Rethinking Doctors Wellbeing Interventions

We have a complex problem. There really is not a single simple solution to the issue of clinician burnout and the poor wellbeing of today’s doctors. We need to accept this. The proponents of yoga and meditation need to know that no amount of mindfulness can fix an abusive hierarchy. Those who think good legislations can stop problems from happening must know of recent examples where unit leadership have failed to enact those regulations and allowed junior doctors to suffer from poor working conditions. The Royal Colleges feel that this is not within their jurisdiction, although in practice, Members and Fellows of the College are the standard bearers on the ground. Mental health of doctors is one of many specific challenges that need to be addressed specifically. Culture cannot be changed by legislations alone. Individual counselling relieves downstream effects but has little effect on upstream problems. Human resources and institutions are caught in a tangled web of limited resources and increasing demands placed upon doctors. Let’s agree that no single simplistic solution can fix this complex problem that has been years in the making. No one intervention is better than another. We need complementary approaches to the many elephants in the room.

There is hope. More and more we are realising that a multifactorial multipronged approach is needed. There are champions of change all over our institutions. The time is right and we are almost at that tipping point for change. We’ve heard of enough suicides and we have hurt alongside their families and communities. We have seen the data on doctor depression and burnout. We are agitated for change. The next few years will see an optimistic cultural change. There will be pockets of delay for sure. There will be small battles occurring everywhere. Change is not easy for many and a change of habit is hard for all.

Conceptually speaking, this is how I think about the levels of intervention that we can apply to our problems. All of us doctors are down at the pointy end of that pyramid: frontline, engaged with the patient and community. But some of us doctors and non-doctors are also at other levels of governance and can exert powerful influences. There are many interventions that can be applied directly and indirectly affecting the doctor at the front line. It would be so exciting to see these interventions applied at all levels.

1. Individual

Personal health and wellbeing. Family. Exercise regime. Meditation. Mindfulness. Pilates. Yoga. Spiritual health. GP. Counsellor. Psychiatrist. Holiday. Social activities. Hobbies. Debriefing. Personal coaching. Mentoring. Personal philosophy. Altruism. Humanitarian activities. Time management. Goal setting. Personal development courses. Nutrition & Hydration. Sleep Hygiene. Journal writing, practicing gratitude.

2. Departmental

Social networking. Leadership development. Mentor training & support. Admin support. Departmental activities. Crisis Leadership training. Media and Communication training. Leadership coaching and relief. Rostering support. The Department Head is a critical player in the wellbeing of doctors in the department. Studies show improvement in leadership has positive effect on staff wellbeing. Staff wellbeing should be a priority for the Head. Staff wellbeing should be a measure of efficiency of Unit Leadership Role. Leaders should be given training in this arena. Every doctor is accountable to a Unit Leader. Every Unit Leader has immediate influence on frontline doctors.

3. Institutional

HR roster support. Resources for relief and cover. Training and support. Staff development. People and Culture Development. Wellbeing Leads and Wellbeing officers. Wellbeing campaigns and programs. Wellbeing Lectures and Grand Rounds. Schwartz Rounds. Formal Staff Health and Wellbeing clinics. Debriefing and crisis timeout programs. Institutional Cultural Change. Investment on Unit Leaders. Organisational Science. Organisational Psychology. Systems thinking. EMR, Computers, Productivity systems. Remove technologies or systems that may reduce clinical efficiency. Empower doctors to rearrange workflow to enable interface with new technologies. Doctors lounges. Quiet Rooms. Align organisational values.

4. Regional and National

AMA, Specialist Colleges, Health Departments, Medical Schools, Medical Defence Organisations, Kindness and Change Campaigns. Doctors Health Clinics. Regulations, Legislations, Laws, Policies, Accountabilities. Big picture cultural standards and code of conduct. What is decided at this level affects and protects the individual doctors even if the authority has no direct jurisdiction. For example, The College of Surgeons may not have direct jurisdiction over the roster of a resident doctor, but The College may exert influence over their Fellows working within that institution. An MDO may not have direct jurisdiction over the working conditions of doctors, but they may exert influence from a legal risk point of view to effect change when a matter is notified to them. Consider effects of Mandatory Reporting on Clinician Wellbeing. Cultural Change from the highest levels of leadership.

This is a big picture conceptual thinking. We need to address this problem with a multipronged approach. We need champions of change at every level. Sometimes we may be coordinated, other times it takes too long to wait for coordination. We may have the resources, or more likely, it may take too long to wait for resources. Many of these interventions do not need to be expensive, exhaustive or intensive. The time is right. There are significant actions that can be taken locally.  It may begin with just a simple conversation over coffee amongst champions of change in your unit. Throw around some simple ideas relevant to your unit.

We need compassion, courage and collaboration for change.

The above is not a definitive list. What other interventions would you add to the list? What has worked in your institutions or country?

Reading Materials for Discussion:

  1. Shanafelt TD, Noseworthy JH. Executive Leadership and Physician Well-being: Nine Organizational Strategies to Promote Engagement and Reduce Burnout. Mayo Clin Proc. 2017;92(1):129-146.
  2. Callahan K, Christman G, Maltby L. Battling Burnout: Strategies for Promoting Physician Wellness. Adv Pediatrics. 65 (2018) 1–17.
  3. Beyond Blue. National mental health survey of doctors and medical students. Melbourne: Beyond Blue, October 2013.
  4. The Dark Side of Doctoring.
  5. Context of Clinician Wellbeing.
  6. Elephants in the Room.
  7. Put on your mask first.
  8. https://das.bluestaronline.com.au/api/prism/document?token=BL/0823
  9. http://www.massmed.org/News-and-Publications/MMS-News-Releases/Physician-Burnout-Report-2018/
  10. https://www.ruok.org.au/
  11. https://mhfa.com.au/

6 thoughts on “Rethinking Doctors Wellbeing Interventions

  1. Great piece!

    A couple of things i’d add under ‘individual personal health and well being’

    – nutrition and hydration (and trying not to skip meals – hard for doctors!)
    https://theconversation.com/want-to-improve-your-mood-its-time-to-ditch-the-junk-food-107358

    – sleep hygiene (hard for shiftwork!), try to turn off phone/computer before sleep
    https://theconversation.com/theres-a-strong-link-between-anxiety-and-depression-and-sleep-problems-and-it-goes-both-ways-76145

    – journal writing, in particular practicing gratitude
    https://www.tandfonline.com/eprint/tvUYqkM8cpgKziMK4vg6/full
    https://theconversation.com/to-reduce-stress-and-anxiety-write-your-happy-thoughts-down-99349
    https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3759583/?report=classic

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  2. Thanks Eric. I’ve found your piece fascinating but sadly, I feel that it applies to all professions within healthcare but most especially with your nursing colleagues. Many are struggling with the ever increasing demands from the public’s expectations to the ever increasing patient acuity. That said, I thoroughly and wholeheartedly support any changes that will better equip our medical colleagues to not only survive but thrive. Take care & stay safe.

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  3. And bringing trauma-informed care (with its emphasis on provider well-being) and trauma-informed wellness programs can help – the latter is something we’ve been encouraging here in Toronto through a annual series of workshops. This fits in well with many of the interventions you mention.

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  4. This is a fantastic article Eric. There are the state and territory doctors’ health services across Australia, though they do vary in activity they all provide a base support of a 24/7 urgent advice line – I know that ours is well utilised mainly from remote doctors (so a vital service for them), we also provide telemedicine and face to face support. Here in SA there is the doctors-only (and medical students) after-hours clinic. This is very successful and sees approximately 500 doctor-patients a year (it is operated as a GP clinic). The SA program is currently undertaking a major evaluation of its program and services, we were successful in gaining a Grant to do this, so we will have an external evaluator coordinating it – so that will provide insight into what does work, and what does not. This is the first time a full doctors’ health program in Australia has been evaluated.

    There is a significant amount of working going on in the space, within the doctors’ health services and across the broader health sector as you have mentioned. Perhaps understanding the greater web might be a focus for the Australasian Doctors Health Conference that is being held in Perth, this November. Abstracts are now open – that conferences website is https://ruralhealthwest.eventsair.com/2019-adhc/

    Also another event occurring in March is the National Forum on Doctors’ Wellness, a 1 day session in Melbourne – the details on this can be found – https://www.eventbrite.com.au/e/national-forum-on-doctors-wellness-tickets-53380073236

    It is so important to support key champions of doctors’ health in the profession, thank you for your continued energy, wisdom and drive!

    Regards Kiara Cannizzaro – Program Manager, Doctors’ Health SA & NT.
    http://www.doctorshealthsa.com.au
    http://www.doctorshealthnt.com.au

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  5. Great article,Eric. You are quite correct that the problem is multifaceted and an abusive hierarchy require major cultural change. I am trying to be the champion of doctor’s well being by conducting courses in “ Mindfulness in Medicine” . There are however many perceived barriers to doctors attending including stigma of admitting our vulnerability and not having enough time .
    You have done a wonderful job at making doctors and hospitals aware of the epidemic of burnout in our profession. Happy to talk about my passion at anytime
    Tony Dunin, Orthopaedic Surgeon and MBSR teacher
    http://Www.mcfm.com.au

    Liked by 1 person

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