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.
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