Mental Health Care for Doctors

Executive summary

This report aims to submit the idea of adapting and upgrading the current programs and policy in partnership with the Victorian State Government to support the mental health of our doctors. It focuses on the mental health of doctors influenced by their environmental and job factors. This report utilises both academic and grey literature to support as well as communication with key stakeholders. Throughout the report, occupational therapy models and concepts are explained and utilised to help identify and explain mental health, the issues associated and the interventions and policy currently in place.

Currently, mental health conditions are costing the government and organisations $10.9 billion each year (PWC, 2014). The policy that is targeting this area of issue was developed in 1999 and stated that it was not to be enforced. This policy in combination with the other programs described in this report required updating, mandating and adapting to be appropriate and effective in improving the mental health of doctors.

Abbreviations and glossary  

PEO- Population, environment, occupation model 

CPPF- Canadian practice process framework 

CMCE- Canadian Model of Client- Centered Enablement

Mental health- a state of emotional and social wellbeing in which the individual realises his or her own abilities, can cope with the normal stresses of life, can work productively or fruitfully, and is able to make a contribution to his or her community” (WHO 1999)

Grey literature- research that is unpublished or has been published in a non- profitable form. Examples of literature include but are not limited to: policy statements, government reports and government documents.

Role of occupational therapy- Occupational therapists help to empower individuals and populations to do what they are wanting to do and participate in the community and everyday life.

Occupational imbalance-  a temporal concept that refers to allocation of time use for particular purposes and is based on the reasoning that human health and well-being require a variation in productive and leisure occupations (Standyk et. al, ADD YEAR).

Occupation – a term that can refer to tasks such as work as well as other tasks that one deems meaningful in their life. Occupations covers a broad range of tasks such as showering or playing a musical instrument.

Introduction 

Currently within Victoria, there are limited services and programs that are targeted towards the issue of mental health problems of doctors. Since the development of the 2014 mental health act, there has been an overall increase in the awareness of mental health and the treatment of mental health conditions. Considering the gap in government responses to this problem, supporting this population is in line with the objectives and principles of the act (Department of Health & Human Services, 2014). 

     1.1 Aim 

This report aims to provide the reader with an outline of the current issues being faced by Victorian doctors, specifically, their mental health. Throughout the report the issues will be analysed utilising an occupational therapy model: The PEO. This model developed by Law et al. (1996) focuses on the complex and dynamic relationship between population, their environments and their occupations. Concurrently, an analysis of the interventions currently targeting mental health in the workplace were analysed in relation to how effective they are. The suggestion is then put forward for the development of a program aimed at preventing mental health issues in doctors with the aim of acquiring the required funding for this project. 

      1.2 Mental Health 

Throughout this report, mental health will refer to the following definition. Mental health according to the World Health Organisation is “a state of emotional and social wellbeing in which the individual realises his or her own abilities, can cope with the normal stresses of life, can work productively or fruitfully, and is able to make a contribution to his or her community” (WHO 1999). Mental health therefore has been found to have a profound effect on the daily functioning and wellbeing of people and as a result, will impact on the way in which an individual is able to participate in occupations. Mental health in this report is not specialised to one condition, however, encompasses a range of conditions. It is important to note that this report does not seek to minimise the prevalence and impact of mental health issues within other health professions. 

     1.3 Data Sources 

This report is supported with both academic and grey literature as well as communication with key stakeholders. Currently, the literature and supporting statistics on this population are narrow. It is therefore acknowledged that interventions and experiences have been drawn from other workplaces and health professionals respectively. 

Population in question

For this report, the population in question will be doctors defined as: those with a medical degree whose job it is to treat people who are ill or hurt (Cambridge Dictionary, 2019). 

Prevalence of mental health in doctors

There is an absence of Victoria statistics, however, BeyondBlue conducted a nationwide survey in 2013 to gain an understanding of the issues occurring in this field (BeyondBlue, 2014). The results suggested that doctors are experiencing higher levels of distress, in particular, female and younger doctors. This stress is partly related to the hours that doctors are working. Doctors who had worked over 50 hours per week reported higher levels of psychological distress (5.7%) than those that worked less than 50 hours (2.6%). Regarding depression, approximately 21% of the 13,718 doctors surveyed reported having ever been diagnosed with depression which is higher than the Victorian average. As well as depression, approximately 9% of doctors reported having ever being diagnosed or treated with an anxiety disorder. It is important to note that this survey detailed that approximately one quarter of doctors reported having thoughts of taking their own life prior to the last 12 months and 10.6% reported having these thoughts within the last 12 months. Lastly, 38% of doctors who had ever received a diagnosis of depression and 37% of those who had ever been diagnosed with anxiety, took time off work because of their mental health. 

Causes of mental health issues in doctors 

Arvanitis (2016) and BeyondBlue (2016) described several key aspects regarding why doctors are experiencing mental health issues. These issues include but are not limited to; long hours, work overload pressure, high levels of responsibility, fear of making mistakes, repeated exposure to death/ trauma, stigma, and belief that being a patient causes embarrassment. The idea of effort- reward imbalance can also lead to mental health issues amongst the doctors in Victoria (Bakker, Kilmer, Siegrist & Schaufeli, 2008). The above-mentioned factors can lead to occupational imbalance which in turn is another risk factor for mental health issues. 

The impact of mental health on doctors 

Financial consequences 

Mental health conditions according to PWC (2014), present substantial costs to organisations, $10.9 billion each year. The figure is broken down into presenteeism, absenteeism and compensation claims. If an effective successful plan to create a mentally healthy workplace was put into an organisation however, it can be expected to have a positive return of 2.3. The gains to the organisation will come from increased productivity, reduced absenteeism and presenteeism as well as lower levels of compensation claims. 

Occupational perspective

The PEO model was developed by Law et al. in 1996 to conceptualise thinking around three main components; population, environment, and occupation. These three factors interact through a complex and dynamic relationship that emphasises occupational performance. This tool can be used to analyse the problematic areas that doctors are facing, and hence, affecting their overall occupational performance leading to increased risk of mental health issues. Please note, for the purpose of this report the person component will be labelled as population. 

Population

Figure 1. PEO Model (Law et. al., 1996)

Role

The role of doctors is not limited to their role of a health professional. Doctors may be undertaking other roles such as partner, parent, friend, and family member. The different roles that they are required to undertake may have an impact on how they are coping as well as the support available if mental health issues arise. (Creary & Gordon, 2016).

Physical performance

The symptoms that are associated with mental health can have an impact on how doctors are participating in their work and other tasks. If doctors are experiencing excessive worries and illogical thoughts they may begin to withdraw from their work. this can lead to the standard that they are performing work tasks at to be decreased. Mental health issues can also lead to stress which can have a dramatic physical effect on the body and again, the way they are performing all tasks.

Environment 

Physical 

In relation to doctors, the physical environment of interest is the hospital. The hospital environment is having a negative impact on the health of the doctors in Victoria. According to Datsis and Tragouda (2007), the hospital is a high-pressure environment. This high-pressure environment stems from the faced past nature, white lights and sterilised surroundings. The above-mentioned conditions can act as risk factors for poor mental health. 

Cultural 

The cultural environment that Victorians are required to work in is again, high pressured. Doctors are working long hours, according to the medical board of Australia they are required to work 38 hours to be considered working full time. However, according to the BeyondBlue survey in 2013 and personal experience from a spokesperson from the Alfred Hospital, doctors are working up to 50 hours per week and are not being paid for overtime. These long hours’ impact on their ability to balance work and personal demands which leads to occupational imbalance. BeyondBlue supports the idea of doctors struggling to maintain occupational balance. The survey states that the most common source of work related stress is the need to balance work and personal responsibilities. This stress can then in turn lead to poor mental health. 

Koinis, Giannou, Drantaki, Angelaina, Stratou and Saridi (2015), state that as part of the culture, doctors are tasked with making decisions about patient’s capacity and other decisions that others are not allowed to. This in combination with the effort- work load imbalance can lead the doctors to struggle with effectively managing their mental health. 

Social 

The social component pertains to factors such as stigma that doctors are facing. According to Garelick (2012), doctors are perceived to be weak by other health professionals if they are unwell or heave a mental health issue. Doctors are also isolated in the work that they are doing and with the increasing size of the workforce, the isolation and competitive nature are both increasing (Vogel, 2018). There is also a general perception from doctors that they are unsupported from their superiors and colleagues (Zamani-Alavijeh, Dehkordi & Shahry, 2017). 

Social support can lead to the doctors feeling more vulnerable and therefore lead to them having a lower capacity to cope with mental health issues. This lowered capacity can ultimately influence the way they are working and how they are partaking in leisure activities. This in turn, could lead to them experiencing occupational imbalance. 

Occupation 

Working long hours, strenuous work, work/ family conflict, work overload or pressure, and the ability to separate work and home effectively. These factors can lead to a term called occupational imbalance. This is described by Standyk et. al (2010) as a temporal concept that refers to the allocation of time use for particular purposes and is based on the reasoning that human health and well- being require a variation in productive and leisure occupations. 

Occupational performance 

The result of the complex and dynamic relationship between the PEO components results in occupational performance. Occupational performance in terms of mental health constitutes symptoms such as poor concentration or memory, low mood, irritability, excessive worry or fears, and not performing well at work (Fieldhouse & Bannigan). Such symptoms can have an impact on the doctor’s capacity to complete work tasks. The general population are reliant on doctors being able to complete their tasks to a high standard. 

Current policies in place in Victoria

National code of practice- hours of work, shift work and rostering for hospital doctors developed by the AMA developed in 1999. It was developed in consultation with key stakeholders including but not limited to Australian hospitals and medical organisations. This code is voluntary and provides practical guidance on how to manage factors such as fatigue and aims to help eliminate certain risks associated with shift work and long working hours. The code provides organisations tools to identify working hours that are unsafe and ways in which to reduce the associated risk factors. It also provides a breakdown of the different levels of risk based on a 7-day period following a risk assessment checklist. This code acknowledges the fact that factors such as lifecycle (other family commitments) and work environment are not taken into consideration. 

Current interventions available in Victoria 

In order to discuss the interventions in place, the Iceberg model of health has been utilised. The iceberg model of health was developed by Talbot and Verrinder breaks down interventions into upstream, midstream and downstream. Upstream and midstream interventions are focused on the population risk conditions and how they in turn have an effect on the downstream factors, or individual risk factors of mental health in doctors (Talbot & Verrinder, 2018). For the purpose of this report, upstream interventions are policies and midstream interventions are programs. 

(Talbot & Verrinder, 2018)

 

To help critique the following programs, the Ottawa charter (health promotion model) has been utilised. The Ottawa charter was developed by the World Health Organisation in 1986. It provides five key action areas that can be used to help programs act beyond the medical treatment of disease and provide a more holistic approach. WHO, 1986). 

Please note, the following midstream level interventions are not designed for and hence are currently not directly targeting the population that this report is focusing on.

 

Health service program

Health service program was developed by BeyondBlue in 2014. It is important to note that this program is not specifically targeted towards the population described in this report, however, it could be beneficial. The aim of this program is the address the mental health issues of anxiety, depression and suicide that staff in health services across Australia are facing. It is a program that is supported by the commonwealth department of health. 

One goal of this program is to provide practical step by step guidance to ensure that health services can implement a mental health and wellbeing strategy that is tailored to their staff. It helps to highlight the benefits of a mentally healthy workplace. This program also provides services the tools they require to act. 

This program appears to align with an occupational therapy framework; the Canadian Practice Process Framework. The CPPF was developed with Polatajko, Craik, Davis and Townsend in 2007. It is a goal driven framework that can be utilised with a population. It helps to illustrate the dynamic interchange between the client (population in this case) and the occupational therapist. It also entails continuous reflection on action taken. The program is broken down into 4 steps that align with the steps of the CPPF. This helps to provide the service utilising the program, numerous points to monitor and adapt the program if required. 

Table 1. Critique of the Health Service program, key stakeholders involved and challenges implementing.

Health promotion area included

Create supportive environments  It is free and accessible to the public/ organisations and hence enables the organisation to more easily build a supportive environment within the workplace  Everyone can access the program and it provides solutions to potential challenges that the organisation may face when implementing this program.

Build healthy public policy This program provides a basic structure for the policies and strategies that the organisation can put in place. It breaks it down into clear steps to ensure that the policy/ strategy is more effectively utilised.

Reorient health services  Helps to change the attitude of the workplace around mental health and the stigma associated. The program can put in place strategies to prevent against the risk factors for mental health issues and occupational imbalance.

Strengthens community action  Ensures the incorporation and cooperation of key stakeholders and ensures that responsibility is not placed solely on those in leadership positions.

Health promotion area to include

Develop personal skills  The program could include a section on how to improve the individual skills of those in the workplace in relation to coping with mental health issues and the associated symptoms as well as the larger population focus.

Recommendations

Research to support its effectiveness would be beneficial as well as where this program has been utilised.  Update in accordance to the mental health act as this program was developed and published prior to the mental health act in 2014.

Challenges with implementing program

Coordinating stakeholders Acceptance of change in the workplace Time and cost in changing the structure of the workplace to include this program

Stakeholders

Employers Employees Mentally healthy workplace alliance  Those that run the company/ those that need to implement  The people who developed the program as they may be needed to help clarify questions  State government- policies they put in place

Heads up 

Heads up is an Australia wide initiative by BeyondBlue and in collaboration with the mentally healthy workplace alliance. It aims to give both individuals and organisations a set of tools that help to create a mentally healthy workplace. Heads up is provided online and offers the reader practical advice, resources and information that enables them to act. To help, the website offers fact sheets, brochures and online learning programs that are free to order and download. This initiative has different sections available for employers, employees, managers and small businesses. 

Heads up enables the organisation to answer a set of questions that in turn provides an action plan. This action plan helps to create a mentally healthy workplace. As part of the development process it allows for individuals to be assigned to particular action areas as well as sending out a copy to the desired members of the team. 

Table 2. Critique of the Heads up program, key stakeholders involved and challenges implementing.

Health promotion area included

Create supportive environments  It is accessible and free for those with internet  Encourages cooperation with the team members  Puts in place strategies to help improve the mental health of doctors

Build healthy public policy Action areas help to create a more supportive and aware environment and workplace

Reorient health services  Puts in/ makes available resources and services to improve the mental health in the workplace Helps to change the attitude of the workplace around mental health and the stigma associated.

Strengthens community action  Involves key stakeholders such as the company and the workers as well as Heads up and other beneficiaries.

Health promotion area to include

Develop personal skills  Make it more specific and hence better outcomes for the workplace Highlight specific tasks relevant to the workplace that can be utilised by the individuals

Recommendations

Update in accordance with the mental health act Research to support whether it was an effective program and the reach that it has

Challenges with implementing program

Coordinating stakeholders Acceptance of change in the workplace Time and cost in changing the structure of the workplace to include this program

Stakeholders

Employers Employees Mentally healthy workplace alliance  Those that run the company/ those that need to implement  The people who developed the program as they may be needed to help clarify questions  State government- policies they put in place

Recommendations

This component of the report will be focusing on how the previously mentioned policy and programs can be updated and/ or altered to target the population more effectively. It is acknowledged that one single level of intervention will not be effective in improving this issue. Instead, a multilevel approach is required to respond to the mental health issues doctors are experiencing. The following table displays recommendations at all levels.

The Canadian Model of Client- Centered Enablement (CMCE) is a model utilised by occupational therapists that helps to describe the relationship between the client, in this case the population, and the therapist as well as enablement achieved for the client (Townsend & Polatajko, 2007). The CMCE provides a list of “enablement skills” that will assist in proposing recommendations for a program directly targeted for Doctors in Victoria experiencing mental health issues and occupational imbalance. In combination with the CMCE seen below, the iceberg model levels of intervention will be incorporated to highlight the population level being targeted.

Figure 2. CMCE model ‘enablement skills’.

Table 3. Recommendations to improve the current policy and program in Victoria targeting mental health of doctors.

Level of intervention	Recommendation
Upstream - policies and socio-economic structures	Update the 1999 National code of practice- hours of work, shift work and rostering for hospital doctors to: Mandate maximum hours that doctors can work in hospitals including their ‘on call’ work (AMA, 2016; Trikha & Singh, 2013). Mandate how to schedule ‘days on/ days off’ to ensure that doctors are not experiencing burn out/ work overload (AMA, 2016; Trikha & Singh, 2013). Mandate night shift or extended hours that lead into night shift to reduce the risk of disruption to circadian rhythms and improve overall health (Harrington, 2018) Mandate the environmental conditions that doctors are working in e.g. amount of light required in each practice setting (Groene & Garcia-Barbero, 2005) Mandate the amount rest required within and between the work periods to ensure that doctors are not experiencing unnecessary fatigue and mental health issues (Afonso, Fonesca & Pires, 2017) -Ensure that these requirements are being followed and adhered to by the hospitals and organisations in Victoria through the use of sporadic audits (Hut-Mossel, Welker, Ahaus & Gans, 2017). CMCE skills: Adapt To improve the current policy that is related to the population, the sections noted above need to be adapted to the current situation that has altered in the last 20 years. Through the updating of sections, the factors that are contributing to the poor mental health of the doctors will be recognised and more appropriately managed. Advocate  To evoke this change in policy, key stakeholders will need to advocate for the doctors with poor mental health. This will require organisation leaders and individuals to highlight the troubles that are associated with doctors experiencing poor mental health and the effect that the proposed changes will have.
Midstream - programs	Update Heads up and Health service program in accordance with the Mental Health Act principles and objectives and more Ottawa charter action areas Priority is given to care and support that are holistic and responsive to individual needs This would involve including a section on how to develop the personal skills of the team as well as ensuring that a multipronged approach is taken (develop personal skills). Promote full participation in community life and promoting recovery  The programs could include a section on how poor mental health in the workplace can influence community participation and strategies that could be put in place to improve said factors. Create supportive environments/ strengthen community actions Person should be involved in all decisions about their assessment, treatment and recovery.  Person should have their mental health needs responded to  By building a healthy public policy that ensures the doctors specific needs are attended to and respected, mental health of the workplace should be improved. This policy should also work to create a more supportive environment with reduced stigma. CMCE skill: Design/ build Designing a program that provides the organisation with a holistic approach that is also targeted to the specific needs of doctors would be beneficial. This would include the strategies that the programs currently utilise as well as including
Downstream - behavioural factors	The above mentioned upstream and midstream interventions will work towards influencing and impacting the downstream factors. Those factors will impact behavioural factors that doctors are experiencing in relation to their mental health and occupational imbalance. It is hoped that through mandating rules regarding the hours that doctors can work, their work- life balance will be improved and they will experience less occupational imbalance. As well as mandating rules, it is hoped that with increased awareness and support from superiors and co-workers, the stigma around mental health issues will be decreased and lead to overall better mental health and well-being.

 

Conclusion 

This report put forward the prevalence of mental health within this population as well as the issues that doctors are facing. It details the causes of poor mental health broken down into perceptible components using an occupational therapy tool. By breaking down the root causes and issues of mental health in this population it highlights that there are clear steps that can be taken to improve this situation. This report also highlights the current gap in interventions

Mental health and occupational imbalance is a prevalent issue being experienced by Doctors practicing in Victoria. It is costing the government more than it needs to. Doctors are tasked with looking after the population however, there are currently only outdated policies in combination with no publicly accessible programs that are aimed directly at doctors and reducing their mental health. Mental health issues could be dramatically impacting the way in which doctors are working and not only effecting their work life, but also their home life as well. When the Mental Health Act was commissioned in 2014 the aim was to protect the rights, autonomy and of those with a mental illness. This act needs to be considered with the population proposed in this report. 

If action was taken with the recommendations proposed in this report, there could be less than $10.9 billion being spent on Mental health issues each year. This action involves utilising the multipronged and population focused approach to interventions and will assist in protecting the rights and mental health of our Doctors. The Victorian Government has a responsibility to respond to the issue at hand and provide an effective population focused intervention.

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