Dilemma: Making yourself your first concern

"I AM a doctor working increasingly long hours and still falling behind. The stress is affecting my home life and I’m finding it hard to sleep. I worry that one of these days I’ll miss something important. Everyone in our team is struggling and I don’t want to add to the overall pressure by requesting time off. What should I do?"

We are all aware of the increasing pressures on doctors at the present time, and all too often many find themselves struggling against a tide of expanding workload and overstretched resources. Working extended hours and cancelling holidays might appear to help but can have a negative impact both on work-life balance and more seriously on a doctor’s health.

A recent MDDUS member survey highlighted the heavy toll Covid-19 is taking on clinicians’ wellbeing and morale. MDDUS also takes many calls from doctors facing the situation described above. How should the problem be addressed?

What is burnout?

Burnout is a state of physical, mental and emotional exhaustion that follows a prolonged period of stress, which commonly manifests as a feeling of being overwhelmed by the demands of the role and an inability to engage effectively with others. This may prompt a doctor to question whether they wish to continue practising medicine.

International Classification of Diseases (ICD-11) considers burnout to be an occupational phenomenon, rather than a medical condition. It is defined as a syndrome resulting from chronic workplace stress characterised by feelings of exhaustion, negativity towards one’s job and a sense of professional ineffectiveness.

Burnout may drain doctors of their ability to communicate with others, and to show empathy and compassion.

Spotting the signs

While doctors are trained to identify symptoms and signs in others, we may not be as good at recognising the warning flags for burnout in ourselves and colleagues – or taking action when we do. This is a necessary first step.

Doctors have an obligation to make the care of their patients their first concern. But in order to work safely and effectively, doctors must also look after their own health and wellbeing, and support colleagues who have problems with their performance or health.

Change what you can

While doctors may have limited control over their working environment, they should seek out areas where they can make improvements. They may be unable to change all of the circumstances of the situation, but they can adapt their responses to it.

Resilience is a term doctors know well and it has on occasion been touted as the panacea to meeting the demands placed on doctors. However, we know that learning to increase resilience is not a long-term solution. Boundaries are essential. These, like the stresses themselves, are personal to us all.

Thinking about burnout as an imbalance between stress and coping mechanisms is helpful. It creates the potential to address burnout from two different directions. It is worth looking at mechanisms to reduce stress and to increase wellbeing separately.

Reach out to colleagues

The doctor in our dilemma should think about what steps need to be taken to address the situation. It can be very helpful to discuss any issues with colleagues to identify whether improvements can be made to work practices. If this is not practical, the doctor should at least try to talk over the issues with a close colleague.

Seek support

The doctor in this scenario may benefit from consulting with their GP, an appropriate specialist or occupational health physician. The advice offered must be followed, even if it means taking time off work. Remember that a doctor who is well is more likely to practise effectively and – crucially – safely.

MDDUS has useful advice for doctors on its website on improving their health and wellbeing and resilience, while the GMC lists a range of support services.

Doctors should consider also whether they could benefit from support for non-work issues, such as money difficulties or relationship problems.

The key message here is: stop, take stock and seek help with the issues you face. Do not just soldier on regardless.

Professional duty

Doctors can be reluctant to consult about their own mental or physical health, but it is important to bear in mind that they also have a professional duty to do so.

The GMC makes it clear in Good medical practice that doctors have a responsibility to ensure they are fit (in the health sense of the word) to practise.

The guidance states: "If you know or suspect that you have a serious condition that you could pass on to patients, or if your judgement or performance could be affected by a condition or its treatment, you must consult a suitably qualified colleague. You must follow their advice about any changes to your practice they consider necessary. You must not rely on your own assessment of the risk to patients."

Equally, doctors have a responsibility in regards to colleagues. A fellow clinician who is struggling should be encouraged to seek help, but if they fail to do so the GMC is clear that it expects intervention – albeit in a supportive, rather than punitive, manner.

Good medical practice states: "You must take prompt action if you think that patient safety, dignity or comfort is or may be seriously compromised.

"If you have concerns that a colleague may not be fit to practise and may be putting patients at risk, you must ask for advice from a colleague, your defence body or us. If you are still concerned you must report this, in line with our guidance and your workplace policy, and make a record of the steps you have taken."

Conclusion

• Burnout is a long-standing issue for doctors and one that has been exacerbated by the Covid-19 pandemic. But help is out there.
• Doctors must be prepared to seek outside support if their difficulties threaten patient safety.
• In all such difficult or complex cases we encourage members to contact MDDUS for advice.

Additional resource

Watch this free on-demand MDDUS webinar on stress and wellbeing during Covid.

Mr Des Watson and Dr Greg Dollman are senior medico-legal advisers at MDDUS