Interventions to minimise doctors' mental ill-health and its impacts on the workforce and patient care: the Care Under Pressure realist review

Project aim

This research aims to improve understanding of how, why and in what contexts mental health services and support interventions can be designed to minimise the incidence of doctors’ mental ill-health.

Project objectives

• To conduct a realist review of interventions to tackle doctors’ mental ill-health and its impact on the clinical workforce and patient care, drawing on diverse literature sources and engaging iteratively with diverse stakeholder perspectives to produce actionable theory.

• To produce recommendations that support the tailoring, implementation, monitoring and evaluation of contextually sensitive strategies to tackle mental ill-health and its impacts.

Review questions

• What are the processes by which mental ill-health in doctors develop and lead to its negative impacts, and where are the gaps that interventions do not address currently?

• What are the mechanisms, acting at individual, group, profession and organisational levels, by which interventions to reduce doctors’ mental ill-health at the different stages are believed to result in their intended outcomes?

• What are the important contexts which determine whether or not the different mechanisms produce the intended outcomes?

• What changes are needed to existing and/or future interventions to make them more effective?

Steering Group

We set up a separate Steering Group to oversee the governance of the project and to provide high-level advice on dissemination strategies and conceptual aspects of the project. The group comprised one academic and clinician, one local NHS transformation manager and one patient representative. The range of expertise of the group included mental health services; nursing and complex intervention research methods; occupational stress in banking; stress involved in ‘fast-moving’ decision-making contexts, such as weather forecasting; and workforce management and resilience at both individual- and system-wide levels in the NHS.

Main search

We developed a search strategy to identify examples of relevant programme theory in the published literature using MEDLINE via Ovid. Searching was designed, piloted and conducted by an information specialist (SB) in consultation with the review team. Search terms were derived from the titles, abstracts and indexing terms of relevant studies already known to the review team from background reading and consultation with stakeholders. These ‘empirically derived’ search terms were supplemented with relevant synonyms selected in consultation with the review team. Several versions of the search strategy were tested in MEDLINE via Ovid by checking that the relevant pre-identified studies were returned and by refining the search terms to optimise the sensitivity and specificity of the search (i.e. maximising the retrieval of known relevant studies while minimising the retrieval of irrelevant studies). In the process of testing and refining the search, we identified additional relevant studies which we also made sure were retrieved in subsequent iterations of the search.

The final search strategy consisted of the three components of the PICo (population, phenomenon of interest, context) question formulation tool:63

• doctors and medical trainees (the population)

• effects of mental ill-health in the workplace, such as presenteeism, absenteeism or burn out (the phenomenon of interest)

• mental ill-health and workplace causes of mental ill-health, such as patient demand or work pressure (the context).

Each of the three components (population, phenomenon of interest, context) comprised relevant search terms combined using the OR Boolean operator. The three components were combined together using the AND Boolean operator. We found that this approach was the most effective way to retrieve our pre-identified set of papers and additional papers identified during the development of the search. Search terms included free-text terms (i.e. terms in the title and abstracts of bibliographic records) and indexing terms (e.g. medical subject headings in MEDLINE). We did not limit the search results by study type, date or language.

In December 2017 the final search strategy was translated and run in a selection of medical and psychology bibliographic databases, including MEDLINE, MEDLINE In-Process and Other Non-indexed Citations and PsycINFO (all via Ovid); and Applied Social Sciences Index and Abstracts (ASSIA) (via ProQuest). The MEDLINE search strategy is reproduced in Appendix 1. Search results were exported to EndNote (X8, Clarivate Analytics, Philadelphia, PA, USA) and de-duplicated using the automated deduplication feature and manual checking.

As our review was particularly focused on the UK context, we supplemented the bibliographic database searches described above (which were conducted in databases that index international literature) with searches that aimed to retrieve UK-based studies. We did this by conducting author, forwards and backwards citation searching on UK-based studies and first authors of studies identified by the bibliographic database searches. UK-based source studies and authors were identified by searching the EndNote library of bibliographic database results for terms such as UK, England, Wales, Ireland and Scotland, in the title and abstract fields. Forwards and author citation searches were conducted on relevant studies thus identified using Scopus and Web of Science. (We first searched for the source study or author and associated citations in Web of Science and if Web of Science did not index the item of interest we repeated the process in Scopus.) Backwards citation searching was conducted manually by inspecting the reference lists of UK-based studies. We also hand-searched journals with a UK focus via the relevant journal websites, including the British Medical Journal and BMC Medicine.

Major

• Studies that contributed to the research questions and were conducted in an NHS context.

• Studies that contributed to the research questions and were conducted in contexts (e.g. publicly and universal-funded health-care systems) with similarities to the NHS.

• Studies that contributed to the research questions and could clearly help to identify mechanisms which could plausibly operate in the context of the NHS.

Minor

• Studies conducted in health-care systems that were markedly different from the NHS (e.g. fee for service and private insurance scheme systems), but where the mechanisms could plausibly operate in the context of doctors working in the NHS.

However, as the analysis progressed, we noted that even those documents that we had assumed would make a minor contribution still contained important and relevant data for our study, and hence we extracted and analysed data from all included documents.

The full text of a 10% sample of documents from the main search and a separate 10% sample of full texts from the supplementary searches were assessed and discussed between DC and CP to ensure that decisions for final inclusion and classification into categories have been made consistently. Small inconsistencies were identified that were resolved through discussion.

Relevance

• Are the contents of a section of text within an included document referring to data that might be relevant to programme theory development?

Judgements about trustworthiness and rigour

• Are the data sufficiently trustworthy to warrant making changes (if needed) to the programme theory?

Interpretation of meaning

• If the section of text is relevant and trustworthy enough, do its contents provide data that may be interpreted as functioning as context, mechanism or outcome?

Interpretations and judgements about CMOcs

• What is the CMOc (partial or complete) for the data?

• Are there data to inform CMOcs contained within this document or other included documents? If so, which other documents?

• How does this CMOc relate to CMOcs that have already been developed?

Interpretations and judgements about programme theory

• How does this (full or partial) CMOc relate to the programme theory?

• Within this same document are there data which inform how the CMOc relates to the programme theory? If not, are there data in other documents? Which ones?

• In light of this CMOc and any supporting data, does the programme theory need to be changed?

We used abductive and/or retroductive reasoning (see Glossary), particularly to infer and elaborate on mechanisms (which often remained hidden or were not articulated adequately). This means that we followed a process of constantly moving from data to theory, in order to refine explanations about why certain behaviours are occurring, and tried to frame these explanations at a level of abstraction that could cover a range of phenomena or patterns of behaviour.

We sought relationships between contexts, mechanisms and outcomes both within the same included study and across different sources (e.g. mechanisms inferred from one study could help explain how contexts influenced outcomes in a different study). Therefore, we often synthesised data from different sources to compile CMOcs, as not all parts of the CMOcs were always articulated in the same source.

In summary, the process of evidence synthesis was achieved by the following analytic processes. 237

• Juxtaposition of data sources: comparing and contrasting between data presented in different articles. For example, when data about mental ill-health in doctors in an in-depth qualitative source enabled insights into how outcomes are achieved, as described in a quantitative study.

• Reconciling ‘contradictory’ or disconfirming data: when outcomes differ in apparently similar circumstances, further investigation is necessary to find explanations for why these different results occurred. This involved a closer consideration of context and what counts as context for different types of ‘problems’, in order to understand how the mechanisms triggered can explain differences in outcomes.

• Consolidation of sources of evidence: when there are similarities between findings presented in different sources, a judgement needs to be made about whether these similarities are adequate to form patterns in the development of CMOcs and programme theory, or whether there are nuances that need to be highlighted, and to what end.

Underdeveloped workforce planning and normalisation of high workload

A significant part of the included literature47,121 recognises that organisational aspects are associated with mental ill-health and can also represent a barrier to the access of interventions (if such interventions are available and accessible). Many studies suggest that both the individual doctors and the organisation have a role to play to address the issue of mental ill-health. 2,4,121,240 This argument is made also in relation to the organisation of medical schools. 142 We provide here two examples from a commentary and a research study respectively:

We are unlikely to ‘resilience our way out’ of this [the Mental Health of Medical Students, Residents, and Physicians] problem. Instead, multipronged interventions are needed that not only help individuals but also reduce the toxicity of the educational and clinical environments.

Slavin and Chibnall, commentary, USA, medical students, trainees, consultants, 2016218

. . . there is a general tendency to blame the person, rather than the job, for burnout. This [ . . . ] prevents a more realistic ‘both-and’ approach, which recognizes that both the person and the organization have a role to play in improving the workplace and people’s performance within it.

Maslach and Leiter, research, USA, doctors, consultants, trainees, medical students, 2017157

Among the organisational causes of mental ill-health in doctors, the included studies highlight the risks of ineffective workforce planning, alongside the lack of support for doctors experiencing work-related pressure. The studies which support this CMOc comprise research, commentaries and policy documents. Examples of underdeveloped work planning include demanding and rigid rotas, weak or absent ‘well-being’ services and weak or absent treatment support services. Examples of intervention include organisational measures to support workforce planning and well-being, and both the organisation and doctors recognising a shared responsibility for doctors’ well-being and patient outcomes.

Normalisation of high workload

Loss of autonomy

Another significant organisational factor that emerged strongly from the analysis of the included studies is the paradox that doctors increasingly have more responsibilities and tasks, but less control over their work. Doctors are trained to deal with complex issues and to be able to make difficult decisions. This requires a certain degree of work autonomy and control. However, the practice of medicine is increasingly subjected to stringent regulations and external control, and is becoming more clerical, leaving less space for clinical judgement and less time for working clinically with colleagues and patient-facing work (see also The relational nature of health, well-being and health care). The analysis shows that this loss of control can be linked to doctors perceiving a tension between their expectations and the reality of what their job entails. This CMOc is linked to the previous two CMOcs, as the increasing bureaucratisation of clinical work can also be perceived as signalling lack of appreciation of doctors and their job at an organisational level. Some studies also mention that technological innovation (e.g. electronic medical records may also play a role in the increasing bureaucratisation of clinical work72). The issue of electronic medical records is mostly present in US literature and is linked to billing practices. 221 However, lack of control and autonomy are also described in UK literature. 182 Crucially, the feeling of lack of autonomy and control is a potential cause of stress in itself, irrespective of other variables such as workload.

Stigma towards vulnerability

The analysis identified a central taboo within the medical culture: the difficulty of managing the status of being a doctor, more specifically a too rigid demarcation between ‘being a doctor’ and ‘being a patient’. This demarcation appears to be endemic in the medical profession, but it can also be influenced by wider societal factors, including the fact that some patients may expect doctors to never be ill, or may find it counterintuitive and uncanny for a doctor to occupy simultaneously the role of doctor and of patient, and members of the medical profession may assume that patients have such expectations. Drawing on the analysis of the included studies, it is plausible to argue that most of the ideas of invulnerability of doctors and the stigma towards mental ill-health stem from a clear-cut distinction and separation between the role of doctors and that of patients. This distinction is coupled by an unrealistic expectation that doctors cannot/should not be patients (or that, if they become patients, their status of doctor is seriously under threat). Vulnerability, including emotional and psychological aspects of self-care for doctors, tends to be considered by other doctors as unprofessional. Although the focus of our research is mental health, it is important to highlight that, overall in the included studies, the culture of invincibility can refer to both physical and mental conditions.

Significant implications of this key element of medical culture include doctors’ lack of self-care skills; their reluctance to seek help, or their tendency to do so when it is ‘too late’ (often when the problems become so serious that it is no longer possible for doctors to hide them); and doctors’ difficulty in providing support to colleagues who are unwell. Moreover, in a similar vein to CMOc 3, this CMOc highlights that such medical culture, and the unrealistic strains and expectations that it puts on doctors from the medical school years, can be a potential cause of stress in itself, irrespective of other variables such as workload.

Context-mechanism-outcome configuration 4 has also strong links to the idea that preventative measures – from training in medical schools onwards – can counterbalance such dangerous medical culture. We will attempt to focus specifically on preventative measures in Reducing mental ill-health: balance and timeliness (see in particular CMOc 14: acknowledging the positive and negative aspects of the profession).

Context-mechanism-outcome configuration 4 focuses predominantly on the aspects of medical culture which may cause doctors to hide their difficulties (i.e. ‘being vulnerable is not professional for doctors’). CMOc 5 describes the same phenomenon, but it places the emphasis on the organisational stigma towards doctors’ vulnerability, which can explain further why doctors may tend to hide their difficulties and not seek support if available (e.g. they may be afraid to undergo severe sanctions and ultimately lose their job).

Isolation

This last CMOc of Processes leading to mental ill-health in doctors links, and makes more explicit, significant patterns in the previous five CMOcs. Taken together, CMOcs 1–5 may point to a risk of isolation among doctors (which may be the outcome of organisational, professional culture, sociocultural and individual dimensions). Linking to CMOcs 1–2, doctors may feel isolated as a result of deciding to take sickness absence, and experiencing fear and guilt for letting down colleagues, managers and patients, even if their sickness absence may also depend on other factors (e.g. lack of work planning measures and lack of support). CMOc 3 highlights how governance and regulatory practices can challenge doctors’ autonomy, increase clerical work and also increase dissatisfaction. One of the consequences of this management regimen can be a feeling of being isolated or disconnected from the essence of their job. Finally, CMOcs 4 and 5 show that doctors inhabit a professional and organisational milieu of stigma (external and internalised), whereby challenges and vulnerabilities (including, but not limited to, CMOcs 1–3) can be experienced as a potential threat to their identity as doctors. In this case, the isolation may occur because doctors may fear losing their status, and their job if they seek support, or try to talk about such challenges, or admit to themselves that they are experiencing these challenges. This multifaceted isolation can also lead to a lack of trust towards co-workers in the work environment (e.g. colleagues, managers, regulations, support). Included studies highlight not only a lack of support for doctors (see CMOc 1: underdeveloped workforce planning), but also that doctors may not seek support even if they are aware of its existence because of lack of trust [e.g. they may see this support as an additional, potentially also punitive or individual-blaming, form of control and management (CMOc 5)]. 191 Isolation can also contribute to explaining why interventions that target the individual level only (e.g. individual resilience training; see also Chapter 1) seem less successful than expected. By targeting and placing the emphasis on the individual and their own skill set, such interventions may feed doctors’ feelings of isolation.

The relational nature of health, well-being and health care

As discussed in Processes leading to mental ill-health in doctors, the included literature suggests that a work environment which encourages or indirectly leads to isolation may make doctors more vulnerable and stressed, and it can therefore represent an important causative or aggravating factor of work-related pressures. Moreover, cultural and professional identity aspects (e.g. the medical culture of invincibility and perfectionism) can contribute to this isolating environment.

In this section, we move from the causes to the factors which can reduce mental ill-health in doctors. The analysis of the included studies suggests that a work environment characterised by a strong sense of connectedness, collegiality and community can reduce the incidence and the intensity of doctors’ mental ill-health. Collegiality can occur at different levels (e.g. with colleagues from the same specialty, from different specialties and from different professional groups). 185 Although resilience training for individual doctors – and other approaches which target only the individual – may work in certain circumstances (see Limits of groups), the analysis shows that resilience is more a relational than an individual feature. This argument is supported by different types of studies: empirical research,176,202 reviews2 and commentaries. 162

Based on our analysis, we can highlight the functions of groups and connectedness (from specific support groups to general relationship and connectedness in the workplace), that is why and how groups and relationality can reduce the incidence and intensity of doctors’ mental ill-health, and/or contribute to ‘genuine’ resilience of the workforce. Group support and a relational work environment have the following interrelated functions:

• Foster a sense of belonging in doctors to their teams/colleagues, and to the profession (belonging and connectedness are prerequisites to individual self-fulfilment and are foundational to individual resilience). 162

• Foster a sense of meaning in work (which can counterbalance the challenges identified in CMOcs 1–3).

• Contribute to alleviate the stigma towards mental health and vulnerability in the medical culture. Groups can normalise, rather than stigmatise, mental ill-health issues. They allow doctors experiencing such challenges to be listened to and be understood by peers, and they offer the opportunity to the whole group to recognise that such challenges are not unusual, but tend to be shared (see CMOcs 4 and 5).

• Protect individuals and groups from work-related pressure by fostering mutual support and ‘mutual care’ (e.g. doctors can recognise sign of stress in their colleagues and support them) (see CMOcs 4 and 5). 131

• Offer more opportunities for improvement of care provided to patients (e.g. doctors can share challenging/meaningful experiences increasing professional confidence) and mutual learning.

It is important to clarify that our analysis refers to groups which function well. Dysfunctional groups will not necessarily provide the possible benefits we have listed in the bullet points above. It is beyond the scope of this review to provide exact details of what is needed for a group to function well. However, we do provide some references and points to consider in How does existing substantive theory link with our findings?, particularly in relation to the social identity approach (see Summary of the 19 CMOcs in four main groupings).

Balancing quality and quantity of time at work

Reducing doctors’ working hours would appear to be a reasonable way to address work-related stress and burnout, but some included studies, mostly research53 and commentaries,162 suggest that reduced hours may increase a sense of disconnection from work, which can in turn exacerbate working pressure and mental ill-health outcomes (see Isolation). Moreover, discussion with stakeholder groups suggested that approaches based solely on a quantitative reduction of working time may foster a competition between ‘life’ and ‘work’, whereby the former may be experienced to be better than the latter (or the latter to become a ‘problem to be avoided or escaped’). Therefore, focusing also on quality of work (i.e. making work a functional and meaningful part of doctors’ lives and fostering a sense of meaning within, rather than outside work) appears to be a stronger strategy to tackle work pressures and mental ill-health. A relational work environment (discussed in The relational nature of health, well-being and health care) can help to increase job satisfaction and meaning. The relational nature of medicine extends also beyond colleagues and the health-care workforce. For many doctors, spending time with patients can represent another key relational factor,190 which creates meaning within work (see Loss of autonomy and The relational nature of health, well-being and health care).

Thus, resilience and other ‘wellness’ interventions in medical education and clinical practice, which focus less on the competition between work and life, and more on making work a functional and enjoyable part of doctors’ lives, may be more likely to achieve their intended outcomes of reducing stress and mental ill-health. Examples of interventions include reduction of working hours or similar ‘work–life balance’ interventions and participation in mentoring networks; or reduction of working hours and more time with patients (i.e. patient-centred care, if this is part of the deontology/ethos of the specialty).

Limits of groups

In realist reviews, ‘knowing how social programmes work involves tracing the limits on when and where they work’. 62 As illustrated in The relational nature of health, well-being and health care, belonging and relationality appear to be key to a healthy work environment and to the success of interventions aiming to address mental ill-health. However, the literature – mostly research studies – also suggests that in certain delicate circumstances individual one-to-one support may be more appropriate than group support approaches, particularly in cases of peer (same specialty) and immediate colleague group support. These circumstances include significant confidentiality issues; doctors being investigated; doctors facing litigation; and doctors experiencing death of patient or colleague. However, concerning the experience of death, we also found empirical evidence that functioning group support could also work, for example (taken from evidence for CMOc 9):

Once individuals felt safe in the group, they would share more personal matters such as fear of overload when faced with a run of deaths or profound feelings of loss at the death of a patient they knew well and sadness for the family’s grief.

Feld and Heyse-Moore, intervention, UK, palliative care, trainees, consultants, 2006105

Highlighting the limit of group interventions is important in the light of the medical culture discussed earlier (see CMOc 4: stigma towards vulnerability and CMOc 5: hiding vulnerability), in which vulnerability is deemed to be unprofessional and stigmatised. Arguably, such medical culture represents an additional factor which may complicate group (support) dynamics, particularly when there are confidentiality issues and delicate distressing situations. Moreover, broadly speaking, certain forms of individual one-to-one support could also work as a proxy to promote or improve connectedness in a work environment, as the person offering support could help the individual doctors receiving it to develop more connectedness and relationship in the workplace, for example:

[ . . . ] tailored mentorship programs for individual residents would allow not only monitoring of stress tolerance and workload imbalance but also development of resident–faculty interactions that might help to bridge existing generation gaps.

Nomura et al. , commentary, USA, primary care, medical students, trainees, consultants, 2016177

‘Organic’ spaces to connect

Some research studies and commentaries provide insight on how organisations could foster relationality. These studies cover both the medical school and the clinical work environments. The overarching point made is that functioning groups are more likely to occur if they are not enforced. Initiatives to foster relationality and belonging are more likely to be successful if relationships between colleagues are not externally imposed through mandatory activities. The literature suggests steps that can be made in this direction. For example, programmes and institutions can create – or protect – psychologically safe spaces, formal and informal opportunities that encourage medical students and doctors to communicate (e.g. share work experiences, difficult cases), without fear of being judged, and to develop collegiality and connectedness, and to learn from each other. This will probably allow doctors and other colleagues to share each other’s experiences, ways of working and values, leading to the emergence of spontaneous connections. More specific examples of promoting connectedness include spaces such as doctors’ mess; newsletters and other opportunities for doctors to share stories; and virtuous humour. Overall, we did not find a significant number of studies to support this idea. Given the limited number of data informing this CMOc, we are not able to draw conclusions around the circumstances in which protected times and psychologically safe spaces are more likely to trigger positive responses. It could be hypothesised that positive relationships between colleagues may need to be in place for protected times and spaces to work towards intended outcomes. However, this idea (alongside CMOc 10) can also serve as a reminder that it takes time and commitment (individual and organisational) to build relationships, and one intervention might not make a difference. For example, as a general practitioner (GP) interviewed in one of the included studies pointed out:

I work in a fantastic team. I love all my partners. I love the team I work with. And that’s something that we have created over, over that, all those years. [ . . . ] it’s not just something I parachuted into; it’s been carefully created by me and my partners over that time.

Riley et al. , research, UK, GPs, trainees, consultants, 2018190

Data also show that certain specialties such as palliative care tend to have more standard support groups105 and debriefing. 150 Chapter 4 will present some key methodological principles that can guide the implementation of interventions, including those that foster connectedness.

Balancing negative with positive

In the NHS, and other health-care services, it is common to report mistakes made by health-care staff or anything else that harms, or comes close to harming, patients. This practice mirrors cultural trends and norms to place more emphasis on identifying and examining failures and mistakes than on recognising and reflecting on positive practice and outcomes. Such ‘negativity bias’ (which often starts to be cultivated in medical schools124) can help to improve patient outcomes, but it also contributes to pressing concerns about workplace cultures of blame, stress and burnout. This negativity bias may also be reinforced by the bureaucratisation of medical work described in Loss of autonomy (i.e. the governance and regulation of clinical work may encourage more focus on mistakes than on positive performance). It can also be linked to the medical culture of invincibility described in Stigma towards vulnerability.

On the other hand, positive feedback can improve learning, morale and sometimes performance in health-care environments. In a similar vein, actively promoting and focusing on the well-being – including the ‘mental health’ (as opposed to mental ill-health) – of doctors is equally important as developing measures to deal with mental ill-health.

A focus on the ‘positive’ can inform preventative measures, which may reduce the incidence and intensity of mental ill-health in doctors. For example, promoting health and well-being may result in the development of measures to tackle underdeveloped work planning and normalisation of overwork described in CMOc 1: underdeveloped workforce planning and CMOc 2: normalisation of high workload.

Acknowledging the positive and negative aspects of the profession

The integration in the medical curriculum, and in further professional development training, of open discussions about the stress and difficulties doctors will probably encounter in their career, the difficult decisions they may make and the possibility of making mistakes can better prepare doctors to practise their work.

Data from included studies show that doctors may encounter difficulties transitioning from medical education to clinical work, particularly76,170,209 the emotionally demanding nature of the work, which includes long working hours and complicated rotas that frequently change at short notice;168 being exposed to complex biopsychosocial situations, including seeing patients with symptoms that are not part of a recognised disease entity; 67,147 being exposed to death and dying;67,91,169,176 being exposed to aggressive interactions with patients;106,241 and doctors suffering from substance abuse206 and financial concerns. 79,190

Our analysis shows that developing such awareness is portrayed as a constructive way to train doctors to deal with difficulties. Our analysis shows that developing awareness of the challenges doctors face in the workplace can be an important first step in preventing mental ill-health. The risk of developing, and consequences of, mental ill-health can increase where the relationship between workplace stressors and the development of mental ill-health is unacknowledged or silenced (see Stigma towards vulnerability and Isolation). It is therefore important to acknowledge this problem, with the provision of training being one way of doing so. This awareness and preparedness can, in turn, contribute to fostering a culture of acceptance towards work pressure and mental ill-health, improve relationships with colleagues and decrease stigma. CMOc 14 is a reformulation of the concepts in CMOc 4 (about the danger of a professional culture of invincibility) from a preventative point of view (i.e. it suggests what can be done to prevent stigma towards mental ill-health in medicine). The idea of introducing more awareness about the difficulties of the medical profession is intended to be complementary to Stigma towards vulnerability, rather than in contradiction. In the light of CMOcs 12 and 13, it is plausible to argue that anticipatory training that seeks to balance the positive and negative aspects of a career in medicine may put present and future doctors in a better position to navigate their career, and to be potentially more equipped to deal with work-related pressures and vulnerability.

Timely support

The timeliness of support can make a significant impact on its success and the health of doctors. This appears to be particularly the case in certain contexts when doctors may be particularly vulnerable (e.g. when doctors experience traumatic events, such as the death of a colleague, sickness absence, when doctors attempt suicide or during the training period). This CMOc is particularly linked with CMOc 10. Some included studies (policy reports mostly72,92) argue that the value of timeliness can also be financial (i.e. in the long term, intervening early may be a more cost-effective strategy than dealing with worse outcomes or even the death of a doctor).

Endorsement

Interventions are more likely to work if they are endorsed by senior levels of the organisation involved. Signs of such involvement include that the organisation openly acknowledges that the profession of the doctor can be demanding and stressing71 (see also CMOc 14: acknowledging the positive and negative aspects of the profession); makes efforts to help doctors to navigate the services and support available; and establishes clear lines of accountability, roles and responsibilities to deliver an intervention. A crucial reason for this principle is that the problem (causes and effects) of mental ill-health in doctors involves different agents and stakeholders (see Underdeveloped workforce planning and normalisation of high workload and Chapter 1).

Expertise

The analysis shows that interventions are more likely to be successful if they are managed and delivered by competent individuals/teams who are able to understand the specific contexts, culture and needs. The need for confidentiality, and the potentially challenging roles of the doctor and patient, are frequently mentioned in the data; these and some other needs, culture and contexts have been discussed in Processes leading to mental ill-health in doctors and Reducing mental ill-health: groups, belonging and relationality. It is important to highlight that such expertise can require specific and regular training for non-medical staff in charge of such interventions, and for doctors (or other allied health-care professionals) who are involved in the delivery of interventions. To a certain extent, the idea of balanced training, discussed in Acknowledging the positive and negative aspects of the profession, could represent a further justification of the importance of such training.

This CMOc about expertise is linked to previous CMOcs in Processes leading to mental ill-health in doctors and Reducing mental ill-health: balance and timeliness. In clinical practice, expertise may be hindered by over-regulation (see Loss of autonomy) and by an excessive focus on fighting negative performance (see Balancing negative with positive). Excessive and ‘negative’ regulations and management of clinical work may decrease doctors’ satisfaction, and make them more vulnerable to stress. However, this CMOc also shows that overemphasis on regulation and on recognising and fighting negative performance can not only become a trigger of mental ill-health in itself, but also hinder the assessment and often delicate care received by doctors experiencing mental ill-health (for an example see Dyer97 and Loss of autonomy and Balancing negative with positive).

Engagement

Engaging doctors and other stakeholders in the design, implementation, monitoring and improvement of interventions can contribute to their effectiveness.

The importance of engagement is discussed in the literature in relation to doctors, medical workforce in general and medical students. From the analysis of the data we can distill several positive aspects of engagement: it can help to tailor interventions to the needs and context of the target audience (this is also linked to the idea of expertise discussed in Acknowledging the positive and negative aspects of the profession); it can help to build trust in the intervention and a sense of control in the target audience, who may feel the need to be listened to; and it could also be a faster way to lead to changes than top-down approaches. Drawing on the idea of the importance of groups and relatedness discussed in Reducing mental ill-health: groups, belonging and relationality, we could also argue that engagement activities, if effective, may also contribute to increase relatedness in the workplace.

Giving more control (space for input) to doctors can also have a ‘therapeutic’ value, particularly in contexts in which doctors feel that regulations and changes are often imposed on them in a ‘top-down’ fashion (‘work control’ is also a dimension of burnout)157 (see also Loss of autonomy).

CMOc 19: evaluation

If the outcomes of interventions and the well-being of the workforce are regularly reviewed and monitored (context 1), and commitment to act on the outcome of these regular review exercises is shown (context 2 and CMOc 16), then doctors may feel more supported (mechanism) and engage with efforts to tailor these interventions (outcome 1). This may also lead to greater awareness about vulnerability and well-being in the workplace (outcome 2).

Examples of intervention strategies include:

• Establish longitudinal surveys of staff health and well-being.

• Carry out anonymous regular monitoring of well-being and morale of physicians, and consider such monitoring in organisation decision-making processes and priorities setting.

Relevant extracts from papers included in the review

[ . . . ] a regular iterative process of inquiry and feedback from physicians can identify issues that negatively affect well-being and barriers to improvement. [ . . . ] assessment of well-being using reliable and valid instruments further establishes the value and creates a common language that can help physicians and the organization address well-being issues.

Dunn et al. , intervention, USA, physicians, trainees, consultants, 200796

Assessing levels of stress among residents may [ . . . ] contribute to a form of intervention. Moreover, the very use of well-being measures among residents could increase their self-awareness and activate helpful and cathartic discussions on stress, coping strategies and vulnerabilities, consequently partly preventing stress symptoms (Levey, 2001).

Myszkowski et al. , research, France, internal medicine, trainees, consultant, 2017174

Knight et al. 10 have been the only group to conduct formal surveys of PHP [Practitioner Health Programme] participants. They found correlations between satisfaction and successful recovery that echoed classic findings in the addictions literature, and underscored the importance of surveying participants as part of the effort to assess treatment engagement and successful completion.

Sanchez et al. , research, USA, doctors, trainees, consultants 2016203

Collectively, these findings suggest that periodic assessment and feedback may have relatively universal benefit for physicians because it seems to provide useful information both to those who are doing well (affirmation and reassurance) and to encourage behavioral change to those who are struggling.

Shanafelt et al. , intervention, USA, surgeons, 2014211

Social cure framework

Social psychology approaches to health and well-being strongly resonated with our analysis (e.g. social identity theory243 and the integrated social identity model of stress244,245). These approaches have recently been synthesised into the ‘social cure’ framework, which proposes that there is a positive impact on health when individuals identify themselves as members of groups that provide them with a positive sense of identity. 243 Social identity is defined as the basis for meaningful group life; group life in turn is seen as central to our human nature and a key source of meaning and purpose. Therefore, social identity is central to good and bad health. 243 This emphasis on group membership foregrounds that humans are relational beings (i.e. in the sense that their life experiences are shaped in relation to their environment and other people). This also frames concepts of autonomy – and arguably resilience – as underpinned by sociocultural and environmental processes, rather than purely within the control of individuals acting independently. In using the ‘social cure’ lens to develop and substantiate our CMOcs, we situate our work within broader research emphasising the relational nature of health,246–248 relational autonomy,249 care ethics, feminist work and other critiques of modern liberal political philosophy. 250

The ‘social cure’ framework has a strong evidence base243 and social identity approaches have been used widely in the study of interprofessional relationships in health care. 251 In our review, we used the ‘social cure’ framework to provide theoretical substantiation and to bring together our key findings on:

• isolation as an important process or aggravating factor leading to mental ill-health in doctors (see Processes leading to mental ill-health in doctors)

• groups, connectedness and belonging as key from preventative, mitigating and therapeutic points of view (see Reducing mental ill-health: groups, belonging and relationality)

• balancing positive and negative aspects of professional identity and performance (see Reducing mental ill-health: balance and timeliness)

• principles necessary to engender trust in interventions (see Implementation methods: engendering trust).

To complement the ‘social cure’ framework, our analysis has also been informed by theoretical work on professional identities in health care. In ways that extend (rather than contradict) our approach to social identity, we viewed professional identities as relational and negotiated in practice through intra- and interprofessional working. 252,253 In doing this, we also aimed to highlight the relevance of professions as self-organising entities in the health-care service and their structural role in influencing power and control dynamics, including conditions of clinicians’ self-identification with the medical profession. Instead of commonplace narratives of professional dominance and stable professional identities, our analysis emphasised ‘the incoherence, self-doubt, insecurity, antagonism or fragility evident in those moments of reflexivity when the actor interrogates rather than secures or glorifies the self’. 254 Professional legitimacy and role relationships are seen not as given and static, but as constantly constructed and reproduced at the intersection of organisational contexts and internalised professional imperatives. 253

Box 2 outlines key tenets of social cure that are relevant to the CMOcs identified in our study. Unless otherwise specified, these tenets are drawn from a recent volume on social cure. 243

Research question 1

What are the processes by which mental ill-health in doctors develops and leads to its negative impacts and where are the gaps that interventions do not address currently?

Our findings suggest that the development of mental ill-health in doctors results from the interaction of a significant and complex workload, organisational management and the professional culture of medicine. Doctors experiencing heavy workloads, together with a diminished level of control over their work, are unlikely to be able to perform at the high standards that they expect of themselves and their profession. In a professional culture which doctors experience as discouraging the sharing of vulnerabilities, in which professional regulation is perceived by doctors as likely to judge mental ill-health as potentially making a doctor unfit to practise, and in an organisational environment that promotes individual rather than collegial responsibility, doctors are unlikely to take steps that could prevent the development of mental ill-health. Although interventions that target individual doctors (e.g. to prevent doctors’ mental ill-health or ameliorate it once established) may address parts of these processes, the way in which individuals and the wider context interact suggests that interventions that address multiple organisational and professional issues simultaneously are more likely to be successful. In other words, the gaps in intervention targets tended to be more associated with ‘level’ (e.g. individual and/or team and/or employer), rather than ‘stage’ of the process.

Research questions 2 and 3

What are the mechanisms, acting at individual, group, profession and organisational levels, by which interventions to reduce doctors’ mental ill-health at the different stages are believed to result in their intended outcomes?

What are the important contexts which determine whether the different mechanisms produce the intended outcomes?

Our second and third research questions focused on the mechanisms, which may operate differently in different contexts, by which it is believed that interventions reduce doctors’ mental ill-health. We interpreted ‘reducing mental ill-health’ as either preventing the development of mental ill-health or ameliorating mental ill-health once it is established, and identified how professional and organisational culture could shape the operation of mechanisms.

We found that doctors’ working relationships, with other doctors and health-care staff as well as with the organisation in which they work, explained a key part of how mental ill-health could be prevented and reduced. Although not operating in a linear fashion, facilitative contexts, such as meaningful workplace relations and functional working groups, enabled the protective mechanisms of a sense of belonging and an ease with vulnerability to function. These mechanisms could interact with (or provide the context for) other protective mechanisms to operate, such as identifying with colleagues and finding meaning in work. Relationality, recognising the importance of meaningful human relationships in the workplace, provides an overarching explanatory concept here.

We also found that the tone set by organisations about a medical career could have important implications for mental ill-health. Constructive workplace feedback on performance, as well as an organisation’s demonstrable valuing of employees’ health and well-being, could provide the context for doctors to contribute to and benefit from an upwards cycle of interacting mechanisms, such as legitimating their own well-being, acknowledging vulnerability and valuing colleagues. A professional culture that recognises both the positive and negative aspects of a medical career could play a role by preventing feelings of inadequacy and helplessness in doctors. Finally, when doctors are affected negatively by significant life events, the provision of timely support in the workplace is crucial for hope to play a role in recovery.

In relation to costs, limitations in reporting meant that we were unable to link cost data to CMOcs. Even when this cost information was reported, there was a lack of methodological detail about how costs had been calculated. A minority of included sources quantified costs and there was a lack of methodological detail about how estimates of direct or indirect costs had been reached and a paucity of detail about direct, indirect or total costs that we could meaningfully extract. No included sources reported a health economic analysis (either cost–consequence modelling or prospective comparative evaluation), but it should be noted that our search strategy was not explicitly designed to locate such studies.

Research question 4

What changes are needed to existing and/or future interventions to make them more effective?

This review has identified how social identity, group membership and the ‘humanising’ of doctors’ work (in contrast to a reductionist view of clinical encounters) can play an important role in the prevention and reduction of mental ill-health in doctors. We noted earlier in this report (see How does existing substantive theory link with our findings?) how approaches drawing on aspects of theories of biopsychosocial health and well-being (the social identity approach243) can be used in tandem with our more specific CMOcs to underpin the refinement of strategies to reduce mental ill-health in doctors. Taken together, this has enabled us to articulate recommendations about strategy development for different audiences (Table 4). We also worked iteratively with the stakeholder group, experts and policy-makers to develop and refine the recommendations (consistent with our protocol; see also Chapter 2, Stakeholder group). Although these recommendations are presented separately to aid comprehension, the interdependency of these levels should be acknowledged in intervention design (e.g. doctors prioritising relationships at work may not be feasible if there are no organisational structures to support this at the level of team leaders and senior management). We have also developed 10 CUP principles to refine interventions, for those who deliver interventions, which draw out the interdependence of the different levels (Box 3).

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Data range searched: 1987 to 6 December 2017.

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