“How are you? Do you really want to know?"
There has been a slow cultural shift to reduce the incidence of poor inter-professional behaviours which have previously plagued medical practice. Problems of poor mental health, suicide and substance abuse continue to be a significant issue. But fortunately there is considerably more openness about the incidence and impact of these issues; as a result a far more positive wellbeing culture is emerging. However, this has brought with it a new challenge: how do individuals deal with problems of poor mental health, suicide and substance misuse in their colleagues now they are acknowledged? One of our Paediatric Emergency Medicine Trainees, Catherine Nunn, explores this in a post reflective of potential real-life encounters that most people working in medicine may have experienced.
I met a colleague I had not seen for some time in the corridor and the following exchange took place:
“Hello Adam, it’s nice to see you. How are you?”
“Alright. You know I’ve split up with Amy? The kids are taking the divorce well, but they’re struggling to get the dose of my antipsychotics right.”
I know that I have one of those personalities that people open up to relatively easily, but I was not prepared for this as an opening to a conversation. I wonder if I am alone in thinking that closer supervision of trainees – with an increasing emphasis on pastoral support and increasing acknowledgement of the impact personal difficulties can have on performance – is likely to uncover previously unrecognised but very relevant issues. Encouraging units to be supportive, friendly and welcoming will foster a culture that supports work and family and help staff look out for (and be kind to) each other. This (rightly) may well lead people to suddenly reveal why you need to be kind to them.
Some of these people will have deep psychological and physical needs which some may realise and acknowledge, but some will not. How far can we meet them? On the whole, medical professionals are not trained counsellors. Most of my colleagues will have had sparse training on how to deal with sexual assault, marriage break-up, the fall out of previous child abuse or domestic violence. The amount of time you take with people will undoubtedly be affected by not only the type of relationship you have with them but the depth of the relationship you have cultivated, as well as the initial purpose of the relationship. With continually rotating teams, both the length of time you have known this person, and the length of time you are going to have to spend with them later, will influence the action you take.
Our responsibility to our friends is clear: a poor friend it would be indeed who didn’t support someone in difficulty regardless of the professional skills they had at their disposal. However, our responsibility to our colleagues has previously only been clearly delineated if they are a risk to patients. As the stigma is taken away from mental or personal issues within health care professionals, it is possible a generation of staff may find themselves not knowing how best to deal with someone who has disclosed a significant life event to them.
Current strategies I have witnessed include delegation of caring: perhaps to their supervisor, someone who knows them outside of work, or to any member of the team who seems to care. I have been delegated “the job” of increasing an SHO’s confidence. This may well be appropriate; your friends can reasonably expect to care more than a new colleague. But if there’s no friend available it should be clear what the task is and what the outcome should be. In addition, the delegated party should have adequate time, experience and motivation for the task.
A stratagem of dark humour has been a mainstay of medical ‘interventions’ but while this may be useful to diffuse the situation and relieve embarrassment it is unlikely to deal with any substantial problems.
Sometimes the problem is reframed as an education or confidence issue. Your divorce may well impact on your confidence and therefore training, but the problem isn’t your confidence. It’s your divorce. Can we really expect trainers to help with that?
Online resources like forums can be a great outlet and also an excellent support network, especially for people struggling with a similar issue. It enables people to seek support anonymously and also instantaneously. I have no doubt that this is incredibly useful, and will have kept some people safe when they really needed it. However, these are answered by humans who just happen to be available, not necessarily with any formal qualifications, special interest or experience.
I have no wish to discourage people being kind to each other, or disparage the incredible and justified efforts of the medical community in trying to get everybody to behave like decent human beings. This is correct, and unfortunately necessary. But like everything else, there are unintended consequences, and how do we deal with them?
Risk stratification will aid thinking out what possible options are and how they should be employed. If this person is a risk to patients, themselves or others then obviously immediate threats should be dealt with immediately. If they are a risk to their learning or career progression then a slow structured approach is more suitable.
Most people will respond to someone simply by listening, and this can be done by any empathetic member of the team. Ideally this should be someone in a supervising role as they will be best placed to assess whether this problem is having any impact on either work or learning, and are likely to be experienced enough to anticipate if that might occur in the future. Experienced supervisors will also be able to ensure clarity on what is expected of colleagues. Depending on the issues there may need to be a jointly documented agreement on expected levels of attendance, learning, or engagement with support agencies.
Some people with either more persistent or serious problems will require more input, and these are best dealt with by qualified professionals. There are well-developed referral pathways for many problems (see our list below), but in the meantime colleagues can simply continue listening and valuing this person.
Doubtless, in an already stretched environment, questions will be raised about how much time you can or should spend on people. I would argue that enabling people to fulfil their potential is organisationally worthwhile, and that it is worth allocating time specifically for this purpose.
There are no simple answers to how much we can, should, or want to care for others in our working lives, except that they are all people, just as we are.
Amica: a free counselling service that all NHS trust employees can self-refer to (Tel: 0116 254 4388)
Chaplaincy: a listening ear – the chaplaincy are offering a free service to anyone in the trust wanting to talk about anything that is causing them stress (Tel: 0116 229 4055; Email: firstname.lastname@example.org or email@example.com)
You may wish to consult your Trust intranet for various ‘Well-being at Work’ schemes available to staff.
Emotional help, mental illness and addiction: BMA counselling and doctor advice service (Tel: 020 7383 6707 or 0300 123 1245)
HEEM: some good counselling and coaching available via the professional support unit, but it’s only available for trainees referred by their educational supervisors.
Several of the royal colleges offer specific help to trainees – visit your royal college site for details.
Tea and Empathy: a Facebook based group that offers online support for all people working in any role in healthcare
NHS Practitioner Health Programme (PHP): this is a free NHS service for doctors and dentists with mental or physical health concerns or addiction problems, in particular where these might affect their work (Tel: 020 3049 4505; Email: firstname.lastname@example.org)
NHS GP Health Service: an NHS service for GPs and GP trainees in England. The GP Health Service can help with mental health concerns, including stress or depression, or an addiction problem, in particular where these might affect work. (Tel: 0300 0303 300; Email: email@example.com)
Doctors’ Support Network (DSN): an organisation whose core function is to provide support and information to doctors and medical students with mental health concerns.
British Doctors and Dentist Group: the BDDG is a mutual/self-help group of doctors and dentists who are recovering from chemical addiction, including alcohol or drugs (Tel: 07825 107 970; Email: firstname.lastname@example.org)
DocHealth: confidential service providing psychotherapeutic consultation service for all doctors, with senior clinicians. This service is delivered by Consultant Medical Psychotherapists based at BMA House in London (Tel: 020 7383 6533; Email: email@example.com)
NHS Resolution: Practitioner Performance Advice (formerly known as NCAS) works to resolve concerns about the practice of doctors, dentists and pharmacists by providing case management services to health care organisations and to individual practitioners (Tel: 020 7811 2600)
No Panic: a registered charity which helps people who suffer from panic attacks, phobias, obsessive compulsive disorders and other related anxiety disorder (Tel: 0844 967 4848; Email: firstname.lastname@example.org)
Royal Medical Benevolent Fund: a doctors’ charity for doctors, medical students and their families, who are facing financial hardship as a result of illness, injury, disability, bereavement or age (Tel: 020 8540 9194; Email: email@example.com)
Please note: this list is not exhaustive. Feel free to talk to someone you trust in your department if you are concerned about any issues raised by this article.