European Junior Doctors meeting, Malta
Address by Gordon Caruana Dingli
In Malta we are very privileged to have a comprehensive free health service for all. So why should doctors require special care? I will try to discuss the reasons.
Doctors have a very stressful job and they suffer from a disproportionately high level of psychological problems and physical ill-health. Due to the nature of their job they find it difficult to access medical services.
Doctors also have significant psychological vulnerability and they are more likely than the average person to suffer from one or more of the ‘three Ds’ – drink, drugs, depression. Suicide rates are high, particularly among anaesthetists, GPs and psychiatrists. It has long been debated whether this is likely to be due to the stress of the job or to pre-existing traits.
Some degree of obsessional personality is common among doctors and this ‘level of conscientiousness’ is often to the detriment of their own health needs.
There is also a culture of ‘working through illness’ and ‘self-treating’ that has developed among the medical community. The perception that doctors are more likely than other professionals to work through illness may be symptomatic of a culture in which an image of invincibility is encouraged and vulnerability is denied.
Many sick doctors don’t seek help because of the stigma of ill-health, peer pressure and professional loyalty. There are concerns about the response of colleagues, fitness to practice and losing the respect of patients and also financial implications. Doctors in training may have concerns about career prospects.
Stress may be a product of the interaction between the demanding nature of doctors’ work and their obsessive, conscientious and committed personalities. Several studies have documented stress and higher than expected levels of psychiatric morbidity in doctors and medical students. Evidence shows that the proportion of doctors and other health professionals showing above average levels of stress has remained constant at around 28 per cent, compared with 18 per cent in the general working population.
The main sources of work-related stress for consultants and GPs are excessive workloads, organisational changes, poor management and insufﬁcient resources, dealing with death, patient suffering and mistakes, complaints and litigation and pressure of work.
Doctors also have to cope with long working hours, inadequate time for rest, disturbed sleep, facing examinations, a lack of healthy coping strategies and the effects on personal and family life.
Doctors are notorious for not having a GP and for not seeking their advice and treatment when needed. Many report that they deal with illness themselves but it is difﬁcult for them to maintain objectivity in diagnosing and analysing their own ill health, often resulting in denial or panic. They often have informal or ‘corridor’ consultations with colleagues. Self-prescribing and prescribing for family members is also very common and this detracts from the human support element of treatment.
Doctors are also reluctant to take sick leave reflecting a tradition of ‘working through’ illness, and also because of practical reasons, such as the absence of cover.
A doctor with health problems often faces unique barriers to obtaining help. They are reluctant to seek medical advice through the usual routes and mechanisms and ﬁnd it difﬁcult to adopt the role of the patient. There is no single comprehensive pathway of care and support that exists for such doctors. They do not make ‘ideal’ patients. They may present late, after having sought opinions from various colleagues or after failing to manage the condition themselves.
On the other side of the coin, it is difﬁcult for health professionals to deal with colleagues. It may be seen to breach the usual borders between professional and personal communication. Although professionals looking after a sick doctor may keep strictly to the rules of conﬁdentiality, the fact that a group of local colleagues have access to personal details about a sick doctor puts that doctor in a vulnerable position, which may compromise future working relationships.
So what are doctors’ health needs?
When they have physical disease they tend to present late
They have increased psychological and psychiatric disease
They don’t attend screening for hypertension, diabetes, mammography, lipids, colonoscopy etc
They don’t follow guidelines for needlestick injuries, vaccinations etc
They don’t have the time to focus on leading a healthy life-style
They are busy, reluctant to seek help and feel the need for privacy from colleagues and patients. Many doctors also feel that their medical records should be private and not accessible by colleagues and management.
How can all this this be tackled?
The first step should be introducing a GP service at Mater Dei hospital for doctors. I envisage this to be run by two senior GPs, to offer a choice between two respected experienced doctors. They will provide a confidential, one-on-one medical service to doctors which will also include career advice and emotional support. There will be established referral patterns for doctors needing specialised care.
This clinic should be easily accessible and private. I suggest that this is held in the afternoon, initially twice a week, at the existing infection control clinic, which is separate from the main outpatients’ clinics at the hospital. Dr Michael Borg has kindly agreed to host us there and to provide secretarial services.
It would ideally be held by appointment but I would not discourage ‘walk-ins’, especially in the initial stages.
Besides being a symptomatic clinic this could be combined with occupational health and with the needle stick injury and hepatitis B immunisation services which will also serve to act as a screen of anonymity.
I think we should also establish a screening programme eg lipids, diabetes and hypertension and perhaps access to breast and colonic screening programmes.
One of the problems that has to be ironed out is how to store medical records. Doctors may be wary of having their records stored in the hospital system, whether paper based or electronic, because of the possibility of the management or colleagues accessing them.
I suggest that medical records are either kept under lock and key at the clinic, or they can be kept by the doctor himself.
MAM would like to develop self-help resources on its website. These have been very useful on the BMA site. This is something that we can do in partnership with other countries.
A third step would be introducing a 24 hour telephone helpline. It would be difficult to justify the cost of this for the small numbers of doctors in Malta and one alternative would be subscribing to the existing BMA helpline in the UK. There are no problems with language and the cost would probably not be very high. There may be problems because of different cultures and differences between the Maltese and British NHS set-up.
This leaves us with the psychological support services. I think that the first port of call should be the GP as mentioned above. However he should be able to refer problems on to a dedicated psychologist/psychiatric service located away from the NHS to allow full confidentiality. Doctors would be provided with confidential consultations by experts who are able to provide specialises psychotherapeutic interventions or psychiatric advice. The problems that could be addressed through this service include stress, burnout, anxiety, depression, OCD, relationship difficulties at work or at home, bullying/harassment, anger management, communication difficulties, adjustment difficulties, bipolar illness, personality problems, examination stress and loss/bereavement issues.
MAM would like to work with the medical council of Malta to establish guidelines on how doctors should be involved in the medical care of family members.
We should encourage audit and research in the field of psychological and physical ill-health in Maltese doctors and co-ordinate with international efforts in the field. Maybe a start would be circulating a questionnaire to see what services doctors feel that they need.
To conclude, doctors are a limited and expensive human resource. An investment in supporting their health and well-being will not only improve their quality of life but it will improve the quality of patient care and patient safety, leading to less mistakes and decreased litigation with cost savings.