Getting help for sick doctors

Professor Sydney Brandon and Dr Jolyon Oxley, chairman and secretary of the National Counselling Service for Sick Doctors (NCSSD), outline the services available for doctors impaired by ill health.

Doctors are a scarce and expensive resource and there are not enough of them to meet identified demands. Concerted action to prevent stress and ill health in doctors and consequent harm to patients and unnecessary loss of doctors should be a priority. The statements and conclusions in this article are based on the experience of the NCSSD since its inception in 1985 together with a review of some of the published literature. Doctors have high standardised mortality rates in respect of cirrhosis, accident and suicide.1,2 Surveys have shown high levels of stress and related disorders among hospital consultants,3,4 general practitioners,5 and doctors in training.6

Why doctors are vulnerable

Qualification in medicine brings automatic social status with expectations of good health, good income, an assured and satisfying job, and identification with a respected profession. At the same time membership demands an acceptance of the ethos in medicine which carries an expectation of dedication, hard work, and long hours. Commitment to the individual patient and to the service makes it difficult for the physician to abandon this obligation because of personal ill health. The structure of the NHS is such that if an individual doctor is unexpectedly absent because of illness there is often no one to provide alternative cover at the same level.

For a variety of complex reasons many doctors are reluctant to seek help in the normal way when they become stressed or ill. From the experience of the NCSSD there seems to be a deeply ingrained fear that admission of vulnerability or illness will result in loss of respect from colleagues and impaired future employment prospects. Any service connected with management, including occupational health, is often viewed with suspicion. Misunderstanding of the role of both NHS management and of the General Medical Council (GMC) is common.

These concerns are compounded by the fact that many doctors either do not have a general practitioner or sign on with someone with whom they work closely. Many doctors rely on informal consultation and sometimes, in the case of doctors in training, with those barely more experienced than themselves. Such consultations, often without notes or systematic investigation, may lead to inadequate care. From an early stage in their careers some doctors begin to self prescribe for convenience or to avoid embarrassment. This may progress to inappropriate and excessive self prescription; drugs may be used to conceal symptoms of stress or of illness.

Many doctors have reservations about using their local services for reasons of confidentiality or fear of meeting patients or colleagues. The extracontractual referral sysem can make it more difficult to consult outside the local facilities. If in patient care is arranged this can bring even greater discomfort to the doctor in the form of an unaccustomed state of dependence and loss of role, the chance of sharing the ward with patients they know or facing colleagues whom they fear may be unsympathetic, or a fear that subsequent professional relationships will be impaired. Thus doctors often wish not to be admitted to any hospital with which they have a working relationship. Two thirds of the doctors dealt with under the GMC health procedures are referred on account of alcohol and drug problems. Doctors who abuse alcohol or drugs develop a remarkable capacity to deceive themselves and others, and often colleagues turn a blind eye to the problem; patients sometimes do the same.

For these reasons doctors tend to present late with serious problemsÑthe average delay between onset and consulting about an alcohol or drug problem is more than six years; similar reluctance and delay is evident for psychological distress.

The Nuffield working party review

Services for sick doctors have been reviewed recently in a report published by the Nuffield Provincial Hospitals Trust.7 This reviewed the evidence of stress related morbidity in the profession, concluding that special services for doctors could be justified in terms of the conservation of a scarce resource. Current arrangements are ill understood, fragmentary, uncoordinated, and are failing to provide a satisfactory level of support. The report recognised that it is important to reduce avoidable stress, if necessary by changing working conditions and the nature of the job, as well as by providing adequate services for those who fall ill.

Independent regional bodies needed

The central proposal of the trust's working party is the creation of a network of fully independent regional bodies to be responsible for reviewing the services available for doctors with health problems, identifying steps that should be taken to improve working conditions where these are found to be needlessly contributing to stress, drawing up recommendations for a longer term programme of improvements, monitoring progress, providing information about local and national services, keeping up with service development, and publishing an annual report.

Self help when stressed or ill

Ideally any doctor who is experiencing stress related problems should be able to consult colleagues, NHS management, the NHS occupational health service, or other local resources with the confidence that help will be provided to tackle the problems constructively.

The appropriate first stop is the doctor's general practitioner, who can assess the problem objectively and arrange more specialised help through the normal services if required. Where a doctor is unwilling to approach a colleague locally, help can be obtained from national services (see box).

Helping a colleague in need

Any doctor who gives rise to concern should first be approached by colleagues willing to share their concern and offer help and information. This task requires skill and experience. Doctors in training and other health professionals need to be assured that they can discuss concerns about the health of senior colleagues in strict confidence and without any risk to their own careers. Where the problems are clearly medical and the doctor concerned seeks help from a general practitioner or appropriate specialist, treatment will usually be possible on an out patient basis. If admission is required, either because of the nature of the problem or to protect patients, this should be arranged quickly in a unit that will provide the maximum opportunities for recovery.

If the doctor does not seek and benefit from help then several alternatives should be considered. All doctors should keep in mind that regardless of their wish to help a colleague their prime responsibility is to ensure the prevention of harm to patients.8 There may be local mechanisms such as the “three wise men” procedure.9 Trust medical doctors, local medical committee secretaries, and health authority directors may need to be involved. The GMC can be consulted for informal advice. The key is to get the problem sorted out locally before any harm to patients occurs.

Alcohol and substance abuse

Where alcohol or substance abuse is a factor, the general practitioner needs to be involved and referral to a specialist service arranged. The Sick Doctors' Trust's national helpline for addicted physicians provides 24 hour advice and an intervention service. The British Doctors' and Dentists' Group, constituted by those in recovery from addiction, provides support groups. It also welcomes students. DrinkLine, a national alcohol helpline, gives advice to those concerned about their own or someone else's drinking.