Living Well Working Well

RACS18Living Well Working Well Workshop

Collaborating for good mental health in our workplaces

@DrEricLevi

Workshop presented at Combined Royal Australasian College of Surgeons and Australian & New Zealand College of Anesthetists Annual Scientific Congress #RACS18 #ASM18SYD on Monday 7th MAy 2018

Introduction, Greetings, Jokes, etc.

The good thing about a workshop like this is that it is a small group and we are preaching to the converted and committed. You are the choir that will sing songs of wellness. You are here this early on a Monday morning because many of you are committed to this issue, or at the very least, know that this is an important issue that is worth exploring further. The goal of this workshop is to give you a framework, toolkit and some practical ideas on implementation. The challenges are unique to each department. The solutions for Middlemore hospital is going to be different to those of Logan Hospital or Frankston Hospital. This workshop should give you some seedlings of ideas that may grow differently in different departments. We also hope that this begins a networking opportunity where we can compare notes on what works and what doesn’t.

Ok. Let me set the stage. I’m going to touch on 3 things.

  1. The problem
  2. The problem with the problem
  3. The problem with current solutions

I’ll be reasonably quick because I’m the appetiser and I want to give Tracey as much time as possible to talk about the framework for solutions.

Firstly, The Problem.

Just this weekend yet another in depth article came up on a major newspaper. This time it was The Australian newspaper that published on Doctor Suicide, titled Wounded Healers. I’ve seen similar articles on The Age, The Sydney Morning Herald, The Brisbane Times and the New Zealand Herald. The New York Times has picked it up too. So does the New England journal of Medicine on it’s more recent editorial.  It is certainly a topic that is gaining momentum and social recognition in the community. It’s a dark topic that carries with it a lot of emotions and frustrations and we have to be respectful in this space, knowing that each of us would probably know someone who has suicided and if we are honest with ourselves, all of us would have been near that point of quitting. Quitting medicine or quitting life altogether.

What is the scope of the problem?

These are the stats that you can quote to your Department Heads and Hospital administrators. These are all taken from The Australian National Mental Health Survey of Doctors and Medical Students published in October 2013 by Beyond Blue. Compulsory reading of the state of play in Australia, and I would also guess, in New Zealand.

Out of 12,250 doctors, 21% reported having ever been diagnosed with, or treated for, depression. If you have 5 operating theatres, one of them would have a depressed surgeon or anaesthetist. This rate of depression is similar to the general population.

However, what is statistically significantly higher than the general population is the fact that 24.8% of doctors reported to have had thoughts of suicide in the past and overall, 2% had attempted suicide. This is significant because someone on your table have had thoughts of suicide and someone in your anaesthetic or surgical department may have attempted suicide. Last year I lost a friend and colleague to suicide. You may have experienced the same too.

Stats on suicide and depression are available in the public domain. These are seriously frightening numbers and we know these numbers. Depression is a clear medical diagnosis. Suicidality is a recordable sign on mental health examination. There is another set of statistics we need to keep an eye on, and that’s the statistics for burnout. In the last 10-15 years research on burnout has been increasing. What is burnout? The term burnout was coined in the 1970s by an American psychologist, but it was only in 2001 did we have the first measurement associated with it, based around the work of Maslach. We call it the Maslach Burnout Inventory. The general consensus is that burnout is a psychological state characterized by 3 things: emotional exhaustion, low professional efficacy and high cynicism (or depersonalization) which are caused by (and this is critical) chronic occupational stress. That’s why the term was coined initially specifically for those in the helping profession. But burnout is not a medical diagnosis. It is not like depression or PTSD. It is not in the DSM5 or ICD10. We do not have a totally agreed upon definitive definition. Some think that burnout overlap with depression, others think that burnout causes depression and yet others think that at it’s core, burnout is depression. Whatever it is we know when we see it, sense it or feel it. Chronic occupational stress, compassion fatigue, the curse of the caring profession.

What are the stats if we measured it in the Australian Doctors population?

  • Emotional exhaustion 47.5% – how can we care for patients, our colleagues and our team members if every other health worker has an empty emotional tank?
  • Low professional efficacy 17.6% – this is bad for business and for patient safety, don’t you think? These doctors make more mistakes, order more defensive tests, and do everything slower. Your hospital admin needs to know that 17% of their doctors are not working at full capacity.
  • High cynicism 45.8%. I’m highly cynical about this number though. In my experience I have never met a cynical anaesthetist and I reckon the number of cynical surgeon is probably close to 100%. You hear it in the way we talk to each other and talk about ‘the other specialty’.

Do you think these numbers are representative of your experience?

Secondly, what is the problem with the problem?

Well, the problem with the problem is that we are the problem. We are the study population itself. We are working within the matrix that precipitates and exacerbates the problems. Like a fish being asked to define water, we are sometimes ignorant of our own environment and experience. We are our own problem but we are our own solution.

We have depression intermixed with burnout. Is it part of a spectrum from stress to burnout to depression to suicidality? Are there 2 different pathways of pathophysiology? Are they overlapping association or are they causative relationship? Is depression from an internal trigger, burnout from an external work trigger? Throw in bullying and harassment, which is rife in surgery and anaesthesia. Add in complications and poor patient outcomes. Is it a bit of PTSD thrown in? Add in difficult exams. Add in generational expectations. Add legal and ethical expectations, the mandatory reporting laws that hinder clinicians from getting help. Add the perfectionistic attitudes that we hold ourselves and our colleagues to. This becomes quite a complex problem and like anything else that is complex in Surgery and Anaesthesia, there are simply no simple solutions. It’s like the elephant in the room. You know the analogy. We are all blindfolded and asked to feel this elephant. Some would describe a wiggly trunk, others a hairy leg, and others the floppy ears. We still haven’t got the full picture on this elephant.

The fact remains, how did we get the brightest minds in the country, the A-students, the resilient characters who are accustomed to hard work and who have aced every exams and who started with the same underlying prevalence of mental health, and we put them through training and on the other side of training we get high burnout and suicide rates?

This is not a generational problem. It’s not about soft millennials. Older consultants commit suicide. This is not a gender problem. Although women are at higher risk, men commit suicide too. This is not a specialty specific problem. This is our problem. And until we say that this is our problem, we will always end up pointing our fingers at something else.

So thirdly, what is the problem with the current solutions?

What do you think has been the most common solution to this problem? Whenever we talk about depression, suicide and burnout, another word keeps getting thrown in. Do you know what that is? Resilience. We have clever minds, doctors who work ridiculous hours, deal with life and death complex problems and have spent years in training, and we tell them, you just have to be more resilient. That can be dangerously victimizing if resilience training is the only solution to this complex problem.

Let me be clear: there are general and specific risk factors for mental illness that is inherent in those who are in health care. Resilience training, mindfulness, self-care are all necessary and important. But they cannot be the only solution. Depression and suicidality is a diagnosable mental illness that requires psychiatric support and medication. Not simply more mindfulness. You need to tap into resilience training, psychiatric and counselling support alongside other solutions. There are systemic issues that cause burnout which also need to be addressed. It’s the frog in the boiling water analogy. You can’t simply teach the frog resilience training. You need to do something about the boiling water as well. Tackle the bullying and harassment. Tackle the poor working condition. Tackle the poor leadership. Tackle the poor occupational support.

We learn in medicine that chronic complex problems require multimodal complex disease management plan. Let’s apply the same principles here. Multimodal, multifactorial approach. This is where the Framework comes in. This is the multimodal approach. This is a way of looking at the multifactorial issues and coming up with tailored plans for your department. This is where we say, this is our problem. This is our colleagues and our future. Let’s make a difference in our working environment.

Tracey will now go into the specifics of the Toolkit. But before we go into the practical end of the workshop, can I leave you with 3 important thoughts as takeaway principles as we explore this framework?

  1. These are people, not problems. They’re not problems to be solved, they are our colleagues. They are people whose lives matter as they devote their lives to caring for others.
  2. Small changes make big differences. Our interventions do not have to be expensive or extensive. Simple weekly coffee or phonecalls. Appointing a caring welfare officer who’s committed in the department. Creating a safe lounge for chats. Our colleagues may not need another video module. They need a place to sleep after a long shift.
  3. A safe workplace is a physically and mentally safe workplace. There is no point having the best facilities but a reputation for toxic work relationships. Creating a safe and positive workplace require people like us championing it from the inside to influence the culture.

Let’s do this. In the words of my good friend, Yes We Can.


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