Portal de Periódicos da CAPES

The Elephant in the Room?

2012; Elsevier BV; Volume: 24; Issue: 10 Linguagem: Inglês

10.1016/j.clon.2012.07.014

1433-2981

B. Marien, F. Mckinna,

Diversity and Career in Medicine

Thirty years ago Anthony Allibone, Chairman of the Health Committee of the General Medical Council, observed ‘the attitude of the medical profession to the health of its members has always been one of disinterest which is temporarily discarded when disaster overtakes one of its number’. This disturbing view of the caring profession seems to be just as prevalent today, with little in the way of research into prevention or treatment for stress-related illness in doctors. Medical careers are associated with higher rates of psychological distress and psychiatric morbidity when compared with other professions [[1]British Household Panel Survey 1993–1994. Colchester: Institute for Social and Economic Research, 2001.Google Scholar] and the general population [[2]Singleton N. Better or worse: a longitudinal study of the mental health of adults living in private households in Great Britain. Office of National Statistics, London2003Google Scholar]. Doctors are more likely to experience depression, alcoholism [[3]Firth-Cozens J. Interventions to improve physicians' well-being and patient care.Soc Sci Med. 2001; 52: 215-222Crossref PubMed Scopus (244) Google Scholar], substance abuse and have an increased risk of suicide [4Hawton K. Malmberg A. Simkin S. Suicide in doctors. A psychological autopsy study.J Psychosom Res. 2004; 57: 1-4Abstract Full Text Full Text PDF PubMed Scopus (73) Google Scholar, 5Hawton K. Clements A. Sakarovitch C. Simkin S. Deeks J.J. Suicide in doctors: a study of risk according to gender, seniority and specialty in medical practitioners in England and Wales, 1979–1995.J Epidemiol Community Health. 2001; 55: 296-300Crossref PubMed Scopus (225) Google Scholar]. The prevalence of psychological morbidity among UK hospital consultants seems to be rising, with oncologists appearing to be particularly vulnerable [[6]Taylor C. Graham J. Potts H.W. Richards M.A. Ramirez A.J. Changes in mental health of UK hospital consultants since the mid-1990s.Lancet. 2005; 366: 742-744Abstract Full Text Full Text PDF PubMed Scopus (141) Google Scholar]. Nearly one third of oncology consultants experience significant career burnout, a syndrome characterised by emotional exhaustion, depersonalisation and a low sense of personal accomplishment. It seems to start early in oncology training, with one in four trainees reporting high levels of stress [[7]Berman R. Campbell M. Makin W. Todd C. Occupational stress in palliative medicine, medical oncology and clinical oncology specialist registrars.Clin Med. 2007; 7: 235-242Crossref PubMed Scopus (24) Google Scholar]. Work-related stress can result in a wide range of adverse cognitive, physical and behavioural consequences. The response to stressful situations is highly variable, both between individuals and within the same individual at different times. Personality variables, mood, previous experiences, cognitive processes and coping strategies can powerfully modulate the perception of stress. The way we think about ourselves, events and the future can all be influenced by our mood state [[8]Tennant C. Work-related stress and depressive disorders.J Psychosom Res. 2001; 51: 697-704Abstract Full Text Full Text PDF PubMed Scopus (380) Google Scholar]. ‘Burnout’ is one consequence of years of exposure to work-related stress. Burnout is bad for the doctor, their family and colleagues and their patients. It is associated with ‘depersonalisation’, a state associated with cynicism or a tendency to treat patients as objects. This erosion of empathy can have a damaging effect on quality of care, patient satisfaction and patient compliance [[9]Shanafelt T.D. Bradley K.A. Wipf J.E. Back A.L. Burnout and self-reported patient care in an internal medicine residency program.Ann Intern Med. 2002; 136: 358-367Crossref PubMed Scopus (1480) Google Scholar]. Burnout, stress and psychological distress are related to clinical errors among doctors [10Taylor C. Graham J. Potts H. Candy J. Richards M. Ramirez A. Impact of hospital consultants' poor mental health on patient care.Br J Psychiatry. 2007; 190: 268-269Crossref PubMed Scopus (51) Google Scholar, 11Firth-Cozens J. Greenhalgh J. Doctors' perceptions of the links between stress and lowered clinical care.Soc Sci Med. 1997; 44: 1017-1022Crossref PubMed Scopus (359) Google Scholar]. Most complaints regarding patient care deal with problems of communication rather than clinical competency [[12]Richards T. Chasms in communication.Br Med J. 1990; 301: 1407-1408Crossref PubMed Scopus (58) Google Scholar]. Doctors (perhaps especially oncologists) need their skills to empathise, and communicate effectively and compassionately. Several studies and reviews show a clear correlation between effective communication and improved health outcomes [13Simpson M. Buckman R. Stewart M. et al.Doctor–patient communication: the Toronto consensus statement.Br Med J. 1991; 303: 1385-1387Crossref PubMed Scopus (629) Google Scholar, 14Stewart M.A. Effective physician–patient communication and health outcomes: a review.Can Med Assoc J. 1995; 152: 1423-1433PubMed Google Scholar, 15Haas J.S. Cook E.F. Puopolo A.L. Burstin H.R. Cleary P.D. Brennan T.A. Is the professional satisfaction of general internists associated with patient satisfaction?.J Gen Intern Med. 2000; 15: 122-128Crossref PubMed Scopus (499) Google Scholar, 16DiMatteo M.R. Sherbourne C.D. Hays R.D. et al.Physicians' characteristics influence patients' adherence to medical treatment: results from the Medical Outcomes Study.Health Psychol. 1993; 12: 93-102Crossref PubMed Scopus (647) Google Scholar]. Personality traits of ‘high achievers’, such as conscientiousness and perfectionism [[17]Gabbard G.O. The role of compulsiveness in the normal physician.JAMA. 1985; 254: 2926-2929Crossref PubMed Scopus (155) Google Scholar], may contribute to the observed vulnerability to psychological problems in doctors. The attributes that make conscientious and caring oncologists may contribute to subsequent problems. Self-criticism and a tendency towards negative emotions (‘negative affectivity’ – a cognitive trait associated with depression), is common in doctors [[18]Brewin C.R. Firth-Cozens J. Dependency and self-criticism as predictors of depression in young doctors.J Occup Health Psychol. 1997; 2: 242-246Crossref PubMed Scopus (48) Google Scholar]. Self-criticism can make it difficult for doctors to accept errors or complaints, or to accept that they are not coping ‘perfectly’. Doctors with perfectionistic traits may routinely internalise or personalise negative events, seeing them as a failure of character. Feelings of doubt, guilt and an exaggerated sense of responsibility can result in chronic feelings of not doing enough, create difficulty in setting limits around work and make it difficult to relax or enjoy time away from work [19Deary I.J. Blenkin H. Agius R.M. Endler N.S. Zealley H. Wood R. Models of job-related stress and personal achievement among consultant doctors.Br J Psychol. 1996; 87: 3-29Crossref PubMed Scopus (170) Google Scholar, 20Ramirez A.J. Graham J. Richards M.A. Cull A. Gregory W.M. Mental health of hospital consultants: the effects of stress and satisfaction at work.Lancet. 1996; 347: 724-728PubMed Scopus (716) Google Scholar]. Emotional distancing from distress is also associated with an increased risk of mental health problems. The stigma and shame of mental illness remains a barrier to doctors seeking help [[18]Brewin C.R. Firth-Cozens J. Dependency and self-criticism as predictors of depression in young doctors.J Occup Health Psychol. 1997; 2: 242-246Crossref PubMed Scopus (48) Google Scholar]. We are more likely to want to portray an image of well-being and perfect health – ‘the mask of relaxed brilliance’ to friends, colleagues and patients. There are a number of major obstacles to acknowledging the ‘elephant’ and changing the status quo. Feeling emotionally distressed about feeling stressed, being upset about being upset is called a ‘meta-emotion’, which is a well-recognised predisposing and maintaining factor in mental illness. The apparent difficulty doctors have in heeding distress signals in their colleagues, or initiating a conversation about psychological issues, is a form of emotional phobia resulting in ‘fear avoidance’. This pattern of behaviour, noted by Allibone, compounds the difficulty faced by the distressed doctor. An additional obstacle is the lack of a clear, confidential, care pathway for doctors in distress. These various barriers contribute to the avoidance of difficult, but essential, conversations and so conspire to maintain medicine's embarrassing blind spot. As a group of oncologists in Brighton, we agreed as a department a proposal for a study researching a preventative strategy using a combination of cognitive behavioural therapy (CBT), neuroscience and relevant insights from psychological medicine. CBT is the most comprehensively researched form of short-term therapeutic intervention, and is approved by the National Institute for Health and Clinical Excellence (NICE) as the primary intervention for depression and anxiety disorders [[21]NICE guidance on management of anxiety and depression NICE CG23. 2007Google Scholar]. Our pilot study was designed to assess the acceptability and feasibility of a group-based CBT programme and specifically explore how participating in a group-based CBT programme affects participants' psychological well-being and working lives. The sessions were designed to provide us with a range of proven techniques to promote psychological well-being, and were specifically tailored to suit our needs and knowledge base. The programme consisted of eight 2 hours group sessions of CBT at about 2 week intervals, with follow-up sessions at 1 and 3 months. Each individual was encouraged to identify their own personal goals, create personal action plans and implement problem-solving techniques and adaptive coping strategies. Sessions were conceived and co-ordinated by a medically qualified cognitive behavioural therapist (BM) with experience of running CBT courses and stress management programmes for health professionals. Our small pilot study confirmed the feasibility of delivering a CBT programme for a group of consultant oncologists. Our group reported benefits including a more supportive working environment, improved communication and team work with colleagues, and being better equipped to deal with complaints and the management of difficult patients and their relatives. Over half of the group had experienced a common mental health problem before the study. Perhaps the most important outcome was the acceptance and normalisation of emotional distress among the group. Gaining a greater emotional literacy seemed to help de-stigmatise stress, anxiety and low mood and to exculpate the individual doctor. No consistent negative effects were recorded. There are clear limitations to this study, and further work is required to evaluate the effect of a group CBT programme for doctors more robustly. Participant numbers were too small to provide statistically significant results. Other significant life events that befell the participants during the course of the programme were not recorded, making individual changes difficult to attribute. This pilot study was carried out in a workplace setting with a group of well-educated employees who were able to find protected time during working hours. Our programme was delivered by one doctor, who was also trained in health psychology and CBT. The success of such an intervention may depend on a variety factors – the experience and characteristics of the trainer and those of the participants. These results could have been influenced by the personal and intellectual biases held by both the researchers and the participants. We need further research using randomised controlled trials to help identify the key ingredients that promote positive outcomes for doctors. The effect of group psycho-educative CBT in occupational settings remains under-researched, yet there is good evidence that improving mental health literacy can help reduce stigma and improve mental health. We have since extended the educational elements of our programme to new trainees and consultant colleagues in Brighton, and are now undertaking a study within our centre for radiographers, managers and nurses. It may be an inconvenient truth, but there is ample evidence that oncologists experience high levels of psychological morbidity, which is associated with widespread and serious sequelae. There is an elephant in the room and there are many individual and systemic factors that perpetuate the status quo. Reducing the burden of mental health problems in the medical profession would benefit doctors, their families, patients and the National Health Service. Developing an evidence-based approach could help reduce the morbidity and the mortality of doctors. The challenge is to raise awareness across the profession, normalise, de-stigmatise and facilitate access to evidence-based treatment. The authors would like to thank the consultant oncologists at the Sussex Cancer Centre who participated in the CBT pilot (David Bloomfield, Anthony Chalmers, George Deutsch, Andreas Hiersche, Sankha Suvra Mitra, Geoff Newman, Joanna Simpson, Richard Simcock, Andrew Webb and Marie Wilkins) and Dr Duncan Gilbert for help with the manuscript. This work was funded by the Sussex Cancer Fund for Treatment and Research. Dr Marien was the Medical Director of a specialist clinical service for National Health Service doctors from 1994 to 2011 and now runs an independent practice in psychological medicine in London and Sussex.