Dr Asta Medisauskaite
When I moved to London in 2012, I worked as a care worker at St Christopher’s hospice for a couple of years. During this period, I have learnt a lot about holistic patient care, UK health system, death and dying as well as myself. More than seven years past from my first day on St Christopher’s wards, however, I still remember it. I was shadowing a senior nurse for the first half of that day, getting to know some of the facilities and patients, performing simple tasks like helping patients to eat or stand up. In the middle of my shift, however, one of the patients died. I was standing aside in the hospice hallway listening to a nurse talking to this patient’s family and nervously waiting for her instructions to what I should do now. After talking to the family, she came up to me and said something I did not expect. She said: “It is 12 now, so it is time for your lunch break”. I wanted to stay and help but she insisted that I go on my break. I took my lunch and went downstairs to the staff room; I was sitting there staring at my lunch box and trying to comprehend what had just happened. At that point I couldn’t understand how I was supposed to sit here and eat my lunch as usual, when just minutes ago something so significant had just happened. A human life – there is nothing more important than that.
This situation struck me. Of course, with time I got more experienced and started viewing things slightly differently. But I’ve never stopped thinking about how health care professionals deal with these types of situations every day. How do they leave their work problems behind, go home, and enjoy life? I was just a part time care worker, but every time after my shift I was spending hours reflecting on my experiences, difficult conversations or situations I had. It made me appreciate smaller things which we sometimes take for granted; however, the thought of going through such experiences everyday felt heavy. Being close to illness and death, around pain and sorrow. How does one deal with that?
This care workers position was temporary as I always wanted to become an academic which meant getting into a PhD programme at university and doing my doctorate research. I had a topic in mind which I was interested in for a few years - about perception biases, and had a proposal written up ready for the university submission. However, after my experience in the hospice, my research interests shifted: I became interested in how work experiences affect health and well-being of those who are taking care of our health and well-being. Something we as patients usually do not think about at all. I have finished my PhD which more specifically focus on doctors and I will briefly discuss the key findings in the next sections.
The impact of occupational stress
The impact of work on health was noticed already in ancient Egypt. Drawings showed workers under the whip building the pyramids and observations of these workers’ ill-health were found in Egyptian writings. Of course, these early writings were observational and lacked actual recognition of the issues. Just centuries later (15th-17th) the effect of work environment on health in various occupations was analysed in more methodical way. However, as one would guess the focus was on physical hazards. How work is done changed significantly over time with increased demands for workers’ skills which also increased an interest in stress and its effects on employees’ health.
In one of our studies, we analysed how stress and work factors affect doctors’ health problems. We found that occupational distress and job characteristics increased the risk of doctors using substances (drinking hazardously, etc.), binge-eating, having sleep disturbances (insomnia, difficulty staying/falling asleep, etc.), and physical health problems (fatigues, upset stomach, headaches, etc.). So stress is dangerous for our health. For doctors, stress is not just dangerous for themselves, it is also dangerous for their patients. A comprehensive meta-analysis (synthesis of previously published studies) by Panagioti and colleagues published in 2019 showed that burnt out doctors were more likely to make medical errors, provide reduced quality of care, and they were more associated with poor patient satisfaction. This study shows that it is of importance to everyone to reduce stress among doctors.
The prevalence of occupational distress
What is the level of the problem? How many doctors are experiencing health problems and reduced well-being? In another study we looked at previously published literature from all over the world about doctors working with high numbers of palliative care patients. In the paper published from part of this study, we report that 32% of 4876 oncologists were experiencing high burnout, 27% of 2384 had psychiatric morbidity (psychological impairment reflecting somatic symptoms, anxiety, depression, insomnia, and social dysfunction), and 42-69% felt stressed at work. Moreover, up to 51% of cancer doctors were screened positive for depression, up to 44% had sleep problems, and up to 30% drank alcohol in a problematic way. Some cancer doctors also frequently experienced stress-induced health complaints such as gastric problems, headaches, and arrhythmia.
High prevalence of health problems is not unique to oncologists. We surveyed 417 doctors from various specialties in the UK  and found that 55% of doctors were burnt out, 33% had psychiatry morbidity, 11% had insomnia, 22-44% had sleep disturbances, and 61% thought about work when they went to bed. 5% had alcohol dependency and 53% drank two or more times a week. We also found that many doctors experienced physical symptoms frequently (69% had fatigue; 33% back pains; 27% headaches, etc.), 8% binge-ate and 24-35% reported having binge-eating features (e.g. eating large amount of food when not physically hungry).
We have also noticed some possible differences between oncologists and palliative care doctors. For example, as mentioned above 27% of oncologists had psychiatric morbidity and 32% were burnt out. Lower prevalence of psychiatric morbidity and burnout was reported for palliative care doctors (19% and 20% respectively). These results are surprising considering that working in palliative care involves higher emotional demands (e.g. frequent patient deaths) which researchers have linked to staff health problems. The results, however, might be explained by the differences in medical cultures between the two medical specialties. For example, the grief is accepted as a natural process in palliative care and is not stigmatised while as Elliott (2011, p.27) mentioned “hospitals don’t do death well”. Hence, even though palliative care doctors work in the highly emotionally demanding work environment, they are better supported which protects them from getting ill.
An intervention to reduce occupational distress
What can be done about high prevalence? System, organisational and individual level interventions should be implemented to reduce raising stress levels among doctors. Developing and testing an individual level intervention was a part of my PhD. This online intervention was developed to challenge the stigmatizing culture of mental distress in medicine. Mental distress might be seen as a sign of weakness which leads to doctors ignoring signs of burnout or blaming themselves for experiencing burnout and isolating themselves or using maladaptive coping strategies such as alcohol use. Therefore, the intervention was teaching medical doctors about stress, burnout, its signs, and coping strategies. This study was a randomised controlled trial when changes in the intervention group was compared to the changes in the control group. In the published study we discuss key results showing that doctors burnout and anxiety levels decreased after completing the intervention.
After the study was completed, we have collaborated with Focus Games Ltd (www.FocusGames.com) to transform the intervention into practically usable tools for health care professionals: an app and a board game (the NHS Practitioner Health Programme supported its development, (www.php.nhs.uk/). I have used the board game, which is called Working Stress Game, several times during conferences and seminars for practitioners and researchers. It is an innovative tool which helps health care practitioners to start sometimes difficult conversation about stress, share their worries, and receive advice through playing.