Sustaining wellness through a career

Work culture is slowly changing for younger doctors with increasing appreciation of the need to maintain work-life balance. However, once doctors reach consultant positions, the workload and level of responsibility can make these good intentions next to impossible, says former AMA Vice President Professor Geoffrey Dobb.

“Ultimately, once you have completed specialist training, the buck stops with you, you are the decision maker and you are responsible for the patient management,” he says.

“These days, we are often also responsible for the organisational outcomes of the department such as meeting the four-hour rule or elective targets, or being involved in things around departmental budgeting. The whole question of burnout is certainly an issue over time.”

According to landmark Finnish research, sustaining wellbeing throughout a career is an important factor in progressing healthily and happily to retirement and beyond^[1].

The study, conducted among 6000 workers over several decades, informed the concept of “work ability”, which assesses the capacity of workers to do their work now and into the future based on health and wellbeing and the demands they face.

The theory is that, over time, work ability declines due to poorer health, declining physical capacity and an intensified work environment, exacerbated in many professionals by the 24-hour demands of mobile technology and pressures to improve productivity. People with the lowest work ability scores are much more likely to retire early due to health issues, research shows.

Dr Martin Mackey, Senior Lecturer in Physiotherapy at the University of Sydney and an expert on work ability, says everyone, including doctors, should have a level of awareness about their work ability level so they can ensure continued wellbeing as they age.

“If you can measure work ability early and identify those with poor work ability, then you can put in place strategies to help people develop better health and wellbeing, or intervene to reduce work demands or alter work arrangements so they can work towards a productive and healthy working life and retirement,” he says.

For many doctors, the key threat to this optimal work ability during middle age and beyond is stress and burnout.

“All of us would feel committed to providing patient care – that’s what gets us out of bed in the morning – but if they overwork, there is a risk of becoming disillusioned and burnt out,” says Professor Dobb.

The AMA points out that not all stress is negative – indeed, some stress is necessary – but there are multiple internal and external stressors in medicine.

Some of the personality traits common in doctors underpin their professional success but can also lead to anxiety and depression, such as dedication, commitment and a sense of responsibility, competitiveness and altruism.

A lack of institutional support is a significant issue for senior doctors, particularly those in private practice. This can be combined in later years with an increasing incidence of chronic disease and fatigue^[2].

Doctors from non English-speaking or Indigenous backgrounds, those who are working in rural and remote areas without adequate support, and those working long hours are particularly at risk of poorer wellbeing^[3].

Psychiatrist Dr Michael Diamond, who treats many doctors among his professional patients, says doctors seeking psychiatric assistance invariably present late in the illness genesis, usually after some attempt at self-management.

Their adaptive attempts might include lifestyle adjustment and taking a break or, more commonly, simply working harder, isolating more or shutting off emotionally from their family, friends and colleagues before turning to alcohol, drugs or other tension-releasing activities.

“Eventually, the attendance is prompted by some sort of crisis in most cases – with their family or marriage, substance abuse, an investigation by a medical registration body or a patient complaint. It is usually a case of too little too late before formal, appropriate assessment and treatment ensue,” he says.

Doctors aged 36 to 65 are far more likely to receive a medico-legal complaint ^[4], particularly those aged 46 to 54. The key stressors contributing to the receipt of a medico-legal matter are working longer hours, working in high intervention specialties, being male and having high levels of distress. ^[5]

Yet research conducted by Avant into doctors’ attitudes to wellness indicates that middle-aged doctors, especially those in the 46-54 age group, are the least likely to perceive a benefit to their practice in medicine from improving their own health.

“If you measure their stressors, doctors at this age are usually financially and job secure, so it comes down to existential angst, burnout and boredom,” says Simon Willcock, Professor of General Practice at the University of Sydney.

“It all comes back to meaning and purpose, to doctors being engaged in their lives, their relationships (both personal and professional) and their communities.”

"It is important to draw a line between work and home – to avoid bringing work home and taking personal issues to work," says Associate Professor James Ross, President of the Australasian Faculty of Occupational and Environmental Medicine at the Royal Australasian College of Physicians.

The College advises doctors to take control of their work hours, for example, by taking days off, making realistic schedules, establishing a buffer zone between work and home, and not feeling guilty about refusing to pick up extra hours.

It is also important for doctors to keep interested in their job. Dr Stephen Jelbart, a GP whose practice treats other doctors, says disillusionment and the tedium of a worn routine is a particular problem for GPs.

“I have had medical colleagues who say ‘I have had enough’ but just continue to practice because they need the money. People think if they grit their teeth and carry on the stress will go away, but often that’s just a recipe for disappearing down a hole.”

He advises being proactive by embarking on something really challenging about which you feel passionate. “It’s a very important area of maintaining your sanity,” he says.

Physical health issues can be of increasing concern to doctors as they age. Dr Mackey points to mounting evidence that sedentary occupations increase the risk of chronic disease: a recent large Australian study found that people who sat for more than 11 hours a day had an increased risk of mortality, regardless of the amount of physical exercise they undertook during the rest of the day^[6].

When overweight people in controlled conditions are provided the opportunity to stand or do light walking every 20 minutes throughout the day, even for one or two minutes, their blood glucose is significantly reduced compared to those who sit continuously throughout the day^[7].

This implies that light activity is as effective as moderate intensity activity in improving biomarkers of chronic disease related to sustained sitting.

“To maintain wellness, doctors, like everyone, should do physical activity according to the recommended guidelines - 150 minutes per week of moderate physical activity – sit less and take regular breaks,” Dr Mackey says.

Although mature workers may lose some physical capacity as they age, there is no evidence that mental capacity declines unless due to disease, says Dr Mackey.

However, with ageing doctors making up an increasing proportion of the medical workforce, mild cognitive impairment or the onset of dementia may compromise more doctors’ ability to practise safely. A Canadian study suggests that more than a third of doctors with competency concerns have moderate to severe cognitive impairment^[8].

��Doctors tend to have their own idea of self-worth very much around their concept of being a doctor, which can lead to delay in retiring, not recognising when their skills and capabilities may be dropping off,” says the RACP’s Professor Ross.

With some evidence indicating reluctance among doctors to notify the Medical Board when they believe a colleague’s cognitive function is declining, compulsory recertification processes have been raised as one way to address this complex issue^[9].

Many doctors, however, are divided about whether this is the right approach. The key is to ensure that these do not increase the bureaucratic burden on older doctors^[9].

1. Gould R, et al. Dimensions of Work Ability: Results of the Health 2000 Survey. Helsinki: Finnish Centre for Pensions, The Social Insurance Institution, National Public Health Institute, Finnish Institute of Occupational Health; 2008.
2. Dobb G. Stresses change, but do not go away. Australian Medicine 2009; 21 (19): 12.
3. Australian Medical Association, Health and wellbeing of doctors and medical students. Canberra: AMA, 2011.
4. Bismark MM, et al. its identification of doctors at risk of recurrent complaints: a national study of healthcare complaints in Australia. Quality and Safety in Health Care 2013; 0:1–955.
5. Nash L, et al. The psychological impact of complaints and negligence suits on doctors. Australasian Psychiatry 2004; 12(3): 278-281.
6. van der Ploeg HP et al. Sitting time and all-cause mortality risk in 222 497 Australian adults. Archives of Internal Medicine 2012; 172:494.
7. Dunstan DW et al. Breaking up prolonged sitting reduces postprandial glucose and insulin responses. Diabetes Care 2012; 35(5):976.
8. Turnbull J, et al. Competence and cognitive difficulty in physicians: a follow-up study. Acad Med 2006; 81(10):915–8.
9. Adler RG, et al. Knowing — or not knowing — when to stop: cognitive decline in ageing doctors. Medical Journal of Australia 2008; 189: 622–624.