to

discuss  problems.  A  mentor  should  be  seen  by  the  mentee  as

independent and trustworthy as well as knowledgeable. In  some

instances  a  mentor  can  be  a  senior  colleague  in  the  same

department but in other circumstances this may be inappropriate

because of conflict of  interests.  In  nursing  there  are  statutory

requirements for newly qualified professionals and those moving

to another area of work to have a designated preceptor for the

first  four  months.  This  type  of  relationship,  if  found  to  be

supportive, may  continue  for  a  much  longer  period.  In  social

work and psychiatric nursing it is usual to have professional and

personal supervision in clinical work. Such supervision may take

the form of a senior colleague advising a junior colleague or may

be arranged on a more equal and reciprocal basis in pairs or small

groups.

In medicine, it is assumed that a consultant acts as an adviser to

trainees working with him and each trainee is required to have an

educational  supervisor.  The  supervisor  is  concerned  with

managing what work is to be done and how education is  to  be

delivered in terms of theoretical knowledge and practical training.

The supervisor should also be concerned with the personal  and

professional  well-being  of  the  trainee  and  how  they  relate  to

colleagues and other staff, their timekeeping, attitude to patients

and other areas of professional behaviour.

In contrast on appointment to a consultant post the doctor is not

usually given any further formal supervision. If he needs advice

he must find his own mentor from among his colleagues. It is at

this  stage  that  support  from  experienced  colleagues  may  be

particularly  needed  and  when  the  availability  of  a  designated

SECTION V - STRESS SUPPORT

18

mentor could be extremely helpful. However, at any stage in a

consultant career support and advice may be needed and in some

situations may not be readily available.

The development of a mentoring scheme should only be seen as

one  part  of  the  total  support  system  for  consultants.  Good

relations within departments are obviously a basic need. The role

of the mentor is to provide support and advice but in no sense to

provide therapeutic help for a consultant who is becoming unwell.

A  mentoring  scheme  should  be  seen  to  supplement  the  sick

doctor  scheme,  while  consultants  should  be  encouraged  to  use

ordinary  medical  channels  if  they  feel  they  are  in  need  of

personal help.

(c) Association of Anaesthetists Sick Doctor Scheme

In 1977, the Association of Anaesthetists of Great Britain and

Ireland, in consultation with the Royal College of Psychiatrists,

pioneered  their  innovative  Sick  Doctor  Scheme  primarily

designed for their members.  This scheme is quietly promoted in

the Association’s literature and its  initiation  and  existence  are

well known to anaesthetists.

The scheme’s aims are to provide support and arrange treatment

on a confidential  basis  for  anaesthetists  who  are  perceived  by

their colleagues and agreed by themselves to be sick and in need

of care and advice.  To access the scheme it is merely necessary

to call the Association’s offices in Bedford Square and ask to be

put in contact with the Sick Doctor Scheme.  They will then be

referred  to  the  responsible  anaesthetist  who  will  make  the

necessary arrangements.

Treatment offered may be given locally or in a region distant to

the place of work of the anaesthetist.  Should the individual sick

doctor refuse treatment  or  support,  this  does  not  in  any  way

reduce the responsibility of  the  referring  doctor  or  doctors  to

take the necessary steps through official channels to protect the

welfare of patients.

The confidentiality of the scheme renders it difficult to assess the

overall efficacy.  Fortunately, since its  inception,  the  numbers

involved have been relatively small but nevertheless there has so

far  been  an  inexorable  growth  in  the  use  of  the  scheme.

SECTION V - STRESS SUPPORT

19

Addiction to alcohol and mental illness are the main causes  of

referral though there is a small but worrying amount of evidence

of abuse of other substances.

(d) Three Wise Men

The ‘Three Wise Men’ procedure was established under the terms

of Department of  Health  Circular  HC(82)13,  dealing  with  the

prevention of harm to patients resulting from physical or mental

disability of hospital or community medical or dental staff.  It

was  set  up  to  tackle  situations  where  a  doctor’s  clinical

performance was well below acceptable standards.  There is still a

major need for local measures and the relationship between them

and the new Performance Procedures being set up by the General

Medical Council still needs to be resolved.

Previously the procedure was initiated by a hospital in discussion

with the Director of Public Health.  It offered the attraction of a

semi-informal largely confidential  process  for  dealing  with  the

problems of hospital doctors.  The chairman of the panel, usually

a very senior and respected practitioner in the same discipline,

had  the  key  role  in  the  procedure  and  the  majority  of  cases

referred to such a panel were capable of resolution by informal

means.  When well handled, it often proved to be a very effective

and efficient means of dealing with complaints and concerns of

colleagues  about  the  competence  of  individual  doctors  whose

behaviour suggested that they were experiencing difficulties.

However,  the  effectiveness  of  the  procedure  was  always

somewhat  negated  by  the  confidentiality  and  secrecy  which

attended it.  The arrangements for appointing the chairman and

members of the panel were not always clear, and panel members

were themselves sometimes unsure about  their  role.    As  in  all

similar procedures, it had the weakness of depending on colleagues

of doctors with problems being prepared to make a report about

them.

The new structure of the NHS has effectively detached the Three

Wise  Men  procedure  from  the  Director  of  Public  Health  and

Regional  Director  of  Public  Health.    The  scope  for  informal

resolution  of  problems  is  potentially  more  restricted,  and  the

future of the system is unclear.  Increasingly the support for an

individual doctor  in  difficulty  will  largely  be  a  matter  for  the

SECTION V - STRESS SUPPORT

20

employing Trust.    It  is  likely  that  the  new  procedure  by  the

General Medical Council to assess  the  incompetent  doctor  will

alter the Three Wise Men procedure as a formal measure, though

some informal mechanism based on the procedure could survive

as a useful tool.

(e) Occupational Health Services

Under the terms of HSG (94)5, ‘Occupational Health Services for

NHS Staff’, all NHS Authorities and Trusts have a responsibility

to ensure that their staff have access to confidential Occupational

Health Services.  OHS should therefore be seen as a potentially

valuable source  of  support  for  hospital  doctors  in  cases  of  ill

health and stress.  However there are grounds for believing that as

things stand doctors do not regard OHS in this light.

The OHS has a dual role as adviser to the employer as well as

advocate of the employee. This has the potential to compromise

their position and their ability for confidentiality and may also be

perceived as giving rise to a conflict of interest.  The wider remit

of OHS, in the provision of information for selection procedures,

in routine medical examinations and in its general concern with

health and safety at work, is likely to create an orientation in

which there is relatively little scope for dealing with doctors with

health (and especially mental health) problems.  

At present the OHS is relatively undeveloped in the NHS with a

paucity  of  consultant  physicians  involved  in  providing  a

universally consultant led service.  It is hoped that the OHS will

be able to play an important role throughout the NHS but doctors

with  health  problems  are  still  likely  to  look  elsewhere  for

support.