Anyone who goes into the caring professions, especially those working in “blue light” emergency response services, will fully accept they are likely to be dealing with stressful and challenging situations. But that doesn’t mean they walk away unaffected. The mental and psychological toll of responding to major emergencies, and how doctors, nurses and others can be better supported, was the focus of a recent conference, as Nic Paton reports.
Last autumn, on Thursday 10 October, individuals and organisations around the world marked World Mental Health Day, the global initiative run by the World Health Organization to raise awareness around mental health issues and concerns.
As part of this, the British Medical Association took the opportunity to urge employers to address what it termed the “mental health crisis” among doctors and provide better workplace support.
It launched a Mental Wellbeing Charter and highlighted its report from earlier in the year, Mental health and wellbeing in the medical profession, which had concluded that 80% of doctors were at high or very high risk of burnout and 40% were suffering from a broad range of psychological and emotional conditions. This, in turn, echoed research from SOM (the Society of Occupational Medicine) and The Louise Tebboth Foundation from 2018, which had suggested UK doctors were at greater risk of work-related stress, burnout and depression than the general population.
Most people who go into the caring professions – especially “blue light” emergency response services – do accept there will be an inevitable “heat and burden” that comes with their role.
Nevertheless, the psychological toll this sort of career can take is something employers – the NHS primarily in this context – and occupational health professionals do need to be recognising and being proactive about in terms of effective support and interventions. One positive in this context was the announcement by NHS England in 2018 of the national roll out of its NHS Practitioner Health Programme confidential support scheme.
The emotional and mental cost of being on the medical frontline, especially the psychological fallout from being caught up in a major incident, was vividly highlighted at a recent conference in London. Among a range of presentations, the “Risky Business” conference heard from doctors involved in the medical response to 2017’s Grenfell Tower fire, Manchester Arena bombing and London Bridge terrorist attack.
Emotional stories from Grenfell Tower
Dr Anu Mitra, consultant emergency physician at Imperial College Healthcare NHS Trust was the A&E consultant on call on the night of the Grenfell fire. At a purely operational level, he emphasised he was proud the response had gone “very, very well”.
But he also recounted one moment that had stayed vividly with him. “As I passed through resus a woman who was on a trolley grabbed my arm. She was pretty hysterical really and told me, ‘no one has spoken to me since I was pulled out of the tower and I haven’t had a chance to talk to anyone; I need to talk to you, I need to tell you what I’ve seen’.
“So for the next few minutes she told me in great detail about the horrors she had experienced trying to escape from the 11th floor of Grenfell Tower. She also told me about her elderly dad, who followed her out of their flat and they fought their way through the heat and the black smoke. And they tried to get into a very crowded lift and he said to her, ‘don’t worry I’m right behind you’. And as she squeezed into the lift she felt his hand push her into the lift, and as she turned round the doors closed and he was no longer there.”
Grenfell Tower was also a very local, and locally felt, tragedy. “For the people of Grenfell Tower, we were their local DGHs. They were the people who came into our departments day in and day out. We even had a couple of staff members who lived in Grenfell Tower; fortunately, they and their families survived. So we were very much directly affected, as were the people who came to us,” Dr Mitra said.
“On a personal level, Grenfell affected me for some weeks. I felt bad about going home and cuddling my daughter and sitting down to watch ‘Paw Patrol’ on CBBC. All I could think about was the families who could no longer enjoy such simple pleasures. I felt guilty about feeling sad and bereaved for these people who I never really knew because we’re supposed to be really ‘hard’, resilient, tough emergency medicine doctors. And my inner drill sergeant kept trying to tell me to snap out of it and stop being so pathetic,” he said.
The memory of the woman with the elderly father was something “I still carry with me to a certain extent,” he added. “And there are lots of stories like this, and there are lots of stories that staff from St Mary’s have carried with us from that night.”
Support mechanisms introduced by the trust have included working to build a culture of “compassionate leadership”, one where managers are prepared genuinely to listen to staff and promote psychological safety, Dr Mitra emphasised.
“We’ve tried to make concrete changes to improve working lives, such as a user-led rota redesign and investing a lot more time and resources into education. We are rebuilding our rest area at Charing Cross. We have a wellbeing forum where reps from every grade meet every few months and we put forward lots of different ideas to support them going forward.”
The trust also runs “Schwartz Rounds”, or forums held every two to three months specifically to enable people – doctors, nurses, healthcare assistants and receptionists – to talk about emotional and psychological concerns.
“It turns out the two most powerful words in the English language are ‘well done’. So, make sure you explicitly thank your team and make it meaningful, and do it on a regular basis. I would urge you to place your staff wellbeing and welfare at the heart of what you do as departments, hospital trusts and GP practices. Not only because it is the expedient thing to do and it makes your team more effective carers; because it is the right thing to do,” Dr Mitra said.
Responding to the Manchester Arena terror attack
Dr Richard Smith, consultant trauma resuscitation anaesthetist at Royal Stoke University Hospital, and Ms Naomi Davis, associate medical director at Royal Manchester Children’s Hospital, both then spoke about the Manchester Arena bombing. Dr Smith had been an emergency responder that night and Ms Davis had been the surgeon commander.
Dr Smith’s presentation in particular was laced with black humour – for example how he’d climbed into his “trusty response Renault” to race up the motorway to Manchester. But it was also clear the events of that night were still with him.
“So, am I all right? Just as Anu [Mitra] said, there are times it gets me. I’m not sure I’m completely all right. About a year later I was coming through Euston Station and there was a helicopter hovering over the station and I had the most unrelenting tachycardia. Sweaty palms, the whole fight or flight response. Just coming through a station, and I had never experienced that. So I am not completely fine; it definitely affected me and I am certainly a bit hyper-vigilant about it,” he pointed out.
“The decisions we made on that night will be analysed with a fine tooth-comb. Those decisions were made with good intent on the information we had, in seconds. But it will be analysed very slowly. And I think that is something the public and press need to remember – that with hindsight and with all the information available to you you can make different decisions. And that is a huge cognitive bias at the heart of our legal system.”
Ms Davis, meanwhile, highlighted how, for her, the trust’s management team (and NHS managers do often of course get a bad press) had been a massive support both on the night and subsequently.
Highlighting a slide showing the frenzied activity in the aftermath, she pointed to the top corner. “Those were our managers, who were with us every minute that night, and with us every minute in the weeks and months that followed, helping us support these families.”
“Our hospital director was there every minute. If all she was doing was ensuring everybody had something to eat and drink, she was doing anything. But it wasn’t just her; there was a whole team making sure that things worked. Let’s just be clear that, after this, we lost 40 operating lists over the next couple of weeks. All that needed to be managed.”
As you’d expect, the medical teams pulled together – the surgeons, anaesthetists, nursing staff, microbiologists, critical care, radiology and so on. But also going the extra mile had been the rehabilitation team, the CAMHS children and adolescent mental health team and many others.
The trust’s psychology department had provided one team to support patients and families and one to support staff, Ms Davis pointed out. “They were helping us to understand what psychological first aid means, and that some of the issues we are going through; they are supporting us all the way. Because of where this happened, we’ve got patients from all round the country, and so liaising around teams who haven’t dealt with this and don’t know what these families have been through is quite difficult, and it takes a big team to do it.
“It wasn’t just health professionals; it was the cleaners who were coming in. There is something bigger there. Post-Manchester, that community feeling was very obvious. The gathering of the flowers in St Ann’s Square, the poem, that community feeling really came to the fore. Manchester still does that really well.
“When people are down and are in a corner and a little bit sadder or angrier than they need to be, you’ve got a ‘family’ still caring for you within your hospital team. We can grab the good out of this, and that is what is important, and that is what makes us resilient,” Ms Davis added.
Supporting medics in crisis
The difficult question of how doctors in crisis can be better supported was addressed at the conference by Dr Clare Gerada, former head of Royal College of General Practitioners and medical director of the NHS Practitioner Health Programme.
The programme, as touched on earlier, provides a free, confidential service for doctors and dentists with issues relating to a mental health concern or addiction problem and so far has seen some 8,000 doctors, she said, most suffering from anxiety or depression.
There was, however, also a sizeable cohort with bipolar disorder, smaller numbers with personality disorder, some with paranoid schizophrenia and other with complex issues. Around 10% had substance disorder issues, mostly alcohol, but there were also addictions ranging from over-the-counter painkillers to anaesthetia drugs through to heroin, she highlighted.
Why did doctors have such high rates of mental illness, between two to five times the rate of suicide, she questioned? And why, too, was medicine the only group where women and men had the same risk of suicide?
“I would argue medicine is an occupational hazard for many doctors. It goes without saying that being a doctor is tough; it is tough. It has always been tough. And no matter what checks and balances are put in place, what support is out there, it is always going to be a job that exposes doctors and nurses to death, despair and disability,” she said.
Alongside the well-documented pressures of workload and unrealistic demands and expectations there were three more subtle pressures potentially came into play, she contended: shame, perfectionism and less “connectedness” within the profession.
“The medical profession is constantly exposing doctors to shaming experiences. And I would argue much more today than in previous generations,” she said. “The impact of errors and the fear of committing them; it seems to be one of the most pressing sources of shame.
“Quite rightly, patients should be allowed to express concern and complain when they don’t seem to get the care they need. But the impact of a complaint on the doctor can be immense – as one told me, it was worse than receiving a diagnosis of breast cancer. A complaint challenges one’s core sense of identity and professionalism. And often leads not just to private and internalised shame but also to public shaming, of being ‘exposed’ on the front pages of the newspapers or in the medical press.”
When it came to perfectionism, this was one of the most pervasive of personality traits found in doctors. “It can lead to becoming hyper-vigilant, anxious and fearful of making errors and, in turn, mental illness. Today’s doctors have to be personally, professionally and nowadays social media-likewise, perfect,” Dr Gerada said.
The last of her triumvirate was connectedness. “I believe medicine has become a risky business because we need to feel connected to each other. Medicine is a relational activity done between people – you cannot have a doctor without a patient. And doctors and others rely on the connections that form in order to sustain us in our job,” she said.
The small, close-knit networks and bonds you used to develop as a trainee at medical school are much looser these days, she pointed out. There is less time to reflect, or even communicate or talk to each other face-to-face.
Work was being done in this area, with doctors’ “messes” returning to some hospitals, the creation of a new chief people officer role within NHS England and greater recognition of the importance of wellbeing within the royal medical colleges, the General Medical Council and the BMA.
“But there is still a way to go. We have to address the causes of distress, address the shame within healthcare, support doctors in how to deal with adverse events when they happen and bring in a no-blame culture. We have to address perfectionism and have a realistic discussion with our patients about the power of medicine. We have to create a new code of conduct for complaints that, rightly, asks patients to raise their concerns but also acknowledges the risks to those complained about if the process isn’t handled properly.
“We have to recreate the spaces where doctors can form and reform connections with each other. If we are to make medicine a less risky profession, we have to declutter the space that gets in the way of caring, what I call that transitional space between doctor and patient, where the magic of healing takes place,” Dr Gerada said.
‘NHS England extends mental health support for doctors’, Occupational Health & Wellbeing, October 2018, https://www.personneltoday.com/hr/nhs-england-extends-mental-health-support-for-doctors/
Mental health and wellbeing in the medical profession, British Medical Association, https://www.bma.org.uk/collective-voice/policy-and-research/education-training-and-workforce/supporting-the-mental-health-of-doctors-in-the-workforce
‘What could make a difference to the mental health of UK doctors?’, SOM and Louise Tebboth Foundation, September 1018, www.som.org.uk/sites/som.org.uk/files/What_could_make_a_difference_to_the_mental_health_of_UK_doctors_LTF_SOM.pdf
‘NHS to prioritise doctors’ mental health’, http://php.nhs.uk/wp-content/uploads/sites/26/2018/10/PHS-Extension-press-release-051018.pdf
‘New Chief People Officer to build the NHS workforce of the future’, NHS England, March 2019, https://www.england.nhs.uk/2019/03/new-chief-people-officer/
‘Funds secure to improve rest facilities’, BMA, May 2019, https://www.bma.org.uk/news/2019/may/funds-secure-to-improve-rest-facilities