Doctors' health

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Instructions

This section provides a summary of the area of practice for this unit and highlights the importance of this topic to general practice and the role of the GP.

Healthy general practitioners (GPs), uncompromised by physical or mental illness or burnout, are more likely to be able to be empathic, communicate and model health messages positively, make fewer mistakes and provide higher quality patient care.1-3 GPs are at the frontline addressing increased mental health concerns in patients and addressing community stresses during natural disasters.2 In the 2020 RACGP survey, The Mental Health of the Nation 2020, one in three GPs ranked their own wellbeing as one of the top three challenges that impacted their ability to provide care to patients during the COVID-19 pandemic.2

GPs, like all other individuals, are entitled to high quality healthcare provision to optimise their health and wellbeing. While physical health and overall life expectancy is higher in GPs than that of the general population because of socioeconomic status and health literacy,1-4 mental health surveys of doctors and medical students in Australia have revealed a number of significant wellbeing and psychological issues.2,3,5 These include an increased prevalence of anxiety, misuse of prescription drugs and suicide compared to the general population and an unwillingness to seek help for psychological distress. This was particularly prevalent in Australian doctors under 30, and for those working in rural and remote areas.5 Female doctors had higher levels of general psychological distress and a higher lifetime prevalence of anxiety and depression than their male colleagues. They were also more likely to have suicidal thoughts or attempt suicide and had increased rates of burnout compared to their male peers.5 Aboriginal and Torres Strait Islander students and doctors were also found to be at increased risk of mental health problems, including higher rates of psychological distress, higher rates of depression and increased suicidality. 

The most common source of work stress reported by Australian doctors related to difficulties balancing work and personal life.2,5 Other stresses included workload, long work hours, levels of responsibility and fear of mistakes.5-7 Vicarious trauma and compassion fatigue are also common,8,9 particularly for GPs working with victims of abuse, survivors of disasters, refugees and people seeking asylum. Aboriginal and Torres Strait Islander doctors and overseas trained doctors reported more stresses related to racism and bullying at work.5 In a 2012 study, 25% of doctors reported being bullied in the workplace in the preceding 12 months.10 

Although Australian doctors were more likely to be able to implement behavioural strategies to ameliorate the negative effects of mental health concerns than the general population,5 barriers to help-seeking persist.11 These include boundary issues such as a collegiate, employer/employee or a personal relationship with a treating doctor, difficulty in role definition within the consultation, time pressures, distance from doctors and services (particularly in rural areas), confidentiality, embarrassment and stigmatising attitudes regarding the competence and career progression of doctors with mental health conditions.5-7,10,12 The advent of mandatory reporting of ‘impaired doctors’ added to concerns about seeking treatment for mental health concerns owing to possible impact on registration and right to practice. However, changes to the legislation which came into effect in 2020 alter the threshold for mandatory reporting by a treating practitioner assisted in alleviating this potential concern.13 

GPs have a responsibility to promote healthy behaviours, encourage wellbeing strategies, and optimise physical and mental health in themselves and their colleagues. GPs treating medical practitioners need to ensure that the same due care is offered as for other patients, tailoring their care to take account of the health literacy and knowledge of the doctor-patient. It is important to avoid assumptions, corridor consultations, informal consultations or undocumented consultations which all compromise the level of care.11

References
  1. Rowe L, Kidd M. Every Doctor: Healthier Doctors = Healthier Patients. Milton, United Kingdom: CRC Press, 2018.
  2. The Royal Australian College of General Practitioners. General Practice: Health of the Nation 2020. East Melbourne, Vic: RACGP, 2020 [Accessed 1 October 2021].
  3. Elliot L, Tan J, Norris S. The mental health of doctors: A systematic literature review. Hawthorn West, Vic: Beyond Blue, 2010.
  4. Australian Institute of Health and Welfare. Australia’s Health 2020: Health Across Socioeconomic groups. Canberra: AIHW, 2020 [Accessed 21 May 2021].
  5. Wu F, Ireland M, Hafekost K, Lawrence, D. National mental health survey of doctors and medical students. Hawthorn, Vic: Beyond Blue, 2013 [Accessed 21 May 2021].
  6. Australian Medical Association. AMA survey report on junior doctor health and wellbeing. Barton, ACT: AMA, 2008.
  7. Petrie K, Crawford J, LaMontagne AD, et al. Working hours, common mental disorder and suicidal ideation among junior doctors in Australia: A cross-sectional survey. BMJ Open 2020;10:e033525. doi: 10.1136/bmjopen-2019-033525.
  8. McKinley N, McCain RS, Convie L, et al. Resilience, burnout and coping mechanisms in UK doctors: a cross-sectional study BMJ Open 2020;10:e031765. doi: 10.1136/bmjopen-2019-031765.
  9. Benson J, Magraith K. Compassion fatigue and burnout. Aust Fam Physician 2005; 34(6): 497-498.
  10. Askew DA, Schluter PJ, Dick ML, et al. Bullying in the Australian medical workforce: Cross-sectional data from an Australian e-Cohort study. Aust Health Rev 2012;36:197–204.
  11. Koppe H. Barriers to good health care. Aust Fam Physician 2010;38:(1-2):71–73.
  12. Schlicht SM, Gordon IR, Ball JRB, Christie DGS. Suicide and related deaths in Victorian doctors. Med J Aust 1990;153(9): 518–21.
  13. The Australian Health Practitioner Regulation Agency. Making a mandatory notification. Canberra: Ahpra, 2020 [Accessed 23 May 2021].

Instructions

This section lists the knowledge, skills and attitudes that are expected of a GP for this contextual unit. These are expressed as measurable learning outcomes, listed in the left column. These learning outcomes align to the core competency outcomes of the seven core units, which are listed in the column on the right.

Communication and the patient–doctor relationship
Learning outcomes Related core competency outcomes
The GP is able to:   
  • communicate effectively and sensitively with doctor-patients to encourage and facilitate discussion of sensitive psychological, physical and workplace issues
1.1.1, 1.1.2, 1.2.1, 1.3.1, AH1.3.1
  • describe and implement sensitive, person-centred, ethical strategies to assist colleagues in difficulty
1.4.3
  • describe environments where it is appropriate, and not appropriate, to conduct sensitive conversations with colleagues regarding personal healthcare
1.1.5, 1.4.1, RH1.4.1
Applied knowledge and skills
Learning outcomes Related core competency outcomes
The GP is able to:   
  • explain the barriers to good healthcare for doctors
2.1.4
  • describe the specific risks of burnout, psychological distress, workplace bullying, depression, anxiety, substance abuse, and suicidality for doctor-patients
2.2.3, 2,2.4
Population health and the context of general practice
Learning outcomes Related core competency outcomes
The GP is able to:   
  • plan for relevant routine screening tests, immunisations and preventive healthcare for doctor-patients
3.1.1, RH3.1.1, 3.2.2
  • outline strategies to mitigate the impact of barriers to good healthcare for doctors
3.2.1
Professional and ethical role
Learning outcomes Related core competency outcomes
The GP is able to:   
  • develop an ongoing learning plan to incorporate reflection on physical and emotional wellbeing and assessment of symptoms of burnout
4.2.2, 4.2.3
  • identify and engage in peer support networks and other strategies to mitigate professional isolation and risk of burnout
4.2.3, RH4.2.1, RH4.2.2
  • develop and implement strategies for self-care into ongoing personal and professional development goals
4.2.3
  • develop and maintain an ongoing relationship with a GP for preventive healthcare and episodic care, avoiding corridor and informal consultation with peers
4.2.3
Organisational and legal dimensions
Learning outcomes Related core competency outcomes
The GP is able to:   
  • explain the current mandatory reporting of impaired colleagues and appropriately interpret the thresholds as they relate to treating doctors
5.2.1, 5.2.3
  • describe how an effective recall and reminder system for routine health checks, screening and follow-up of results benefits doctor-patients
5.1.1, 5.1.3, RH5.1.1
  • build a practice environment that ensures staff and colleagues in their practice (or sphere of professional influence) feel safe from harassment and bullying
5.2.6

Instructions

  1. Read this example of a common case consultation for this unit in general practice.
  2. Thinking about the case example, reflect on and answer the questions in the table below.

You can do this either on your own or with a study partner or supervisor.

The questions in the table below are ordered according to the RACGP clinical exam assessment areas and domains, to prompt you to think about different aspects of the case example.

Note that these are examples only of questions that may be asked in your assessments.

Extension exercise: Create your own questions or develop a new case to further your learning.

Doctors' health

Your colleague, Gordi, 32, is studying for his upcoming FRACGP written exams in two weeks. He approaches you in the tearoom and asks you for a script for some temazepam because he is not sleeping and wants to be fresh to study.

Questions for you to consider Clinical exam assessment area Domains

How would you approach this situation?

How would you approach this situation if you were Gordi’s GP, rather than a colleague?

What would be the differences and/or similarities in your approach if Gordi was an Aboriginal or Torres Strait Islander?

What would be the differences and/or similarities in your approach if Gordi was an international medical graduate or from a culturally and linguistically diverse (CALD) background?

  1. Communication and consultation skills
1,2,5

What sources of information, other than Gordi himself, could be useful to help you assess your colleague's wellbeing and safety? (What sources of information would you access for any other patient making this request?)

What screening tools could you use to assess if Gordi has symptoms of anxiety, depression, stress, or difficulties relating to alcohol or substance abuse?

How would you assess if Gordi was experiencing workplace bullying or intimate partner violence?

  1. Clinical information gathering and interpretation
2   

What are the possible health problems that may be behind Gordi’s request?

  1. Making a diagnosis, decision making and reasoning
2   

Would you prescribe this medication for your colleague? If so, why? If not, why not?

  1. Clinical management and therapeutic reasoning
2   

What supports and services could you recommend to Gordi?

How would you support Gordi if he didn’t have easily accessible supports in the rural town in which he works?

What different or additional supports could you suggest if Gordi was an Aboriginal or Torres Strait Islander?

What different or additional supports could you suggest if Gordi was an international medical graduate or from a CALD background?

  1. Preventive and population health     
1,2,3

What are the potential issues in providing ‘corridor consultations’ and prescriptions for friends and colleagues?

Would your approach to Gordi change if you were his supervisor? Or if he were your supervisor?

How would your approach be affected if there had been staff or patient complaints about Gordi, or if you also noted signs he may be under the influence of drugs or alcohol (eg smelling alcohol on his breath)?

  1. Professionalism
4   

What are the criteria for mandatory reporting of a doctor to AHPRA?

  1. General practice systems and regulatory requirement
5   

What potential issues could affect your confidence in performing office procedures such as excisions and venesections on colleagues?

How would you approach intimate procedures such as cervical screening or rectal examination for a colleague? How would this be different in a rural or remote area where access to other healthcare providers is limited?

  1. Procedural skills
2   

If you advised Gordi to see his own GP but were unsure that he would, how would you follow up with him?

If you were Gordi’s GP, how would you approach the situation if you were uncertain if there was an underlying mental health issue or if he presented with non-specific symptoms, such as fatigue?

  1. Managing uncertainty
2   

What are the warning signs that a doctor’s health is deteriorating, and that they may suffer burnout and/or develop mental illness?

How would you determine if the doctor-patient was suicidal, and how would you manage this if they were resistant to your management plan?

  1. Identifying and managing the significantly ill patient
2

Instructions

This section includes tips related to this unit from experienced GPs. This list is in no way exhaustive but gives you tips to consider applying to your practice.

Extension exercise: Speak to your study group or colleagues to see if they have further tips to add to the list.

  1. Find yourself a GP, in a different practice to your own if possible, who you feel comfortable talking to about work and personal stresses, and attend regularly for preventive health. If you work in an isolated area, you may at times need to seek acute care locally, however, try to find a GP away from your town or practice for ongoing care and preventive health, using a combination of face-to-face care and telehealth.
  2. Remember you are a person ‘who works as a doctor’ and not just ‘a doctor’. It is important to attend to all aspects of your life, including family, friends and non-medical interests.
  3. Attend to your own health, wellbeing and abilities in order to provide care of the highest standard (as per the Physician’s Pledge updated in 2017).
  4. Find a peer support network or mentor to support your wellbeing and safety (eg Hand-n-Hand peer support, AIDA mentoring program – see learning resources section). It is often helpful to find a support group relevant to your needs; for example, to suit your career stage, of similar ethnicity or practising in similar circumstances. It is likely that your support needs will change throughout your working life, and you may have several different peer supports/mentors over time.
  5. Having ongoing case discussions with a mentor, peer or small group is an important part of lifelong learning. When doing this, consider both the medical and emotional issues at play in difficult consultations. Managing the emotions in the room (both the doctor and patient) contributes significantly to the doctor workload. Reflecting on and building skills and strategies to manage this work is an important part of case discussions with a mentor or peer.
  6. Find small ways to refresh and recharge every day. Ensure there are planned gaps between appointment bookings and ‘on the day’ appointments to cater for the inevitable acute presentations. And always have your next holiday planned.

Instructions

This section has some suggestions for how you can learn this unit. These learning suggestions will help you apply your knowledge to your clinical practice and build your skills and confidence in all of the broader competencies required of a GP.

There are suggestions for activities to do:

  • on your own
  • with a supervisor or other colleague
  • in a small group
  • with a non-medical person, such as a friend or family member.

Within each learning strategy is a hint about how to self-evaluate your learning in this core unit.

On your own

Download The Essential Network App (TEN) (or access it from the Black Dog Institute website) and undertake the ‘test and track’ mental health wellbeing survey.

  • How are you going? What areas of your life need attention and how could you address these?
  • Are you up to date with your health screening?
  • Is there any healthy lifestyle advice that you would give to patients that you should or have implemented for yourself? 

Complete a module on doctors’ health on either the DRS4DRS website or gplearning.

  • Do you have any doctor-patients that you currently see? If so, are there any changes that you will make to your consultations after completing the module? What strategies from the module can you use to improve your care of doctor-patients in the future?
  • How do the recommendations in the module compare with your own experience as a patient?

Join a peer support or discussion group; for example the GPiT faculty, the GPs Down Under Facebook group, the GPRA Facebook Group, or the RACGP New Fellows Facebook group, and find five topics raised in the discussion that you relate to.

  • Why do you think these issues are relevant to you? What could you do in your own life and work to manage these issues in a healthy way?

If you don’t already have your own GP, find out if your local primary health network or the AMA has a list of doctors who are experienced in seeing other doctors. Identify a local GP who you might be able to see.

  • Do you already have your own GP? Does your family have their own GPs? If you don’t, were you able to find this information? If not, where else could you look? Is there someone else you could ask?
With a supervisor

Ask your supervisor how they manage workplace and personal stresses and keep mentally and physical well.

  • In what way does the appointment system in your practice affect GP wellbeing? How could it be changed to improve things? Are there any other things in the practice that promote (or hinder) wellbeing; for example shared lunchtimes, approach to sick leave, approach to critical incidents, staff meetings or social interactions?
  • What motivates your supervisor and keeps them in their job? How does this compare with what drives and motivates you?

Discuss any experiences your supervisor has had with colleagues who are impaired or in difficulty.

  • How did your supervisor address them?
  • What are the criteria for mandatory reporting to AHPRA?   

Discuss any experiences your supervisor has had in treating other doctors.

  • What do they see as the barriers and difficulties? How have they overcome them?

Role-play the case consultation example described above with your supervisor to practise how you would handle this situation. Then role-play a consultation between Gordi and his GP.

  • What were some of the strategies that your supervisor used? How did they manage the consultation? What could you learn from this to apply to your own practice?
In a small group

Read the journal articles listed in the learning resources section, and as a group, discuss concerns, boundary issues or barriers you have experienced – either as a patient or as a GP for another doctor.

  • What are the barriers to effective communication with a patient who is a doctor? What are the differences when you are the patient, or when your patient is another GP or specialist?
  • How would you feel if your treating doctor or GP patient was more or less experienced than you?

Discuss any issues that have come up for you as a doctor when family, friends or colleagues ask for informal healthcare.

  • How have you handled this?
  • What is best practice in this situation?
  • How do you address health issues in your own children, if you have any?
  • How might these issues be influenced if you work in an area with limited access to healthcare; for example a rural or remote location?

Join a Balint group or case discussion group to discuss cases or professional situations which you have found difficult or stressful. Another option would be to discuss professional issues at a small group practice meeting; such as angry patients, bullying and harassment issues, and creating a safe and healthy workplace.

  • What strategies have your peers used to manage these stresses?
  • What practice systems, and professional and personal strategies could you put in place to reduce these difficulties?
  • How can the wellbeing of all staff be enhanced at your workplace?
With a friend or family member

Discuss the potential ethical and professional issues that can arise in treating family members or friends informally.

  • Is there a problem with writing an occasional script?
  • What are your boundaries?
  • What are your friends’/family members’ expectations of you? Do they expect you to provide medical advice, write an occasional repeat script for them, etc? How would this be influenced if you were working in an area with limited access to medical care or there are long wait times for an appointment?

Discuss with family and friends the level to which each of you would be comfortable treating your own children.

  • Are there any potential issues with treating ‘minor’ health complaints in your own children? Compare your thoughts and discussions with the advice given by your medical defence organisation. (The DRS4DRS website has links to medical defence organisations and their resources in doctors' health.)

Instructions

These are examples of topic areas for this unit that can be used to help guide your study.

Note that this is not a complete or exhaustive list, but rather a starting point for your learning.

General doctors’ health issues and care of other doctors
  • Understand the barriers that doctors may face in accessing healthcare.
  • Know what professional and personal support resources are available for doctors.
  • Approach boundary issues supportively and sensitively in consultations with other doctors.
  • Use appropriate communication strategies and structure consultations to provide supportive and sensitive consultations with doctor-patients.
  • Identify through history and examination/observation common psychological issues doctors face; for example stress, burnout, addiction, bullying and interpersonal relationship difficulties.
  • Recognise behaviours that may suggest a colleague is in difficulty.
  • Support colleagues in difficulty; including those who have had complaints made against them.
  • Understand the factors that impact on wellbeing and underpin burnout; such as health system pressures, medical culture, practice ownership and employment structures.
  • Understand the potential for bullying within the medical culture and strategies to ensure practice colleagues, junior staff, nursing staff and administrative colleagues feel safe in their working environment.
  • Understand legal responsibilities in reporting doctors to AHPRA.
Self-care
  • Develop a self-care plan that includes:
    • strategies to maintain own physical and mental health; including finding own GP for independent medical advice and preventive care
    • how to maintain appropriate boundaries whilst maintaining family's health and wellbeing
    • finding and maintaining personal and professional supports to minimise stress and avoid burnout
    • how to deal with a crisis should it arise tomorrow
    • developing and maintaining interests and activities outside of work life.

Instructions

The following list of resources is provided as a starting point to help guide your learning only and is not an exhaustive list of all resources. It is your responsibility as an independent learner to identify further resources suited to your learning needs, and to ensure that you refer to the most up-to-date guidelines on a particular topic area, noting that any assessments will utilise current guidelines.

Journal articles
This series of articles provides a thoughtful, practical approach both to being a ‘good patient’ and a ‘good doctor’ for a colleague. The prevalence of bullying in medicine, including in the general practice setting, and strategies to ensure a safe workplace and to assist patients who have been bullied at work. Issues associated with burnout in junior doctors and the important themes of expectations of self, self-care and the expectations and response of others.
Online resources
Contact details of the state-based doctors’ health advisory services, a telephone advice service, resources and training modules for doctors treating other doctors. Information and support to manage burnout and maintain good mental health. Free confidential peer support for health professionals in Australia and New Zealand. Run by volunteer facilitators and available as one-on-one or group sessions. Self-care and mental health resources for general practitioners. Guidelines for making mandatory notifications about registered health practitioners and registered students.
Learning activities
Insights in how to approach consultations and medical care for patients who are doctors. (You will need to create an account to access this learning module.) A good overview of the health issues, in particular the psychological issues, for doctors; also provides good self-care strategies.
  • The Royal Australian College of General Practitioners, gplearning activity:
    • Addressing doctors’ health: Caring for ourselves and our colleagues.
Other
Information about the AIDA mentoring program (visit member area). Courses and resources for the remote and isolated health workforce. Free counselling support for all RACGP members. Information and resources about wellbeing.
  • General Practice Registrars Australia. Wellbeing.
Medical Board of Australia code of conduct.
  • The Medical Board of Australia. Good medical practice: A code of conduct for doctors in Australia, Chapter 11, Ensuring doctors’ health.
This contextual unit relates to the other unit/s of:
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Printed from the RACGP website at https://www.racgp.org.au/education/education-providers/curriculum/curriculum-and-syllabus/units/doctors-health 27/09/2022