These days, it's not uncommon to read about doctors who have committed all manner of crimes, from indecent exposure to voyeuristic underskirt filming and molestation, to drug abuse and drink-driving. And tragically, even suicide. Just as having the risk of developing physical illnesses, doctors are equally likely to develop mental ones. There is no study of the prevalence of mental illnesses among medical practitioners in Singapore. A recent paper in Taiwan showed that prevalence of mental illnesses was lower compared to the general population. However, a study in Canada suggested that help-seeking behaviour among physicians was significantly lower. This may be related to stigma and fear of disclosure of what the doctors suffer from until something bad happens.
Burnout: a state of mental exhaustion
Beyond the problem of identifiable illness is the problem of well-being. Well-being is defined as a continuous process of growing and thriving and in layman parlance, happiness. There have been many stories of unhappy doctors who are struggling with their lives and work. Dr Elisabeth Poorman, a resident working in Massachusetts, US, describes this in an interview. "By the end of my first year of residency, I knew I was in trouble. I was overwhelmed by the 15-hour days, the unbearable sadness of the tragedies I witnessed, my feelings of impotence and my fears of making a mistake. My life was my work and everything else seemed to be falling apart: my physical health, my relationships, my ability to sleep after months of night shifts." This unhappiness can gnaw at the doctors and make them think of death even in the absence of clinical depression. Hebert Freudenberger, a German psychologist, coined the term burnout in 1974 to describe this state of mental exhaustion that emanates from professional work. Burnout can be described in three inter-related symptoms: emotional exhaustion, depersonalisation (a detached feeling of self which can be deeply disturbing) and a reduced sense of accomplishment leading to loss of purpose and meaning. Studies of burnout across the world suggest that many doctors (between 30% and 70%), especially junior ones, have at least one symptom and the range varies between specialties.
Practising physicians today face a myriad of challenges. From the outside, they must deal with increasingly demanding patients who are educated, have high expectations and yet are cost-conscious. The system continues to look at human fallibility as a way to blame the individual, often ignoring the system-level problems that lead to error. In general, healthcare professionals and doctors have self-regulatory frameworks that are increasingly coming under public scrutiny. A doctor's ethical dilemmas are publicly debated in courtroom settings which focus on transparency. Fearful of the consequences of not following standardised practice, physicians become increasingly defensive in the way they practise. In fact, it is now no longer sufficient to practise what everyone else does (Bolam-Bolitho test); the doctor must now provide the appropriate treatment advice and information to patients and their family (modified Montgomery test). The recent emphasis by our Court of Appeal, for the modified Montgomery test to be considered alongside the Bolam principle, ensures that doctors must work with patients. The expectation is for the doctor to empower patients to make meaningful decisions in their own care. This requires clinicians to spend more time explaining to and educating patients, which adds to the increasing amount of work that must be done.
Increasing incidences of physician abuse
Another issue that doctors and other healthcare professionals face is the increasing incidences of abuse. Several articles, including a World Health Organization report and a 2016 New England Journal of Medicine review, suggest that physician abuse is an increasing hazard in healthcare. In 2015, a physician in Boston was shot dead by the son of a deceased patient, sparking widespread discussion on the issue. In certain settings, it is a given that doctors and nurses are regularly battered physically and emotionally by irate patients and their family and friends. A local editorial in 2015 estimated that seven in ten healthcare workers have faced physical abuse and that there is generally "significant under-reporting" in this area. Across industries, the healthcare industry is far more prone to workplace violence than others. If you walk into hospital clinics and emergency departments today, you will be greeted by signs that urge you to not abuse our healthcare workers, suggesting that this is not uncommon.
These external pressures work on the internal ones a doctor faces. Apart from completing medical school, every new doctor, through our development of the American-style residency training programme, is expected to sit for a series of formative and summative examinations to be fully trained and qualified. This includes the GP. A paper on residency burnout in 2018 suggests that our residents have higher levels of burnout and lower levels of empathy compared to their counterparts in the US. A quick review of a few studies across disciplines (eg, internal medicine, palliative care and mental health) and across professions (eg, nursing) suggests that this is a system- wide problem in healthcare.
Tackling burnout
What are the possible solutions to this? The obvious external factors can be ameliorated. Academics suggest reducing workload such as night calls, improving physical resilience through exercise, and even team building. One group suggested the importance of mindfulness and relaxation. Skills training to manage stress can certainly be taught and included within the general competencies that doctors learn alongside clinical techniques. But there is little emphasis on the internal factors that make a doctor.
The doctors today have been selected based largely on academic abilities. Today, all three medical schools in Singapore have an academic criterion as a first cut for entry. But is the ability to do well in examinations a sufficient criteria for the identification of the physician of tomorrow? A study of medical students in Australia showed that students have different personality traits that make them vulnerable to different situations. Personality traits reflect their characteristic patterns of thoughts, feelings and behaviours. This suggests that besides the ability to process information, make accurate diagnoses and other cognitive skills, there is also a need for an evaluation of the student's ability to handle problems, withstand stress and be resilient in the face of changing needs and demands. Some of this can be trained but other aspects may be deeply ingrained personality traits that should form part of the criteria for identifying suitable candidates to be doctors in the first place.
The three medical schools use a variety of screening measures developed across the world. There is of course no perfect system, but a system in which personality profiles are identified, and strengths and weaknesses are recognised from the outset, has a better chance of improving long-term outcomes and predicting the likelihood of burnout. It is also timely that in the last five years, the Institute of Healthcare Improvement has been increasingly arguing for the need to have its triple aim of population health, cost-effective care and patient satisfaction supplemented by a fourth aim (thereby calling it a quadruple aim): provider satisfaction. The joy in work initiative and white paper has received widespread recognition and is not just a touchy-feely appeal to improving our job satisfaction. Instead, it is a clarion call for us to work together, ask the question of what gives meaning and purpose, overcome the impediments and share this across the healthcare organisation to develop systemic change using improvement science. Improving care also comprises caring about improvement. Only with a renewed sense of purpose will the doctor be able to function as an effective member of the healthcare team focused on building relationships – not just externally with patients but just as importantly, internally with one another.
As I pondered these issues of burnout among physicians, I wanted to understand this at my own workplace, the Institute of Mental Health. Over the last few years, several studies are suggesting that our healthcare staff face significant stress. This is not surprising as across the world, mental health professionals face intense pressures of external stress and internal turmoil. Working together with our human resource and research departments, I have noticed a worrying trend of medical leave and attrition by some groups of staff. It would be easy to give simple reasons such as attractive job prospects in other areas of healthcare or the lure of private practice. Along with a group of like-minded colleagues, we are starting out on a journey to combat burnout by trying to understand the meaning and purpose of a public mental health service that practises what it preaches. It is important that in our value-driven healthcare system focused on outcomes, we create value not only for our patients and population, but one that our healthcare providers will also value.