Helping distressed patients - A strategy for reducing the doctor's anxiety

Ross Phillipson, MBBS, (Hons) FRACGP, M Soc Sc (Counselling) is a general practitioner and counsellor in Brisbane. He is an external clinical teacher with the RACGP Training Program and Honorary Secretary of the Doctors Health Advisory Service Qld. (Inc).

OBJECTIVE This study was designed to test whether belonging to a counselling supervision group reduces the anxiety of doctors when dealing with emotionally distressed patients.

METHOD Identical questionnaires were distributed to the counselling supervision group (the study group) and a matched control group in March and August 1997.

Respondents were asked to rate their perceived level of anxiety when faced with nine clinical scenarios and their overall anxiety when dealing with emotionally distressed patients. The results were then compared.

RESULTS The study group showed generally higher levels of anxiety than controls in the first questionnaire. There was a shift to lower reported levels of anxiety in the study group at the end of the supervision process. No similar change was observed in the control group.

CONCLUSIONS Although sample size was too small to apply tests of statistical significance, it would appear that belonging to a counselling supervision group may reduce the anxiety of doctors dealing with emotionally distressed patients.

Introduction

Stress - an inherent part of being a doctor

High rates of mental illness and suicide set doctors apart from other professionals.¹ Psychological problems are detectable in medical students and many medical students exhibit perfectionism and obsessionality as part of their personality.²^-⁴

Community expectations that doctors are immune to fatigue and do not get sick can add to the stress.⁵,⁶ The hours worked by doctors,⁷ the number of patients seen in a given time and treating patients with complex pathologies are added stressors faced by members of our profession.⁸,⁹ McDonald describes dealing with the 'heart-sink patient', defined as those with difficult medical and psychosocial problems, as one of the stressors that doctors face.¹⁰

Supervisors have an important role to play in stress reduction in younger colleagues by being supportive, rather than adopting a process of 'education by humiliation'.¹¹

Supervision for doctors not a new idea

In the 1950s Michael Balint and his wife, Enid ran groups consisting of 8-10 general practitioners facilitated by one or two psychiatrists.¹² The GPs were encouraged to present their 'difficult' cases and to give as full account as possible of their emotional responses to the patient. Eubank, Zeckhausen and Sobelson emphasise the importance of personal and professional growth that can arise as a result of participation in a physician support group.¹³ However Newman cautions that while the sharing of painful experiences may be highly valued, many medical practitioners are reluctant to do this in a peer group, for fear of ridicule.¹⁴

This pilot study attempts to evaluate whether belonging to a counselling supervision group not only enhances skills but reduces the anxiety felt by doctors who are dealing with emotionally laden consultations.¹⁵

Method

Against this background, a general invitation was issued to all GP registrars and their supervisors inviting participation in a counselling supervision group commencing in 1997. The first 12 responders were offered a place in the group. A control group, matched for gender and year of graduation was identified from the Training Program data bank. The study group met every 2 weeks from March to August 1997 and was facilitated by a psychiatrist for the first 6 sessions and by the author for the final 7 sessions. Members of the group took turns presenting their 'difficult' cases (of a counselling nature) for discussion. The demographics of the study and control groups are shown in Tables 1 and 2.

Table 1. Demographics - study group
	Year of graduation
	Pre 1984	84-86	87-89	90-92	93-95
Male	1	0	0	1	0
Female	0	0	0	6	2

Table 2. Demographics - control group
	Year of graduation
	Pre 1984	84-86	87-89	90-92	93-95
Male	1	0	0	1	0
Female	0	0	1	4	3

In April 1997 a questionnaire was sent to each member of the study group and the control group asking them to rate their perceived levels of anxiety in each of nine different clinical scenarios and to rate their overall level of anxiety when dealing with emotionally laden consultations (Table 3). The scenarios are not uncommon in general practice and had been tested informally for validity by the author's practice colleagues.

Table 3. The questionnaire

I feel anxious when.....

Patients unexpectedly burst into tears during a consultation
Patients hint that they have contemplated suicide
Patients have a panic attack during a consultation
Patients present with a marital problem
Male patients present with loss of libido
Female patients present with loss of libido
I talk to teenagers about their use of recreational drugs
I confront patients about excess alcohol use
Patients become angry with me during a consultation
I have to deal with emotionally distressed patients

Using a 5 point Likert scale the mean response was calculated for each question and the results tabulated.

While a formal qualitative analysis of the content of the supervision group was beyond the scope of this study, the researcher took particular note of the use of words by the presenters which might indicate that they were experiencing anxiety in managing their cases. Note was also taken of the responses made by group members which appeared to be helpful.

At the end of the supervision process in August 1997, the same questionnaire was again distributed to both groups and the results analysed as before. The mean scores were then compared to see if there was any change between April and August in the doctors' perception of how much anxiety they might feel in the clinical scenarios and overall.

Results

The first questionnaire

The mean scores for the first questionnaire for the study group and the control group are shown in Table 4 and are noted to be lower for all questions in the control group compared with the study group. The only exception to this was the level of anxiety experienced by doctors when patients are angry with them. In this situation, the results were exactly the same for both groups.

The second questionnaire

The mean scores for the second questionnaire show an approximation between those of the study group and those of the control group which is highlighted by looking at the mean variation. This suggests a reduction in the reported levels of anxiety in the study group in August, compared to those reported in April (Table 4).

Table 4. Variation in mean responses in study group
	*Mean response April 1997**	Mean response August 1997	Variation in mean
Question
Tearful patient	3.1 (1.7)	2.2 (1.7)	-0.9
Suicidal ideation	3.3 (2.4)	3.1 (2.8)	-0.2
Panic attack	3.4 (2.2)	2.5 (3.0)	-0.9
Marital problem	3.6 (2.1)	2.9 (2.1)	-0.7
Male libido problem	3.3 (2.8)	2.3 (2.9)	-1.0
Female libido problem	2.8 (2.0)	2.0 (2.4)	-0.8
Recreational drug use	2.3 (1.7)	1.9 (2.0)	-0.4
Alcohol use	2.4 (1.9)	1.9 (2.0)	-0.5
Angry patient	4.4 (4.4)	3.7 (4.4)	-0.7
Overall anxiety	3.4 (2.0)	2.2 (1.8)	-1.2
* Mean response was calculated using a 5 point Likert scale (1 = strongly disagree, 2 = disagree, 3 = uncertain, 4 = agree, 5 = strongly agree).
Control group response in brackets.

Discussion

This was a pilot study designed to evaluate whether an intervention such as a counselling supervision group assists in reducing doctor anxiety. Confidential group discussion of 'difficult' cases seemed to provide a relatively 'safe' mechanism for the participants. The generally low level of intensity of feelings expressed by the participants was indicative of the awkwardness that doctors generally feel when discussing their reactions to difficult patients in a peer group. This is in accordance with the literature.¹⁶^-¹⁸

Numbers were too small to apply tests of statistical significance and in drawing conclusions from this study the likelihood of selection bias in the study group needs to be considered, as those doctors who were aware of their own anxiety may have been the first to respond to the invitation to join the group. The dual role of researcher and group facilitator also carries a high risk of observer bias. A question to consider is whether the reported reduction in anxiety in the study group indicated a better handling of actual cases or simply the belief that the doctors could handle such cases more easily in the future.

Conclusion

The emotional cost of dealing with patients in distress is ignored at our peril. A group supervision process or individual supervision if preferred may be of benefit. Further research is needed to evaluate whether it is 'real' or 'perceived' improvement that occurs as a result of belonging to a supervision group. Journal keeping and observation by a trained observer may be ways of evaluating such improvement. Perhaps there is a role for the RACGP Training Program and the Doctors Health Advisory Service in each state to provide opportunities for supervision as part of their ongoing commitment to the profession.

References

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