Overview
This lecture covers doctors’ own health: the scale of the problem and the “four Ds” of impairment, the distinct pictures of burnout and compassion fatigue and how to treat them, the rule against self-treatment or treating those close to you, and the legal duty under the Health Practitioners Competence Assurance Act (HPCAA) 2003 to notify a health practitioner’s inability to practise. Two case scenarios frame the material: seeking care for your own acute illness, and recognising and responding to a colleague’s possible impairment.
Scale of the problem and the four Ds
- 1-2% of doctors may be performing poorly due to ill-health at any time.
- Around 15% will be impaired at some point in their careers.
- The four Ds of doctor impairment:
- Depression (anxiety and depression are higher among doctors than in the general population).
- Drugs (including alcohol).
- Dimming (burnout and compassion fatigue).
- Disruptive behaviour.
- Doctors have a suicide rate roughly twice that of the general population.
Burnout
- Definition: a state of emotional, physical and mental exhaustion due to chronic stress, usually with gradual onset.
- People experiencing burnout may be “at the end of their tether”, become cynical, and become inefficient at their work.
- Symptoms: lack of motivation and poor performance; fatigue, poor sleep, difficulty focusing; increased mental distance from work; increased negativism/cynicism towards work; decreased feelings of personal accomplishment.
- Associated with a very high workload and/or a non-supportive work environment.
Compassion fatigue
- Definition: results from continued exposure to patient trauma and suffering; a form of secondary traumatic stress. Caring, feeling and acts of compassion decline and are replaced by outward impassive detachedness and emotional numbness.
- Onset can be more acute than burnout, sometimes triggered or exacerbated by a particular event.
- Can give rise to negative emotions: anger, annoyance, intolerance, irritability, cynicism, leading to interpersonal problems, difficulty concentrating, and declining cognition and judgment.
- Disturbs the ability to think clearly, modulate emotions, feel effective, and maintain hope.
- Symptoms: becoming more task-focused and less emotion-focused; pulling away from others; becoming socially isolated; profound physical and emotional exhaustion; becoming disappointed, disheartened, disillusioned with work; avoiding patients/situations that normally require compassion.
Why doctors are at risk
The job itself is stressful, and personal characteristics common in medical students and doctors may add further risk:
- Prioritising strength and being in control (including over emotions).
- Expectation of coping.
- Elitism.
- Individualism.
- Maladaptive perfectionism (excessive concern about others’ perceptions).
- Adaptive perfectionism (conscientious striving for achievement).
Treating burnout and compassion fatigue
- Recognise symptoms early; the brain and body can only handle feeling overworked and overwhelmed for so long.
- Find the source of the stress (work, relationships, personal life) and identify immediate changes, e.g. speaking to your employer/supervisor to reduce hours or workload, or taking a break/holiday.
- Leave work at work, set boundaries, find balance, and do things that bring joy.
- Look after holistic health: sleep, eat well, exercise.
- Practise self-compassion; take back control where you can.
- Turn to other people (friends, family); get professional support (therapist, psychologist), especially where a specific event/setting has driven the compassion fatigue.
- Re-evaluate goals, values and priorities; replenish mind, body, heart and spirit.
- Seek emotional support, peer support and supervision; stay connected to what gives you meaning; engage in reflective practice.
Providing care to yourself and those close to you
- Rule: “A doctor who treats herself or himself has a fool for a doctor and an idiot for a patient” — you should not treat yourself or those close to you.
- The Medical Council expects that you will not provide care to yourself or those close to you in the vast majority of clinical situations.
- Rationale: treating someone in the context of a close personal relationship can adversely affect the standard of care, and this also applies to self-diagnosis or self-prescribing.
- Council expects every doctor to have their own GP to provide ongoing, objective care; your GP is also best placed to keep your clinical records reflecting your long-term health needs and management.
Legal obligations: HPCAA 2003, section 45
- Under the Health Practitioners Competence Assurance Act (HPCAA) 2003, s45 (“Notification of inability to perform required functions due to mental or physical condition”), reporting duties apply to: you; your colleagues, in respect of you; and the Head of the Medical School.
- s45(2): if a person in charge of a health service organisation, a health practitioner, an employer of health practitioners, or a medical officer of health has reason to believe a health practitioner is unable to perform the functions required for their profession because of a mental or physical condition, that person must promptly give the Registrar of the responsible authority written notice of all the circumstances. “Mental or physical condition” includes conditions caused by alcohol or drug abuse.
- s45(4)-(5): the same duty extends to a person in charge of an educational programme (a prescribed qualification course) who has reason to believe a student completing the course would be unable to perform the required professional functions because of a mental or physical condition — they must promptly notify the Registrar.
- s45(6): no civil or disciplinary proceedings lie against a person for a notice given under this section, unless they acted in bad faith.
Case scenarios
- Scenario 1 (PGY1, sore throat during a busy surgical run): illustrates the temptation to avoid taking sick leave and instead self-diagnose/self-treat (asking a friend to examine and prescribe, or self-prescribing antibiotics) rather than taking leave and seeing your own GP.
- Scenario 2 (PGY2 rural GP placement): a well-regarded GP mentor shows signs of possible impairment (harsh/angry views expressed privately, despondency, recent relationship breakdown, being on antidepressants that she may be self-prescribing). Options considered include respecting her privacy versus expressing concern directly, asking whether she has her own GP/health professional support, raising the self-prescribing concern with her, or speaking with another colleague — testing the balance between the duty to notify under HPCAA and supportive, direct approaches to a colleague.
Self-test
- List the four Ds of doctor impairment described in the lecture.
- What proportion of doctors may be impaired at some point in their careers, and how does the doctor suicide rate compare with the general population?
- Define burnout and describe its typical symptoms.
- Define compassion fatigue and distinguish it from burnout in terms of cause and onset.
- Describe the personal characteristics of doctors and medical students that the lecture suggests may increase their risk of burnout or compassion fatigue.
- List the strategies suggested for treating burnout and compassion fatigue.
- What is the Medical Council’s expectation regarding a doctor treating themselves or those close to them, and why?
- Under HPCAA 2003 s45, who has a duty to notify the Registrar about a health practitioner’s inability to perform their functions due to a mental or physical condition, and what triggers that duty?
- What protection does s45(6) of the HPCAA give to a person who makes a notification, and what is the one condition that removes that protection?
- In case scenario 2, what specific concern about the GP mentor should the student consider raising, and what options are available for doing so?
Answers
Reveal answers
- Depression, Drugs (including alcohol), Dimming (burnout and compassion fatigue), and Disruptive behaviour.
- Around 15% of doctors will be impaired at some point in their careers; doctors have a suicide rate roughly twice that of the general population.
- Burnout is a state of emotional, physical and mental exhaustion due to chronic stress, usually with gradual onset. Symptoms include lack of motivation and poor performance, fatigue, poor sleep, difficulty focusing, increased mental distance from work, increased negativism/cynicism towards work, and decreased feelings of personal accomplishment.
- Compassion fatigue results from continued exposure to patient trauma and suffering (a form of secondary traumatic stress), with caring and compassion replaced by detachedness and emotional numbness; unlike burnout’s gradual onset, it can have a more acute onset, sometimes triggered by a particular event.
- Prioritising strength and control (including over emotions), expectation of coping, elitism, individualism, maladaptive perfectionism (excessive concern about others’ perceptions), and adaptive perfectionism (conscientious striving for achievement).
- Recognise symptoms early and find the source of stress; make immediate changes such as reducing hours/workload or taking a break; leave work at work and set boundaries; look after sleep, diet and exercise; practise self-compassion and take back control; seek support from friends, family or professionals; re-evaluate goals/values/priorities; seek peer support and supervision; engage in reflective practice.
- Wherever possible you should not treat yourself or those close to you, because doing so in the context of a close personal relationship (including self-diagnosis or self-prescribing) can adversely affect the standard of care; instead you should have your own GP for ongoing, objective care and accurate long-term records.
- The duty applies to: a person in charge of an organisation providing health services; a health practitioner; an employer of health practitioners; a medical officer of health; and a person in charge of an educational programme, in respect of a student. It is triggered when that person has reason to believe a practitioner (or student) is/would be unable to perform the functions required for the profession because of a mental or physical condition (including one caused by alcohol or drug abuse), requiring them to promptly give the Registrar written notice of all the circumstances.
- No civil or disciplinary proceedings lie against a person for a notice given under s45, unless the person acted in bad faith.
- The student should consider raising the possibility that the mentor is self-prescribing her antidepressants (contrary to the expectation of having an independent GP), alongside options such as selecting a suitable time to express concern and offer assistance, asking whether she has her own supporting health professional, or speaking with another colleague about the concern.