THE DIFFICULT DOCTORor

THE DOCTOR WITH DIFFICULTIES

Simon Willcock

August 2008

NicholasNicholas

Nicholas is an Advanced Registrar working in your regional town practice for a year . He is 28 years old. He has had an average record of achievement in his studies and previous terms.

He has been regularly calling in sick, and did not turn up for a rostered Saturday morning shift. His explanation is that he forgot. The front desk staff says that he has been difficult – uncooperative and argumentative.

What could be happening to Nicholas?

Is Nicholas a bad doctor? Should we institute any measures, and if so

what options do we have?

Anxiety

Lack of support

Depression

Substance use

Family problems

Unhappy with career choice

IncompetenceFinancial problems

What could be happening to Nicholas?

After talking to Nicholas you find that he and his wife are living in a one bedroom apartment.

He has a new baby and his wife is suffering from post natal depression.

He is struggling to support his wife emotionally.

Why didn’t Nicholas ask for help?

“Doctors should cope”“Admitting you can’t cope equals

incompetence”Loss of control / loss of facePersonality factorsAssessment / progression

What makes a good doctor?

Organises time well and can work to a schedule

Pays great attention to detail

Hardworking Self sacrificing Ethical Can lead a team and

takes responsibility Confident in ones skill

Pre-occupied with details rules and lists

Perfectionist Devoted to work Over-conscientious and

concerned with ethical and moral values – inflexible

Reluctant to delegate to others

Shows rigidity and stubbornness

(Unable to discard worn out objects) (Overly thrifty)

OBSESSIVE COMPULSIVE PERSONALITY TRAIT

IPDEQ Subscale Frequencies Time 1

PARANOID n %NO 107 97.3YES 3 2.7

SCHIZOIDNO 91 82.7YES 19 17.3

DISSOCIALNO 100 90.9YES 10 9.1

IMPULSIVENO 100 90.9YES 10 9.1

BORDERLINENO 107 97.3YES 3 2.7

HISTRIONICNO 69 62.7YES 41 37.3

ANANKASTICNO 36 32.7YES 74 67.3

ANXIOUSNO 98 89.1YES 12 10.9

DEPENDENTNO 105 95.5YES 5 4.5

Total 110 100.0

Internal Stresses (personal characteristics)

Personality and coping styles in the caring professions

High achievers

Self denying

Obsessive

Prone to depression

(good for patients, bad for self-care)

Doctor’s health statistics

Heart disease Smoking related illness Motor vehicle accidents Liver disease Depression Anxiety suicide

Less than population Less than population 2x population 3x population 3x population >3x population >3 times population

Doctors as an at risk group?

Doctors are more likely to: be alcoholic – alcoholism is the major cause of

impairment in doctors over 50 be drug addicted – drug use is the major reason for

referral to the Medical Board for impairment be stressed be anxious or depressed commit suicide

These are powerful indicators of poor self care

In figures from 1996 (Lawrence J) Male doctors – 1.5 to 3.4 times the suicide rate

for the population Female doctors – 2.5 to 5.7 times

Over represented areas• Anaesthetics• Psychiatry• General practice• Emergency Medicine

Known Suicide of Medical Practitioners(NSW Medical Board)

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Hume and Wilhelm 1994 Intern StudyPrince of Wales / Prince Henry Hospitals

Showed 17% reported having sought help for previous emotional problems

During intern year 8%reported seeking help - anxiety, depression and eating disorders

During the year 4% had ‘often’ considered life was not worth living and 3% had entertained (but not acted on) suicide plans

72% reported ‘often experiencing significant and distressing episodes of anger.

Performance and Competence

Look below the surface of performance distracters Most students and young doctors are there

to try and do a good job Look out for those whose behaviour

changes suddenly Would Nicholas’ friends have noticed a

change in his behaviour?

What resources do you have to help Nicholas?

Supportive colleaguesAccess to professional assistance e.g. GP,

psychologist, psychiatristGeneral PractitionerMedical Benevolent AssociationDHAS

What if Nicholas’ attendance or attitude fail to improve?

SupportProgression

Robert

Robert is a 25 year old student in Med 4, doing a long placement in your practice. He has always been one of the top students and has great reports from the clinical school.

He is undertaking an honours project in cardiothoracic surgery. He is a good sportsman, plays first grade rugby for the university and is an accomplished musician. His father is the professor of surgery at a leading university. Everyone says he is going to be a great doctor.

It has been reported that he was rude to a patient who complained about his manner and he got into a brawl at the local club.

You’ve organised to meet with Robert to discuss these issues.

What will you do to prepare for this interview?

When Robert comes to see you he breaks down in tears and says he is leaving the medical program because he will never be a good doctor

Anxiety

Lack of support

Depression

Substance use

Family problemsInterpersonal problems

Unhappy with career choice

IncompetenceFinancial problems

What could be happening to Robert

Stress and Burnout

Concepts of Stress , Distress and Impairment

We all experience stress

We may become distressed

If we are distressed for long, we may become impaired

IS STRESS A MENTAL ILLNESS?

No! - Some stress is good

Better Reduced

Perf. Perf.

Performance

Stress

Coping well Distressed Impaired(? 15-30%) (1-3%)

External(Environmental)

factors

Internal(Personal)

factors

External Stresses

Assessment

Workload

Family expectations

Exams, options, honours

Vocational issues – length of time, limited choices

Relationship issues

Family problems – children and parents

Financial problems

The work environment – low morale, aggression and bullying, traumatic experiences – the elective term

Signs of “distress”

Depression (and anger)

Burnout

Changes in behaviour e.g. drinking more, taking risks

Relationship problems (family, patients, staff)

Financial problems

Withdrawal

What is Burnout?

“The origin of burnout is in occupations where large amounts of time are spent

with the problems of others” (Heiter and Maslach, 1988)

3 Dimensions of Burnout

Emotional exhaustion

Depersonalisation

Reduced feelings of Personal Accomplishment

Medical Practitioners and Burnout

Medical practitioners as a group tend to have “moderate” levels of burnout across all 3 dimensions

There are times when burnout levels are generally increased

e.g. internship

Change in Reported Burnout over Time (T1=early final medical student year, T6= late internship year)

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Emotional Exhaustion

Depersonalisation

2. Is burnout inevitable?

Burnout Prevalence

(Willcock et al – 2000 study of GMP graduates)

Midway through final medical student year (Time 1), 27.7% of participants met criteria for burnout (either high DP score (>=10) or high EE score(>=27)).

This level of burnout then gradually increased to 74.7% by mid way through the internship year (Time 5).

Change in Burnout over Time

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Depersonalisation (Mean Diff T6-1, p<0.001)

Emotional Exhaustion (Mean Diff T6-1, p<0.001)

Personal Accomplishment (Mean Diff T6-1, p<0.001)

Correlations

Females were more likely to become emotionally exhausted, while males were more likely to exhibit depersonalisation

The higher the degree of emotional exhaustion, the higher the “assessed” term performance !

3. Is Burnout bad for you?

Relationship between burnout and risk of psychiatric disorder

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GHQ-28

Below 7/8 cut off

GHQ-28

Above 7/8 cut of

What can you do to help?

Recognise the symptomsEducation for studentsRealistic goalsPsychologistMentor / faculty independent support

person

LisaLisa

Lisa is a locum at your practice. Practice and hospital staff have noticed that she is keeping to herself. She has lost weight and doesn’t talk at all in practice meetings.

Her clothes look dishevelled at times. A few patients have refused to see her. Sometimes she can be seen just sitting alone staring blankly.

Anxiety

Lack of support

Depression

Substance use

Family problemsInterpersonal problems Unhappy with career choice

Incompetence

Financial problems

What could be happening to Lisa

Stress and Burnout

Physical illness

Serious mental illness – bipolar disorder or psychosis

Anorexia

Doctors and medical students are people too Physical Illness Psychological illness

Impairment

A doctor (or a student) is impaired if they suffer from any physical or mental illness which is likely to affect their capacity to work safely.

Impairment implies that the individual lacks insight into their own ability to work safely.

Illness likely to cause Impairment

Psychiatric illness Bipolar Depression Anxiety and OCD Eating disorders

AddictionPhysical illness and disability

Who would notice this behaviour?How should we encourage doctors or

students to report their concerns?

What can you do?

Remember what we are all here for – patient safety.

The key problem in impairment is lack of insight

Talk to someone – the person, your colleagues, DHAS, your indemnity organisation

DHAS? Refer to the Medical Board

Sarah

Sarah is a difficult student. She is unpopular with the other students and frequently complains about aspects of the course and the behaviour of other students. She often asks for ‘special consideration’ at exam time.

When counselled by sympathetic Faculty members she appears to lack insight and blames external factors. She has failed her last assessment but she is complaining to the Dean that the test was unfair.

Another student has complained that Sarah emailed other students very unpleasant information about a tutor and told them not to bother attending tutorials.

Sarah has been to the Associate Dean crying and saying other students don’t include her in their group and don’t value her opinion.

Anxiety

Lack of support

Depression

Substance use

Family problemsInterpersonal problems

Unhappy with career choice

Incompetence

Financial problems

What could be happening to Lisa

Stress and Burnout

Physical illness

Serious mental illness – bipolar disorder or psychosis

Anorexia

Personality problems‘the Disruptive Doctor’

ISSUES

Separating competency from conductSeparating support from progressionHow can this student be assisted to gain

competencyWhose responsibility is she?

Recognise the need for Behaviour management Performance and progression assessment Student support committee Documentation ++++ Everyone should be aware of decisions

Can one person do all of these roles?

Performance and support

The presenting behaviour is usually just the tip of the iceberg

Summary - 4 Basic Tasks

1. Diagnose the problem

2. Appropriate support

3. Manage performance

4. Manage unprofessional behaviour

Taking care of BASICs

BASIC

odyffectocialntellectosmos

New Jersey Medical Assoc. Physician Health Program

+ -Selfless Selfish

Nutrition avoid dehydration

minimise toxins

Exercise

Rest sleep is not a luxury

Recreation - “rest for mind and spirit”

Good Medical Care

Boundaries and Balance

B is for Body

A is for Affect

Mood Attitudinal and Emotional Health “Emotional Intelligence”

self awareness ability to manage emotions positively empathy delayed gratification, but not indefinitely!

Dealing with negative emotions

Emotional Sensitivity

Emotional Exhaustion

Psychological Distress

Personal Accomplishment

Personality Burnout Distress

Autoregressionp<0.0001 p<0.005

Predictor Model of Psychological Distress

Dependent Type Personality

Depersonalisation

Low Confidence In Coping Skills

Disability

S is for Social

Pay attention to your loved ones

“In and through community lies the salvation of the

world” (MS Peck)

Trust and take risks

Give and receive feedback

Support each other

Experience love and intimacy

I is for Intellect

Hobbies

Current events

Reading

Re-evaluate your worldview,

belief systems, ethical and

moral standards,

ideals and expectations

Deal with feelings of entitlement

C is for Cosmos

A personal sense

of meaning

and purpose

Spiritual Health

It is easy to lose perspective in the rigours of

daily medical practice

We need to keep the ability to experience awe,

wonder and surprise

BASIC

B A S I C

odyffectocialntellectosmos

Breathing Awake Satisfied Intelligible Continent

Into your 30’sInto your 30’s Into your 80’sInto your 80’s