Lockdown might be easing, but a second wave is predicted, and Covid-19 means doctors have never been under more pressure. Geriatricians and GPs are working on the front line and not only is their physical health at risk, but so is their mental wellbeing.
“What we do know is that right now medics and all frontline health care staff are facing unparalleled exposure to trauma. The pandemic risk is unprecedented and can be put in the same category psychologically as a war or natural disaster,” says psychotherapist Noel McDermott, founder and CEO of Psychotherapy and Consultancy, Sober Help, and Mental Health Works.
The personal impact of the Covid-19 pandemic on doctors' wellbeing has been revealed in a major BMA survey [1 June 2020]. More than 7,000 doctors responded to questions about their mental health and more than 2,000 provided personal accounts of the impact the Covid-19 pandemic has had on them.
A snapshot of responses includes: "I am frequently tearful about all those who have died; continuously fearful of contracting Covid and secondarily infecting my family,” and, “My anxiety has been relentless and changed the way I work, my self-worth and what I can provide for my patients. There feels like no light anywhere and no relief”.
The survey also found that 41% of doctors were suffering with depression, anxiety, stress, burnout, emotional distress or another mental health condition relating to or made worse by their work, with 29% saying this had got worse during the pandemic.
Multiple stresses facing doctors during Covid-19
Long working hours in unfamiliar settings, intensified conditions, worries about PPE, fear of contracting Covid and passing it on to their loved ones, losing such a high number of patients, seeing bereaved families, and a sense of isolation. These are just some of the reasons doctors’ mental health and wellbeing is being affected, they say.
Caroline Cochrane, head of psychological services, NHS Borders, says geriatricians and GPs have faced “multiple stresses” as a result of the pandemic. “They’ve had to change and adapt to services while at the same time having to deal with concerns about their own exposure to Covid-19.
“While geriatricians and GPs are used to dealing with end of life situations, they are not used to dealing with these numbers. And with Covid-19 there are so many unknowns, making conversations about having a ‘good death’ that much harder,” says Ms Cochrane.
Dr Jennifer Burns, a consultant geriatrician at Glasgow Royal Infirmary, recalls there was a “high level of anxiety” during the initial period of Covid-19, and a need to be vigilant about not inadvertently causing any patient harm because of the risk of transmission, while also having “concerns about their own personal and family health”.
The combination of intense acute work together with a reduction in break times, increased hours on-call and more weekend working with no real annual leave also took their toll on doctor’s mental health. “People just kept going – but at some point became exhausted and needed to take a break” says Dr Burns.
As medical director of the Practitioner Health Programme and chair of registered charity Doctors in Distress, Clare Gerada says she’s seen a lot of doctors experiencing fatigue and “overwhelming sadness” about what they’ve been through. For GPs, she says, it’s hard having to remotely consult with patients and break bad news to families. And not being able to see colleagues has contributed to individuals feeling “isolated and lonely”.
Having to frequently make difficult decisions during the pandemic – from triaging of patients through to discussions around DNAR - has taken its toll on doctors’ mental health. Mr McDermott says frontline staff, like geriatricians and GPs, have been faced with what is termed ‘moral injury’, where they have been asked to make decisions that conflict with their moral code around who should live or who should die.
Fear of litigation post-Covid is another worry for clinicians. A survey of Medical Protection Society (MPS) members [May 2020] found that 34% of doctors were concerned about facing an employer, GMC or criminal investigation for a clinical decision made while working in a challenging, high-pressure environment during the pandemic. Similarly, 43% said they were fearful of investigation due to adverse patient outcomes resulting from delayed referrals or non-Covid-19 NHS services being unavailable or limited.
Classic signs and symptoms of doctor burnout
As every clinician knows, but may themselves ignore, classic signs and symptoms of anxiety, depression and/or stress, include sleep disturbances, cognitive distortion – such as an inability to concentrate – poor or excessive appetite, racing thoughts, exhaustion, irritability, loss of pleasure, and a disconnection from events and people. Individuals may also experience feelings of hopelessness and helplessness, a sense of unease or dread, and they may turn to drink or drugs to ease the pain of these feelings.
Doctors in the frontline are vulnerable to Post Traumatic Stress Disorder (PTSD), which Mr McDermott defines this trauma as “the overwhelming symptoms we experience from an event we can’t process effectively”. Signs and symptoms of PTSD include panic, intrusive memories, thoughts and feelings associated with stressful events, and in some individuals, full-blown flashbacks. And these experiences typically happen a month after the traumatic event, but can sometimes emerge years later.
“Even though we’ve gone back to some sort of normality, as people reflect on what’s happened over the last few months and their experiences, maybe even over the deaths of relatives and friends, this can be the ‘straw that breaks the camel’s back, that leaves them feeling that they’re really struggling,’ says Dr Richard Vautrey, BMA GP committee chair.
Mental health support for doctors
Support for doctors’ mental health and wellbeing is available from their GP or other services if and when required. “What has been prominent in the health service over this period is the focus on wellbeing,” says Dr Burns. At her hospital this includes daily team “huddles”, wellbeing hubs in various areas throughout the site where “people can come out of a ward and take a break”, and signposting to psychological support, “anything from a Mindfulness App to a referral to someone to talk to”, she says. And some Trusts have set up a buddy system where people look out for, and take care of each other, and designated spaces, or ‘wobble rooms’ have created for staff to visit if they are feeling overwhelmed and need some peace.
Doctors can also get help from professional bodies and charities. The BMA has expanded its doctor support line, the Practitioner Healthcare Scheme is taking on new referrals, and the British Geriatric Society has posted mental health resources and articles geared to supporting members’ wellbeing during this time.
Doctor heal thyself
Doctors can consider the value of ‘healing thyself’ by acting on the advice they give to patients about anxiety, stress and depression, and employing the strategies they have learned over the years to help them cope with difficult situations.
Sharing thoughts on difficult work situations with teams, and using local and wider networks, for example via the British Geriatrics Society, can help clinicians manage their work stress, Dr Burns believes.
She also advocates the value of maintaining a work-life balance. “It is acceptable to leave work and to hand over care to others, and to take time to socialise with friends and family,” she says.
Simple fitness strategies can help keep mind and body healthy. Regular exercise, a balanced diet, good sleep hygiene, and relaxation exercises such as meditation and breathing techniques, can reduce physiological signs of distress and elevate mood, Mr McDermott advises.
Doctors also need to try and make time to acknowledge their emotions – sadness, grief, helplessness – and then to “reflect, think about how to take things forward, and take stock in a compassionate and realistic way”, says Ms Cochrane.
While self-help can be useful, more could and should be done for clinicians suffering with poor mental health and wellbeing. The BMA is calling for a long-term strategy that “protects and maintains the physical, mental, and emotional wellbeing of the workforce must be a top priority for the NHS, lasting beyond any interim Covid-19 support”.
Dr Vautrey says the BMA has also been discussing GP appraisals and the need to reduce the focus on bureaucracy and collecting CPD evidence, and to make it a safe space for discussion about wellbeing.
And the MPS has urged the Government to direct some of the extra £3 billion NHS funding for a possible second wave of Covid-19, towards a mental wellbeing plan. The doctors’ defence body also wants the Government to introduce temporary, emergency laws “to protect doctors from investigations relating to their treatment of patient’s during Covid-19 and the decisions they have made in good faith”, says Dr Pallavi Bradshaw, medicolegal lead, risk prevention at MPS.
For Dr Burns, support for geriatricians with mental health problems should be more acceptable, accessible, and inclusive, acknowledging that some doctors, such as locums, may struggle to get the help they need during the pandemic, and beyond.
But while Covid-19 has pushed frontline doctors to their limits, both mentally and physically, Dr Burns believes there are some positives to come out of the crisis. “There’s been huge support for the NHS workforce, and a definite sense of common purpose which has been rewarded with gratitude from patients. And there’s been a strong sense of being able to deliver what was needed. That does give you a real, positive, clap on the back.”
Mental health help and resources for doctors
- British Geriatrics Society: COVID-19: Health and care staff wellbeing https://www.bgs.org.uk/resources/covid-19-health-and-care-staff-wellbeing
- BMA: Your wellbeing: https://www.bma.org.uk/advice-and-support/your-wellbeing
- NHS Practitioner Health: https://www.practitionerhealth.nhs.uk/
- Doctors in Distress: https://doctors-in-distress.org.uk/
- Royal College of Psychiatrists: PTSD: https://www.rcpsych.ac.uk/mental-health/problems-disorders/post-traumatic-stress-disorder