Chapter 14. The doctor and the importance of self-care
- Working with those who are experiencing family violence can be emotionally challenging and result in the experience of vicarious trauma315
- It is important to maintain an environment, both individually and in practice, where there is adequate protection from burnout or the vicarious trauma that may come from hearing the stories of patients involved in abuse and violence315–317
- Health practitioners cannot give to others if they are experiencing compassion fatigue, so it is advised that self-care and a whole of practice approach be addressed so that patients receive the best care318 Practice Point
- Working as a team within the practice by using a system that provides peer support and the ability to discuss distressing cases may help protect against stress315 Practice Point
Managing the effects of abuse and violence on our patients can be a rewarding aspect of general practice, however, it can be stressful. If GPs feel empowered, then that empowerment can positively enhance the doctor–patient interaction. Factors that may contribute to this enhancement are ongoing training, clearly delineated practice policies, case management supervision, peer support, clear doctor–patient boundaries and a developed network of resources and referrals.
As well as the usual stresses associated with difficult and time-consuming clinical encounters, there are factors that are important for GPs to address when working with patients who have experienced abuse or are currently being abused. The trauma that these patients have experienced constantly challenges our individual limits and drains personal resources.319 GPs often face professional isolation, ambiguous success, unreciprocated giving and failure to live up to our own expectations for ensuring positive change.320 Dealing with these issues is important, not just for the health of the GP, but also so that we can maintain as objective a stance as possible to facilitate a successful outcome for the patient, and maintain good relationships with the patient’s family, friends and community.
Vicarious traumatisation is the inner transformation of the care givers experience as ‘a result of empathic engagement with victims, clients and their trauma material’.321 It can ‘encompass changes in frame of reference, identity, sense of safety, ability to trust, self-esteem, intimacy and a sense of control’.322 This is a particular danger when dealing with those who are, or have, experienced abuse and violence. GPs who have a similar background to the community they serve are at a higher risk of vicarious trauma. This may include GPs of Aboriginal and Torres Strait Islander descent, those who were refugees and many international medical graduates (IMGs). These situations will be particularly difficult for GPs who have personally experienced abuse or have experience abuse in their families.
It is important to maintain an environment in which there is adequate protection from burnout or the vicarious trauma that may come from hearing the stories of patients involved in abuse and violence. The medical profession has a ‘long and admirable, but often unhealthy, tradition of self-sacrifice to work’.316 Those who work in this field need to be vigilant about ways to overcome compassion fatigue, renew the joy in practice, create life balance,317 and adequately care for their own physical, mental, emotional and spiritual health.
A rural perspective
GPs who work in rural areas are at a higher risk of problems with stress, burnout and vicarious trauma. They are highly likely to find it difficult to access locums, peer support and ongoing training, and usually have more after-hours work, are more isolated and find it more difficult to maintain clear boundaries between themselves and their patients.316
Many rural GPs are IMGs who have the added burden of having to negotiate different cultures, ethnicities, language, religion and the difference between rural and urban environments in Australia. They will also have to learn about the expectations Australian patients have of their doctor and about a new health system and its attendant bureaucracy. As well as the risk of ‘culture shock’, their anxiety, isolation and insecurity in the face of all these differences is likely to be much higher.323
The role of GPs and their practice in self-management
‘You cannot give to others out of emptiness in yourself’ (Quote from a GP)
Saakvitne and Pearlman321 developed a model that allows GPs to explore their situation and think about solutions. This occurs by identifying issues of awareness, balance and connection in each of the GP’s ‘realms’:
Using this model (Table 21) may help set the stage for good self-care319,321
Table 21. Example of awareness, balance and connection strategies
- Proactively instigate self-care strategies
- Understand and improve your awareness of when you are stressed, tired, overwhelmed
- Ensure your practice has a mentor or supervisor to support your professional development
- Consider using debriefing strategies (formal or informal) in your practice
- Cultivate open and supportive dialogue with your practice team
- Ensure organisational boundaries are known and understood by patients (eg home visits, consultation length)
- Review your lifestyle and consider healthy options
- Seek balance in all spheres of your life: physical, psychological and social
- Review workload regularly to ensure that all members of the practice team are adequately supported
- Take care in scheduling complex care needs patients
- Consider joining a social action group where you have a passion for change
- Talk to others about work, debrief safely
- Nurture positive relationships with family and friends
- Join a peer support or Balint group or informal network
- Undertake regular continuing professional development with your colleagues
The following explores this model in relation to the management of patients who are experiencing or have experienced abuse or violence.
- When the GP has a similar background to the patient, the possibility of family violence may be more difficult for to consider115 as the GP may actually have ‘normalised’ the abuse and disregarded it.322
- Others may feel more personally vulnerable when abuse is disclosed.
- The GP can be drawn into the deceit; the unwillingness to openly discuss or report the violence.115
- The GP may feel powerless and fearful for the patient’s safety when that patient chooses a path the GP considers dangerous.115
- The patient could remain at risk and the GP has to learn to live with that concern.115
- It is a difficult and stressful path supporting and empowering the patient while resisting the temptation to be directive.115
- Hearing about abuse and violence confronts the GP’s own beliefs about the family and the world. It can make them feel uncomfortable and challenge their own sense of security.
- Dealing with complex and seemingly hopeless situations over and over again can erode the GP’s optimism and self-confidence, and diminish their sense of purpose and enjoyment of their career.324
- It is important for GPs to stay connected with their core reasons for choosing to work in a challenging area and to maintain a respect for the patients themselves.325
- GPs need to recognise their personal signals of distress and find ways to articulate the feelings and act to redress the distress.326
- The lack of safety and security in the lives of patients involved in abuse and violence repeatedly confirms the physical and emotional perception of alarm, danger and its impact. The GP may also be left with the same feelings of a personal sense of vulnerability and intolerance of violence.
- Courage involves stepping outside their comfort zone but not so far that they lose their own sense of safety.
- Dealing with the perpetrator of abuse or violence is even more difficult than dealing with the victim, especially in rural practices where the entire family is likely to be well known to the GP.115
- The GP is likely to also feel at risk, especially if they are drawn into the power dynamics of the violence or if they are dealing with the perpetrator.115
- Maintaining an ‘intellectual engagement’ with difficult work can assist as a protective strategy.325
GPs have been trained to deal with individuals and to take personal responsibility but are now moving towards working in teams.326 This brings challenges around sharing information and maintaining confidentiality.
Dealing with abuse and violence requires using a whole-of-practice approach and working with other services in the community.
- Lifestyle choices that promote ‘wellness’ include relationships, religion or spirituality, focusing on success, maintaining a balance in life and a positive outlook,317 as well as simple measures such as getting enough sleep, exercise, nutrition and laughter.
- There is a need for purposeful physical, intellectual, spiritual and relationship sustenance.317
- Without a positive countervailing exposure to human good and world order, a GP may experience the same loss of a sense of personal control, freedom and trust.
- Appropriate support for the doctor in training and clinical practice needs to be readily available, especially considering that 14% of male doctors and 31% of female doctors have a personal history of child abuse or physical violence with an intimate partner.115
- GPs with less perceived control, greater stress from uncertainty, higher job demands and fewer social supports are at greater risk of burnout.327
- One of the difficult balances in abuse and violence is the stress of maintaining confidentiality and still getting added support from other health professionals.
- Learn to celebrate small achievements rather than feel overwhelmed by the big picture.322
- As with other complex and time-consuming occupations, it is important to have clear boundaries between work and home, attend peer support groups and maintain professional development and training activities.324
- As a defence against the sometimes intense feelings of helplessness, a GP may take on the role of a rescuer or saviour. There is a fine line between caring for someone and disempowering them from finding their own solutions.
- Organisational balance involves a sense of control over the practice environment, social support from colleagues and satisfaction with work demands and resources.327
- Many organisations may become caught in a struggle between promoting the wellbeing of their patients and trying to cope with the policies and structures in a system that tends to stifle the empowerment and wellbeing of their staff.328
- There needs to be a balance between caring for patients appropriately by giving them the time they need, earning a reasonable income and satisfying the organisations’ requirements for performance.322
- GPs need physical security and a safe, confidential workplace, support for continuing education, and adequate vacation and sick leave.
- Problem-solving rather than blaming helps the patient and the GP be more objective and balanced.323
- Staff will be supported by a shared aim and purpose, adequate staffing and a sense of team management. This will decrease the risk to individuals within the practice, as well as to the organisation.
- Control working hours in the challenging area and, if possible, balance this with other less challenging jobs.325
- Working in teams is associated with being better able to cope with stress.315,326
- If a GP is becoming burnt out, there may be increased substance use, pessimism and suspiciousness of patients and colleagues.324
- If a GP is experiencing compassion fatigue or burnout, they need to ask for help and find activities that connect with mind, body and support networks.324
- Social support systems can provide understanding and renew emotional reserves.324
- Confidentially debriefing with colleagues can reduce stress levels by sharing the experience.
- Normalise emotional reactions, develop more understanding of reactions and learn stress management strategies.
- Peer support groups, professional development and training activities can be replenishing and reinforce the value and meaning of work.
- Working and communicating well as a team with the GPs, practice nurses and receptionists within the practice, and with public health nurses, teachers, police and other agencies, is very important in the identification and management of abuse and violence.115
This chapter has highlighted the importance of self-care for the GP when working with families experiencing violence and abuse. It encourages self-reflection, peer support and working as a whole of practice approach to these families.
Please refer to Tool 7 for resources nationally and in your area.
- Keeping the doctor alive – this guidebook provides information and resources on strategies for self-care as an essential element of professional life. It aims to encourage medical practitioners to recognise and discuss the challenges facing them, promote self-care as an integral and accepted part of the professional life of medical practitioners, and assists medical practitioners to develop useful strategies for self-care. It is available to purchase from the RACGP website at www.racgp.org.au/ publications/ordering/tools
- General practice – a safe place: tips and tools – available free of charge at www.racgp.org.au/ your-practice/business/tools/ safetyprivacy/gpsafeplace
- Rowe L, Kidd M. First do no harm: being a resilient doctor in the 21st century. North Ryde: McGraw Hill Australia, 2009.
- Understanding and addressing vicarious trauma. Headington Institute. Self-study available at http://headington-institute.org/Default.aspx?tabid=2647
- Vicarious Trauma, available at www.headington-institute.org/ topic-areas/125/trauma-and-critical-incidents/ 246/vicarious-trauma
- RACGP GP Support Program – a free service offered by the RACGP to foster a culture of self-care. It is available to all Australian RACGP members who are registered medical practitioners, regardless of where you live or work. Members can access professional advice to help cope with life’s stressors which may include personal and work related issues that can impact on their wellbeing, work performance, safety, workplace morale and psychological health. The GP Support Program can provide help to RACGP members with a range of issues, including: handling work pressures, managing conflict, grief and loss, relationship issues, concerns about children, anxiety and depression, alcohol and drug issues, traumatic incidents. More information is available at www.racgp.org.au/ yourracgp/membership/extrabenefits/ wellbeing/
- World Health Organization. Responding to intimate partner violence and sexual violence against women: WHO clinical and policy guidelines. Geneva: WHO, 2013.
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- Coles J, Dartnall E, Astbury J. Preventing the pain when working with family and sexual violence in primary care. Int J Fam Med 2013;2013:7.
- Rowe L, Kidd M. First do no harm: being a resilient doctor in the 21st century. North Ryde: McGraw-Hill Australia, 2009.
- Weiner E, Swain G, Wolf B, Gottlieb M. A qualitative study of physicians’ own wellness-promotion practices. West J Med 2001;174:19–23.
- Clode D, Boldero J. Keeping the doctor alive – a self care guide book for medical practitioners. Melbourne: The Royal Australian College of General Practitioners, 2005.
- Hudnall-Stamm B. Secondary traumatic stress: self-care issues for clinicians, researchers and educators. Lutherville: Sidran Press, 1995.
- National Centre for Posttraumatic Stress Disorder. Working with trauma survivors: what workers need to know. National Centre for Posttraumatic Stress Disorder. Washington: Department for Veteran’s Affairs, 2007. Available at www.ptsd.va.gov/ professional/provider-type/ responders/working-with-trauma-survivors.asp [Accessed May 2014].
- Saakvitne K, Pearlman L. Transforming the pain: a workbook on vicarious traumatisation. London: Norton; 1996.
- Bloom S. Caring for the Caregiver: Avoiding and Treating Vicarious Traumatization. In: Giardino A, Datner E, Asher J, editors. Sexual Assault, Victimization Across the Lifespan. Maryland Heights: GW Medical Publishing, 2003. p. 459–70.
- Benson J, Thistlethwaite J. Mental Health Across Cultures. A practical guide for health professionals. Abingdon: Radcliffe Publishing Ltd, 2009.
- Snowdon T, Benson J, Proudfoot J. Capacity and the quality framework. Aust Fam Physician 2007;36:12–4.
- Stevenson A, Phillips C, Anderson K. Resilience among doctors who work in challenging areas: a qualitative study. Brit J Gen Pract 2011:404–10.
- Edwards N, Kornacki M, Silversin J. Unhappy doctors: what are the causes and what can be done? BMJ 2002;324:835–38.
- Freeborn D. Satisfaction, commitment, and psychological well-being among HMO physicians. West J Med 2001;174:13–28.
- Figley C. Coping with traumatic stress disorder in those who treat the traumatized. New York: Brunner/Mazel, 1995.