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| Dr Refshauge, Prof Beverley Raphael, the Director, Centre for Mental Health, and Dr Tony Williams, the Independent Chair of the Doctors' Mental Health Implementation Committee, celebrate the launch of the policy and strategies. |
The NSW Government has hailed a new mental health policy for doctors as a landmark initiative. Speaking at the launch of the NSW Doctors' Mental Health Policy and Strategies for Area Health Services Health Minister Dr Andrew Refshauge said that the initiative would lead Australia in protecting the mental health and well being of doctors.
"This initiative will provide appropriate, accessible support to doctors by setting clear pathways to obtain confidential treatment," Dr Refshauge said.
'Doctors are notoriously bad patients - and I am no exception! There is a tendency for self-diagnosis and treatment, self-prescribing and corridor consultations.
"We have a responsibility to ensure that doctors' work practices and work environments are safe, healthy and provide the appropriate support."
The key points raised in the policy include the following:
 | Stress management and promotion of mental health should be taught as an essential part of being a doctor |
| Every doctor is recommended to have their own general practitioner |
| At times doctors need to step out of the caring role and be cared for themselves; and |
| The Doctors' Health Advisory Service is endorsed as a confidential service for advice on mental health and stress-related problems. |
The Strategies for Area Health Services are geared to assist those organisations to implement the policy. The aims of the strategies are to create a positive work environment that promotes the well being of medical staff.
The policy and strategies were developed by the NSW Doctors' Mental Health Implementation Committee. The next key facets of its work to be completed are Strategies for Medical Colleges and Strategies for Medical Schools.
| Doctors across NSW will soon receive a new brochure informing them of the development of a comprehensive program to address their mental health and well being. At the time of publication the Doctors' Mental Health Implementation Committee was making final refinements to the brochure, and was expecting to distribute it in early July. |
The Doctors' Mental Health Implementation Committee was born from the original Doctors' Mental Health Working Group that released a major report in May last year. The Working Group, chaired by the Director of NSW Health's Centre for Mental Health, Professor Beverley Raphael, published its findings about the incidence of suicide among medical practitioners and growing evidence of unrecognised and untreated stress and mental illness. It outlined 80 recommendations to address the problem.
The Implementation Committee was established subsequently to condense the recommendations and other findings into a practical and workable policy containing strategies targeting NSW students and medical practitioners. It has a wide ranging membership and is acting in a medical climate where there has been a groundswell of support among not only NSW doctors, but medicos across Australia and around the globe for more effective prevention and treatment for doctors suffering from the stresses of medical practice.
According to the Independent Chair of the Committee, Dr Tony Williams, the first act to promote doctor awareness about what the Committee’s efforts is the distribution of a brochure to every registered medical practitioner in NSW.
The brochure outlines the plans of the Implementation Committee including the development of a Policy and strategies for doctors' mental health and well being. It includes information taken from local and international studies and will inform doctors of the extent of the problem and of the plans to address them.
Dr Williams, who is a consultant psychiatrist, says that what the Committee is trying to put across to doctors is that it is okay to be a patient. "There are times when they have to step out of their role of caring for others and look after themselves," Dr Williams said.
"And also it is important to convey to them that they shouldn't be treating themselves and engaging in corridor consultations, but in fact have their own personal doctor - their own GP - and feel comfortable about seeking help when necessary."
The proposed mental health and well being policy is geared to help Colleges, Area Health Services and Universities develop appropriate programs to assist medical students and doctors to maintain their mental health and well being and measures for intervention if problems develop. According to Dr Williams medical organisations currently don't have formal guidelines or policies in place to refer to when a difficult situation arises.
"It is often left up to individuals with no particular guidance working in the particular medical organisations, and it is clear that at times this hasn't worked,' Dr Williams said.
"What we're hoping is that this policy will lead to doctors looking after themselves from the mental health and well being point of view in a better way.
"But also it will mean earlier intervention and hopefully the prevention of problems and tragedies."
Following approval by the Implementation Committee the Policy document is due to be disseminated to all the relevant medical organisations within the next month or so. The Committee will then liaise with key representatives from each organisation to help formulate strategies and programs in line with the policy.
The NSW Doctors in Training (DIT) Forum met for the first time in April 1998 at AMA House, St Leonards. Junior doctor representatives from urban and country hospital RMO associations, learned college training programs, the NSW Postgraduate Medical Council and industrial bodies as well as the NSW AMA DIT Section attended the all day meeting on a Saturday. The meeting comprised a series of presentations in the morning and an open meeting concerning several current issues affecting postgraduate medical training in the afternoon. This was the first time such a wide and representative group of NSW junior doctors had met, covering all stages of training from medical students to senior registrars.
The presentations covered the recent Brennan report to
the Medical Training
Review
Panel (MTRP) concerning selection into training programs; the AMA Safe Hours
campaign; the NSW Doctors' Mental Health Implementation Committee; a proposal
for more university-based postgraduate medical training; and the registrars'
self care project from the National Registrars' Association (NRA) of the RACGP.
Mr Russell Noud, Industrial Officer at the Federal AMA, gave an update on the latest developments surrounding the Safe Hours Campaign. Mr Noud revealed that the Committee overseeing the project was aiming to establish a code of practice that regulates the hours that junior doctors work, and then develop a database to build that code. He mentioned that data had been collected at seven major hospitals across Australia to gain an accurate indicator of the hours worked by junior doctors and the activities completed during those hours.
Mr Noud also stated that one of the key aims of the campaign was to see junior doctors' working hours and Fostering pattern implemented into Occupational Health and Safety Legislation.
Dr Tony Williams informed the Forum attendees 
of
the activities of the NSW Doctors' Mental Health Implementation Committee. Dr
Williams, the independent Chair of the Committee and a consultant psychiatrist,
told the meeting that the Committee was finalising a brochure
explaining its philosophy and what it has been doing to this point. (See the July
issue of The NSW Doctor for further information about the brochure). The
Committee is now formulating a series of policies and guidelines focussing on
detection of mental ill health and possible actions to treat it. The plan was to
develop those policies and guidelines in conjunction with the NSW
Department of Health, the AMA,
learned colleges and the Rural Doctors Association.
One of the liveliest discussions of the Forum came during the session about the General Practice Training Review and the Registrars Self Help Program, which was presented by National Registrars Association Chair (and RACGP Registrar Liaison Officer) Dr Fiona Middleton. During the question time following Dr Middleton's address a barrage of questions were directed at her about the GP training program and the current training position ceiling of 400. The forum participants expressed strong concerns about this figure and the fact that last year over 700 people had applied for a position. Dr Middleton explained that it was not the RACGP that dictated that limit, but the Federal Government, which decides the College's funding avocation. However she added that GP registrars felt that there should be more training places made available.
In the afternoon session of the Forum an open meeting was held. This meeting was a chance for junior doctors to discuss the issues brought up by the morning's presentations and to help the AMA identify issues of concern. The round table format was very successful and indeed several felt that for the first time their concerns were being heard by all.
The meeting identified several issues of concern to all, including: safer and shorter hours of work in hospitals; support and identification of junior doctors in difficulty; the implications of provider number restrictions on access to careers and training; and the role of the AMA in protecting the professional and collegiate interests of junior doctors.
The meeting confirmed that the concept of a NSW DIT Forum was sound, and that it should meet on a regular basis. Its major roles should be to share information; provide a venue for discussion of professional and training issues, provide a conduit for junior doctors to present issues of concern to the NSW AMA; and provide consultation on DIT issues to the NSW AMA Branch Council.
What was gratifying in convening the Forum was the commonality of concerns amongst so many groups, and a recognition that by working together common goals were achievable. There was a distinct atmosphere of genuine hope and achievement amongst the attendees. The meeting hoped that the NSW AMA could continue to convene Forum meetings.
By Martin Foster
| The
Doctors' Mental Health Working Group report has laid the foundations for a
comprehensive new strategy focussing on the stress illnesses and mental
health of medical practitioners across NSW.
In this special feature: |
 |
The Doctors' Mental Health Working Group has been convening since June last year and its discussions from the initial meetings to this point have produced the data for a comprehensive report into the mental health of NSW medical practitioners.
The report was compiled in direct response to concerns about the incidence of suicide among medical practitioners, and growing concerns about doctors who are suffering from unrecognised and untreated stress and mental illness. Since 1992 there have been 21 known cases of medical practitioners taking their own lives, and recently the issue of doctors' mental health has entered the public forum via sustained high profile exposure among the wider media.
As a key member of the 20 person Working Group AMA NSW Medical Secretary Dr Craig Lilienthal has watched the report evolve through every phase of its compilation. Dr Lilienthal, who is also the Honorary Secretary of the Doctors' Health Advisory Service (NSW), said that its findings highlight how important it is for all medical practitioners to look after themselves and their colleagues'.
"One of the major problems is that medical practitioners don't see the preservation of their own health as a major priority," Dr Lilienthal said.
"Corridor consultations, self-diagnosis and self-prescribing of medications all lead to increased health problems amongst medical practitioners. Many are simply reluctant to admit they have a problem and to seek treatment.
"We recommend that all professional bodies implement policies that encourage doctors to regularly consult their own general practitioners, avoid prescribing medications to themselves or their families, look after their own health and manage the mental health problems of their colleagues."
The report's other key recommendations include:
| All intern and resident programs and registrars and specially trainee programs should develop formalised support systems for doctors, and schedule regular sessions to discuss stresses experienced by interns, RM0s, registrars and specialty trainees and to promote coping strategies to deal with those stresses |
| Undergraduate courses should provide training in stress management and coping skills to all undergraduates, and provide training in "life skills", emphasising the importance of developing and maintaining interests outside medicine |
| Doctors should have training in early recognition of signs and symptoms of stress and psychiatric illness. |
| Doctors have a responsibility to regularly consider their own behaviour and emotions, and seek help if they suspect that stress or mental illness may be affecting their functioning |
The report was officially launched to the public at a media conference on May 29. It was released by the NSW Deputy Premier and Minister for Health Dr Andrew Refshauge, together with the NSW AMA and Professor Beverley Raphael, Director of NSW Health’s Centre for Mental Health, and the Chair of the Working Group.
Dr Refshauge said the report was all about caring for the carers.
"While this is a complex issue ... my focus will be on prevention and early intervention," Dr Refshauge said.
"Doctors spend their days providing help to others, but often find it difficult to ask for help for themselves.
"Doctors have to realise that they too are human, and like the rest of the community can experience mental health problems."
The State Government has already thrown its support behind a number of new initiatives that will form part of the first phase of the new mental health strategy, and will be put in place as a matter of urgency. They include:
| A hotline for doctors to obtain advice about how and where they can seek help |
| The Centre for Mental Health and the AMA will jointly provide expert advice on ways to best help and support staff affected by the suicide of a colleague. |
| A 'Healthy Hospital Scheme' focussing on staff mental health education and awareness |
The AMA and NSW Health have established an implementation working group to begin to transform the report's recommendations into actions. In the next few months the group will be liaising closely with Area Health Services, Specialist Medical Colleges and University medical schools in a bid to encourage the development of its mental health schemes. The AMA is hopeful that the end product of the Working Group’s strategy will be model for other health professionals.
'The NSW Branch of the AMA is looking forward to working with the State Government and the NSW Health’s Centre for Mental Health in a united campaign to address the issues surrounding the mental health of doctors," Dr Lilienthal said.
Depression is a common disorder affecting many people in the community.
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| AMA NSW Medical Secretary Dr Craig Lilienthal, NSW Deputy Premier and Minister for Health Dr Andrew Refshauge and the Director, Centre for Mental Health, NSW Health, Professor Beverley Raphael launching the Doctors Mental Health Working Group Report. |
Doctors, like all other members of the community may experience both depressive symptoms and depressive disorders. Recent concern about the suicide of doctors clearly indicates that despair and depression are major contributing factors, yet there is relatively little known about the prevalence of these disorders among the medical, or for that matter other health professionals.
The report of the Doctors' Mental Health Working Group highlighted the paucity of published data concerning doctors' mental health both in Australia and overseas. The few studies examining depression and anxiety have consistently reported one year prevalence rates of depression in the order of 13-20 per cent, and rates for anxiety of up to 30 per cent (1, 2). The majority of studies pertaining to doctors' mental health have focused on rates of substance abuse, but are characterised by relatively low rates of response and self-reporting. However trends emerge, the most significant of which is that benzodiazepine and opioid abuse and dependence are more prevalent than in non medical peers, with the extent of reported lifetime alcohol abuse or dependence varying from 2 -13 per cent (3-5).
It is difficult to determine true rates of suicide by doctors, as it is known that not all suicides are identified, and in doctors this may be compounded by deliberate misrepresentation on the death certificate to avoid embarrassment (6). Additional difficulties arise from the fact that suicide is actually a relatively rare event and there are a small absolute number of suicides, that in NSW the Medical Board only has (incomplete) data for a few years, and that it is difficult to determine exactly how many doctors are practising/living in NSW at any one time.
Most studies of suicide in doctors report a substantially higher rate of suicide for doctors compared to both the general population and to other professionals, with a roughly two times increased risk (6-8). The relative increase in risk is even greater for female doctors.
The working group noted that there were 21 known suicides of doctors between 1992 and March 1997, while it least one other tragic suicide has come to attention since then (9). Assuming 22,000 registered doctors, this very crudely equates to a rate of 19/100,000 p.a. (compared with a NSW community rate of 12/100,000, and an age/sex matched rate of around 15/ 100,000) (10-11). However anecdotal evidence supports a considerably higher rate of suicide, with at least nine Anaesthetic registrars and specialists thought to have suicided in the past 4 years (Australia wide) (12).
There are no clear studies documenting reasons doctors may be particularly vulnerable to depression and suicide, and in fact although the rate of depression in doctors is very significant, it may be that this rate is roughly equivalent to that in the general population. However stressors which have been suggested to be especially relevant to doctors include the high levels of responsibility and urgency associated with working in emergency settings, the prolonged and rigorous higher education process, constant exposure to physical and psychological trauma in patients and their families, long working hours under poor conditions, conflict between work and family responsibilities, and working in systems which have unrealistically high expectations and are intolerant of failure. Recent changes in the practice of medicine may exacerbate these stresses, and include increasing emphasis on efficiency, increasing requirements for formalised accountability, increasing threats of litigation, decreasing cohesiveness of the profession, decreased opportunities for unhurried consultations, perceptions of a decline in the status of medicine, and uncertainty about future career options.
As well as being exposed to stressors peculiar to medical life, doctors may have additional risks in terms of not being attuned to the idea that they can also suffer the ills that they are trained to treat. Personality factors may also contribute to both a lack of recognition of problems, and difficulty in seeking and accepting treatment. By definition most doctors are high achieving, competitive, able to defer gratification and to a greater or lesser degree preoccupied with their profession. While these traits are generally advantageous, they may limit a doctor's ability to recognise, or acknowledge, difficulties. Even if a doctor does recognise the problem, he/she may deny its severity or significance, and is at risk from inappropriate self diagnosis and treatment.
Other inhibitions may arise from the doctors' unwillingness to accept the role of patient, perpetuated by their sense of responsibility to their own patients. The dependence of many doctors on viable and functioning practice to generate income, and the fear that suffering from mental illness or stress may result in disqualification from practice, are also barriers to seeking help. Practical difficulties arise from the lack of clear referral and management pathways for ill doctors, and the lack of disseminated expertise in treating the disorders and precipitants which are particularly relevant to doctors.
The major focus of the recommendations of the working group is on prevention and early intervention, and is aimed at encouraging doctors and medical students to develop strategies and work practices which will ameliorate the stresses associated with medical practice. Emphasis is placed on doctors being aware that they are at risk from stress and mental problems, and that they have a responsibility to "look out" for both themselves and their colleagues, and to seek appropriate professional care as patients.
It is also crucial that clear systems of referral, treatment and rehabilitation for doctors with mental health problems or difficulties be developed, and that postvention programs are developed to minimise the impact of a doctor's suicide or impairment on their family and peers.
The AMA (NSW Branch) and the NSW Health Department have formed a small "Implementation Committee" to develop strategies to aid in meeting the recommendations of the working group. Formal meetings will be held with key stakeholder organisations who will be involved in implementation to discuss their participation and contribution to the strategy, with the longer term aim of forming a Standing Committee to oversee and promote developments in the sphere of doctors' mental health. One of the immediate responses, which I and Dr Hugh have a particular interest in, will be to develop protocols to provide support to colleagues and hospitals in the event of suicide.
It is important to note that the working group is but one step in a continuing process which seeks to address the issues relevant to doctors mental health, and that ongoing commitment, research, discussion and intervention is required if significant gains are to be made. Self examination and treatment is a difficult art, and one that is likely to be flawed by the biases of the examiner. The message from the Doctors' Mental Health Working Group is that while this is generally inappropriate for individual doctors, it is vital for the profession to be committed to self examination, in order to protect and promote the well-being of its individual constituents.
REFERENCES
7. Richings J, Khara G, McDowel M: Suicide in Young Doctors. Br J Psych 1986,149, 475-478,
9. Johnson P, NSW Medical Board. Personal communication 1996
10. Stewart G, Chipps J, Sayer G. NSW Public Health Bulletin, 1995, 6, 49-52
11. Stewart G, NSW Health Department, Personal communication 1997
12. Goulding G, "Welfare of Anaesthetists" group. Personal communication 1996
Copyright
© 1998-2004.
Medical Benevolent Association of New South Wales. All rights reserved.
Citation suggestion:
Medical Benevolent Association of NSW, NSW Doctors Mental Health Implementation
Committee Scrapbook (http://www.dmh.org.au/dmh/scrapbook.html) [date
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Last revised: 20 April 2004 16:05
