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The pressure to cope

Alastair Watt’s death raised serious questions about how the NHS looks after it doctors when they return to work after illness. Robert Wrate finds parallels with his own research into an NHS culture where doctors soldier on in all circumstances, even though the service is not resourced to meet demand

I read with dismay the circumstances of Alastair Watt’s death, sharing the sadness that all must have felt who were familiar with his circumstances.

Notwithstanding that in Dr Watt’s case, psycho-biosocial factors were involved, the article in the May issue of The Doctor entitled The hard road back highlights a striking difference from acute medical care: the apparent absence of any sustained application of well-coordinated skills to drive through a resolution of his escalating difficulties.

Anxiety was a prominent theme throughout descriptions of him; before his head injury, anxiety about his workload as a sole consultant in an under-staffed service and then on his return to work.

Previously accustomed to managing clinical uncertainty, he became engulfed by uncertainty arising about his place at work; his anxiety became intolerable.

Managing uncertainty is an important task within many professions; for those in medical practice, frequent clinical uncertainty ‘comes with the territory’.

Their training involves the progressive acquisition of clinical skills to explore complexity, where maintaining curiosity requires becoming unafraid of uncertainty.


Adverse culture

Drawing on his war-time experience, the psychoanalyst Donald Winnicott likened this to developing the capacity to ‘think clearly under fire’, not rushing to judgement.

His observation was intended to apply to complex clinical scenarios, not on how to manage when feeling under fire on return to work. Dr Watt’s first occupational health consultant appeared to recognise the distinction but this may become lost inside large employers, and clear sight of the needs of vulnerable employees lost.

‘Accounts of unacceptably poor mental healthcare are sadly only too common’

Accounts of unacceptably poor mental healthcare are sadly only too common, including the likely role of stigma but, as Dr Watt’s wife Ruth highlighted, the culture of the NHS plays an important role, a culture which adversely affects vulnerable employees.

It’s a culture of which we are all a part, and the lessons are for everyone.

Almost from inception the NHS has accumulated idyllic myths, not just the principle of freely available healthcare for all but that clinical care depends on human contact, including that patients feel ‘cared for’ by staff who are appropriately skilled and well supported… and that all this is sustainable despite increasing evidence of inadequately staffed services.


Great expectations

From Edinburgh, funded by the NHS Management Executive in London, a prospective national study of doctors was undertaken that seemed to indicate that doctors themselves, if not always buying into these myths, nonetheless place excessive reliance on being seen to ‘cope’ with such expectations.

This is not just on return from sickness absence but as each young doctor sought a place in the NHS that personally fitted them, which later adverse life events and ill health episodes can disrupt.

The health behaviours and wellbeing of this cohort, who were first recruited in 1986 on entry to a Scottish medical school, have been reported elsewhere.

Since qualifying, the doctors responded to five further waves of assessment, by interview or post, most recently in 2002-03.

To explore what may underlie the cohort’s self-reported health behaviours, which had been observed to be excessively stoical in 1993 and were still marked in 2002-03, 38 subjects were selected, by stratified random sampling, for further interview from those still working in the NHS.


Themes emerge

Analysis of the 38 interview transcripts, by grounded theory, identified eight common themes. These were: professional learning; coping; health; personal learning; relationships with consultants; research; work-life balance; and gender.

We then proposed two constructs that underpinned these themes. All the main findings from the 38 interviews, including these two propositions, were then validated through responses to an open-ended questionnaire posted to the full cohort.

The first of the two constructs had concerned ‘fit’, the rather hit-and-miss process by which most respondents found their place in medicine, and the place of medicine in their lives.

‘In some the underlying anxiety might be debilitating, a few may feel catastrophic’

The second concerned ‘language’ – how individuals articulated their experience of their workplaces, which was related to participants’ concerns with coping, and fears of being regarded as acopic.

Irrespective of whether or not they had experienced ill health, or were vulnerable to it, or were particularly resilient across the decades since medical school entry, we discovered that fears of being seen as acopic were widely held. 

Those with ill health maintained excessive stoicism (by reporting more days at work still unwell) but the most resilient doctors had become less inappropriately stoical. Nevertheless, they were equally likely to fear being seen as acopic. Even the acquisition of a clinical skill set (the sample included some prodigiously successful academics) was clearly offering little protection.

A crowded curriculum, competitive career environment, and cultural beliefs in medicine may all have added to the absence of effective training in managing workplace uncertainty.


Coping unwell

As UK medicine is embedded in the NHS, doctors’ fears may be exacerbated by holding on to idyllic myths about the NHS – that irrespective of adversity, ‘doctors cope’, whatever their personal uncertainty in the workplace. In some the underlying anxiety might be debilitating, a few may feel catastrophically unsafe.   

More effective training in managing workplace uncertainty might be one lesson from Keith Cooper’s article, either universally provided or targeted to specific need, allowing vulnerable individuals to feel safe. From my own experience, it was never safe to be single-handed in an under-staffed service.

Another lesson might be an examination between politicians, the public, and health professionals on the core values and idyllic myths of the NHS, taking the long, hard road to agree on what is practically possible.

Robert Wrate (pictured below) is a retired consultant psychiatrist from Edinburgh

Call BMA wellbeing support services on 0330 123 1245

Read The hard road back

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