Doctors, their wellbeing, and their stress

Countless studies of the levels and sources of stress in doctors have taken place in the UK over the past 20 years. My own longitudinal study, begun with students in 1983,¹ was in response to two registrars asking me if someone could do something on the stress and depression that they saw around them. Two of their house officers had killed themselves in the last month, and no one had discussed or mentioned it within the teams. It was unmentionable. Over the years some things have changed, and some have stayed the same. This week's theme issue in Career Focus concentrates on ill and stressed doctors.

The proportion of doctors and other health professionals showing above threshold levels of stress has stayed remarkably constant at around 28%, whether the studies are cross sectional or longitudinal, compared with around 18% in the general working population.¹,² What has changed over the years is that, contrary to the experience of the two registrars, doctors have become used to discussing the topic of stress and even to admitting to it in themselves. Theyare more aware of their colleagues' symptoms than they were, which means that they may be more likely to help colleagues through a difficult time or suggest they get help when they need it.

Interest in stress has broadened as organisations have finally accepted that stress costs them vast amounts of money—through absence, litigation, and the fact that unhappy, tense, tired, or anxious doctors do not produce quality care.³ Indeed, stressed doctors may make considerably more errors than those whose sense of well being is high.⁴ This is particularly true if they have insufficient hours of sleep;⁵ however, we now know that working long hours in itself is not the cause of problems provided a doctor feels well supported. Stress and all its related problems come both from the workplace and from the individual. Individual causes may be to do with personality or with ways of thinking, such as being particularly self critical, or having certain types of unsupportive early family relationships; or they may come from job related factors such as lack of sleep, poor communication, and poor teamwork.³ Better teams have less stressed staff,⁶ probably because they support each other, notice when one person is performing below par, and step in to help.

Making mistakes is a major stressor—not a new one, but one which is escalating alongside the price of error and the raucous publicity that surrounds it. The misery that can follow, unless such errors are turned into genuine learning opportunities, can stay with doctors throughout their lives.⁷ Handling error sensibly and sensitively for patients and doctors alike has become a critical requirement of management.

So what is being done to lower the stress levels of our medical staff and thus raise the well being of their colleagues and their patients? What is now being done that was not done 20 years ago when stress was a forbidden word? Well, soon after the first reports of high levels of stress and depression in doctors became apparent, the National Sick Doctors scheme began, the BMA set up a telephone helpline, and most regions began to provide a free counselling or psychotherapy service for doctors. Initiatives from the Department of Health come and go. Hours have reduced and sleep patterns improved, largely due to pressure from Europe. However, I am not aware that a truly proactive means of attending to the health of NHS staff, including doctors, has been planned.

What we need is a systematic approach to the problem.³ We need to accept (rather than constantly rediscovering) that we know enough about the main causes of high stress levels in doctors to address the principal organisational stressors using primary preventive interventions. Providing teamwork and leadership training to clinicians would be an excellent beginning, and making quite simple changes to the way work is organised—such as having a 12 month house officer rotation in one hospital rather than two—appears to affect stress levels dramatically.⁸

There can be primary prevention for individuals too through training, career counselling, and educating about error. When these strategies are not enough, there need to be secondary services providing coaching, counselling and psychotherapy, or alcohol and drug treatment that are available rapidly for staff, showing the acceptance that things do go wrong for most people at some time or other.

Stress is here to stay and the sooner we accept that tackling it is a normal part of management, and an essential part of patient safety, the sooner the lives of doctors and their patients will improve.