20 September 2018

In the second in our series focusing on Generic Professional Capabilities, Dr Chris Tiplady – Consultant Haematologist and Director of Education for Northumbria NHS Trust – tackles the subject of stress at work.

It was appraisal season and this was his first day back after a break. He came into my room wearing scrubs with a bright blue cast on his right arm; he had broken a bone while snowboarding somewhere sensational. From where I was sitting, I could see greying areas on his cast that would make infection control shudder.

“What am I going to do about my e-portfolio … I can’t type?” He asked.

“Aren’t you on the arrest team? How are you going to do that with that on – and how on earth will you be able to get your hands clean?” I asked back.

It had simply not occurred to him that this injury could stop him seeing and treating patients. A quick referral to Occupational Health and some phone calls to the team followed to sort things out.

Spotting invisible illness

I have seen many examples like this – doctors coming to work with obvious physical symptoms that would keep most people at home. The prevailing medical culture is often to work through illness, though at least physical symptoms can be easy to spot and colleagues can intervene.

But if we are covering up our physical illnesses what are we doing with our anxiety, stress and mental health? What if it is the actual work, the workplace or even our colleagues who are driving our anxiety, our demotivation or our depression? How will these problems show to our colleagues or ourselves – and what can we do about them?

In my experience, it doesn't matter what the underlying issue is, there are some common ways that doctors reveal distress. These may only be recognised by or shared with those closest to the doctor, so it’s really important we all know the signs, and what to do when we have concerns.

The National Association of Clinical Tutors published a very useful guide for recognising a struggling doctor, mainly aimed at trainees but relevant to all of us. Here’s my own adapted list of things to look out for:

  • The “disappearing act” – not answering bleeps; disappearing; lateness; frequent sick leave.
  • Low work rate – slowness; arriving early, leaving late and not achieving a reasonable workload.
  • Ward rage – bursts of temper; shouting matches.
  • Rigidity – poor tolerance of ambiguity; inability to compromise; difficulty prioritising.
  • Bypass – junior colleagues or nurses find ways to avoid seeking the doctor’s help.
  • Career problems – difficulty with exams; uncertainty about career; disillusionment with medicine.
  • Insight failure – rejection of constructive criticism; defensiveness; counter-challenge.
  • Lack of engagement in educational processes – fails to arrange appraisals; late with learning events/work-based assessments; reluctant to complete portfolio; little reflection.
  • Inappropriate attitudes – like blaming a secretary when it’s busy or feeling like patients are getting at them deliberately.
  • Errors and complaints – these happen more often when things are not right.

Starting the conversation

Of course, spotting the signs is perhaps the easy bit. I know of doctors being found asleep at their desks, consultants struggling to make decisions, constantly seeking opinions and unable to discharge patients. I know of doctors staying so late their families must hardly know them, and others who just argue with everyone.  Has anyone been brave enough to sit down and talk with them? It’s a difficult task, and one that can seem extremely daunting.

Fundamentally, we have to develop cultures that allow us to have that talk, to feel it is OK to share insecurities and to have time to reflect with colleagues. We also must be encouraged to look after our own physical and mental health. Over my years supporting trainees and other doctors in my department, I’ve learned a few key things that have helped to keep the risk of burnout as low as possible.

1. Set an example to establish a healthy culture

You are the boss, so set the tone for your department. Say hello, talk to people, get to know them and what makes them tick. Knowing someone has a poorly relative at home may be all you need to make sure that person just gets a little more time in their day. Go home on time, be positive, be consistent and trust your team. Don’t get angry in public – have a special place to go and do that. Don’t respond to angry emails, use the phone or go and see people instead. Turn work email off as you go home, or at least don’t be emailing in the middle of the night.

2. Talk about stress and burnout together

Stress and burnout will happen, so put them on the agenda. Talk about burnout in meetings every now and again, so that everyone knows it’s OK to not feel OK. Make sure your whole team is watching out for each other so that you, or the appropriate person, gets to know if someone isn’t their normal self. You can discuss how things should be handled so everyone knows who to talk to both about themselves or others. And, if you are a departmental or clinical lead, you should ensure you know about the services available through your Trust. If in doubt, speak to your Occupational Health department.

3. Make the right approach

If something in a colleague’s behaviour concerns you or a member of your team, then use facts and detail to describe what you have seen. For example, instead of saying someone is always late, say you have noticed that they arrived at 09:45am on three days last week.

Allow your colleague time to reflect and respond. There may be a simple reason and not the one you are thinking of. I always think of “good cop/ bad cop” when explaining how to do this. Your “bad cop” voice may be telling you to shout that someone is always late, opinionated or difficult but your “good cop” voice could tell you to give them a break because they are unwell or stressed. Be the good cop – you need to be clear and sure of your facts, and no one appreciates gossip.

4. Don’t make assumptions

Doctors can burnout or struggle for all sorts of reasons. It’s essential to keep a very open mind and remember you might not hear everything from them – some of these issues could be very personal. You might not be able to fix things; you may need to get them to seek that help; you might need to talk several times.

There could be personal issues (health, stress, family), organisational issues (bullying, workload, managerial) or clinical performance issues behind their difficulties.

5. Look after yourself and recognise burnout in yourself

Doctors are not always the best at looking after themselves, but I can definitely say that regular exercise helps me. I run. It clears my head, gives me time to think things over and helps me sleep. Eat well, watch your alcohol and caffeine intake, get things checked if they bother you and don’t be frightened to go and see your GP. Corridor consultations with colleagues at work are no good at all – just don’t do it.

Also, watch out for the early signs of burnout in yourself – feeling angry about patients; feeling guilt; feeling you are a failure; being unable to stop thinking about work. If you feel these things, then talk to someone you trust, go to Occupational health or go and see your GP. The BMA do a nice self-checker based on the Oldenburg Burnout Inventory.

Finally, take part in appraisal regularly and make you get as much feedback from colleagues as possible to discuss with your appraiser. A good appraisal should feel supportive and positive, giving you a way forward to help manage difficulties at work. It can be a chance to discuss things calmly and confidentially with a colleague who can help. After all, sometimes all people need to do is talk and be listened to. 

A final word

Sadly, it is not always possible to spot problems in colleagues or even yourself, but you can help make it easier for anyone who is struggling by ensuring all of these things are in place. Most of all, try to do as much as you can to ensure things are picked up as soon as possible – your own health included – and help members of your team feel safe to speak out if they need support.

More tips for team leaders

Supervision is another key activity that will, in future, be assessed as part of all pathology curricula. Read Chris's guide on how to sharpen your skills.