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THE DIFFICULT STUDENT or THE STUDENT WITH DIFFICULTIES

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THE DIFFICULT STUDENT or THE STUDENT WITH DIFFICULTIES Powered By Docstoc
					THE DIFFICULT DOCTOR
           or
  THE DOCTOR WITH
     DIFFICULTIES
      Simon Willcock




                       August 2008
Nicholas
 Nicholas is an Advanced Registrar working in
  your regional town practice for a year . He is 28
  years old. He has had an average record of
  achievement in his studies and previous terms.
 He has been regularly calling in sick, and did not
  turn up for a rostered Saturday morning shift. His
  explanation is that he forgot. The front desk staff
  says that he has been difficult – uncooperative
  and argumentative.
What could be happening to
Nicholas?

 Is Nicholas a bad doctor?
 Should we institute any measures, and if so
  what options do we have?
           What could be happening to Nicholas?

                                                    Anxiety
                      Depression

                                     Incompetence
Financial problems




                 Family problems
                                               Lack of support




             Substance use
                                    Unhappy with career choice
After talking to Nicholas you find that he
 and his wife are living in a one bedroom
 apartment.
He has a new baby and his wife is
 suffering from post natal depression.
He is struggling to support his wife
 emotionally.
Why didn’t Nicholas ask for help?

“Doctors should cope”
“Admitting you can’t cope equals
 incompetence”
Loss of control / loss of face
Personality factors
Assessment / progression
What makes a good doctor?
 Organises time well and    Pre-occupied with details
  can work to a schedule      rules and lists
 Pays great attention to    Perfectionist
  detail                     Devoted to work
 Hardworking                Over-conscientious and
 Self sacrificing            concerned with ethical
                              and moral values –
 Ethical                     inflexible
 Can lead a team and        Reluctant to delegate to
  takes responsibility        others
 Confident in ones skill    Shows rigidity and
                              stubbornness
                             (Unable to discard worn out objects)
                             (Overly thrifty)
                            OBSESSIVE COMPULSIVE
                              PERSONALITY TRAIT
IPDEQ Subscale Frequencies Time 1

    PARANOID      n      %    HISTRIONIC
      NO         107   97.3     NO        69   62.7
      YES         3     2.7
                                YES       41   37.3
    SCHIZOID
      NO         91    82.7
                              ANANKASTIC
      YES        19    17.3     NO        36   32.7
    DISSOCIAL                   YES       74   67.3
      NO         100   90.9   ANXIOUS
      YES         10    9.1     NO        98   89.1
    IMPULSIVE                   YES       12   10.9
      NO         100   90.9
                              DEPENDENT
      YES         10    9.1
    BORDERLINE                  NO       105   95.5
      NO         107   97.3     YES       5     4.5
      YES         3     2.7   Total      110   100.0
 Internal Stresses
 (personal characteristics)
Personality and coping styles in the
 caring professions
 High achievers
 Self denying
 Obsessive
 Prone to depression
  (good for patients, bad for self-care)
Doctor’s health statistics
 Heart disease              Less than population
 Smoking related illness    Less than population
 Motor vehicle accidents    2x population
 Liver disease              3x population
 Depression                 3x population
 Anxiety                    >3x population
 suicide                    >3 times population
Doctors as an at risk group?
Doctors are more likely to:
  be alcoholic – alcoholism is the major cause of
   impairment in doctors over 50
  be drug addicted – drug use is the major reason for
   referral to the Medical Board for impairment
  be stressed
  be anxious or depressed
  commit suicide
      These are powerful indicators of poor self care
In figures from 1996 (Lawrence J)
  Male doctors – 1.5 to 3.4 times the suicide rate
   for the population
  Female doctors – 2.5 to 5.7 times

  Over represented areas
        •   Anaesthetics
        •   Psychiatry
        •   General practice
        •   Emergency Medicine
Known Suicide of Medical Practitioners
(NSW Medical Board)
            10
             9
             8
             7
   Number




             6
             5
             4
             3
             2
             1
             0
                 89-90   91-92          93-94   95-96
                                 Year
Hume and Wilhelm 1994 Intern Study
Prince of Wales / Prince Henry Hospitals


   Showed 17% reported having sought help
    for previous emotional problems
   During intern year 8%reported seeking help
    - anxiety, depression and eating disorders
   During the year 4% had ‘often’ considered
    life was not worth living and 3% had
    entertained (but not acted on) suicide plans
   72% reported ‘often experiencing significant
    and distressing episodes of anger.
Performance and Competence

Look below the surface of performance
 distracters
  Most students and young doctors are there
   to try and do a good job
  Look out for those whose behaviour
   changes suddenly
  Would Nicholas’ friends have noticed a
   change in his behaviour?
What resources do you have to help
Nicholas?
Supportive colleagues
Access to professional assistance e.g. GP,
 psychologist, psychiatrist
General Practitioner
Medical Benevolent Association
DHAS
What if Nicholas’ attendance or attitude
fail to improve?
Support
Progression
Robert
 Robert is a 25 year old student in Med 4, doing a long
  placement in your practice. He has always been one of
  the top students and has great reports from the clinical
  school.
 He is undertaking an honours project in cardiothoracic
  surgery. He is a good sportsman, plays first grade rugby
  for the university and is an accomplished musician. His
  father is the professor of surgery at a leading university.
  Everyone says he is going to be a great doctor.
 It has been reported that he was rude to a patient who
  complained about his manner and he got into a brawl at
  the local club.
You’ve organised to meet with Robert to
discuss these issues.
What will you do to prepare for this
 interview?
When Robert comes to see you he breaks
 down in tears and says he is leaving the
 medical program because he will never be
 a good doctor
              What could be happening to Robert

                                                       Anxiety
                       Depression

                                        Incompetence
Financial problems



                                          Lack of support
                  Family problems
               Interpersonal problems

                                            Unhappy with career choice

             Substance use


                                        Stress and Burnout
Concepts of Stress , Distress and
Impairment


   We all experience stress

   We may become distressed

   If we are distressed for long, we
    may become impaired
IS STRESS A MENTAL ILLNESS?

 No! - Some stress is good

                 Better      Reduced
                 Perf.         Perf.
   Performance




                    Stress
Coping well         Distressed         Impaired
                    (? 15-30%)           (1-3%)




     External                     Internal
  (Environmental)                (Personal)
      factors                      factors
External Stresses
 Assessment
 Workload
 Family expectations
 Exams, options, honours
 Vocational issues – length of time, limited choices
 Relationship issues
 Family problems – children and parents
 Financial problems
 The work environment – low morale, aggression and bullying,
  traumatic experiences – the elective term
Signs of “distress”

   Depression (and anger)
   Burnout
   Changes in behaviour e.g. drinking more,
    taking risks
   Relationship problems (family, patients, staff)
   Financial problems
   Withdrawal
What is Burnout?

“The origin of burnout is in occupations
where large amounts of time are spent
     with the problems of others”
                        (Heiter and Maslach, 1988)
3 Dimensions of Burnout

Emotional exhaustion

Depersonalisation

Reduced feelings of Personal
 Accomplishment
 Medical Practitioners and Burnout

Medical practitioners as a group tend to
 have “moderate” levels of burnout across
 all 3 dimensions

There are times when burnout levels are
 generally increased
               e.g. internship
Change in Reported Burnout over Time
(T1=early final medical student year, T6= late internship year)



                        30




                        20




                        10
                                                                      MBI Subscale


                                                                      Emotional Exhaustion



                         0                                            Depersonalisation
                               1     2      3     4     5         6


                                         Access Time
2.   Is burnout inevitable?
Burnout Prevalence
(Willcock et al – 2000 study of GMP graduates)
 Midway through final medical student year
  (Time 1), 27.7% of participants met criteria for
  burnout (either high DP score (>=10) or high EE
  score(>=27)).

 This level of burnout then gradually increased to
  74.7% by mid way through the internship year
  (Time 5).
Change in Burnout over Time




                                                                                                            95% CI MBI Burnout Personal Accomplishment
28                                                                                          14                                                                                               41


26
                         95% CI MBI Burnout Depersonalisation




                                                                                                                                                                                             40
                                                                                            12

24
                                                                                                                                                                                             39
                                                                                            10
22
                                                                                                                                                                                             38
20
                                                                                            8
                                                                                                                                                                                             37
18

                                                                                            6
                                                                                                                                                                                             36
16


14                                                                                          4                                                                                                35
 N=      101       103                                           95     84     83     88     N=      101                                                 103     95     84     83     88      N=      101       103     95     84     83     88

         1.00      2.00                                         3.00   4.00   5.00   6.00            1.00                                                2.00   3.00   4.00   5.00   6.00             1.00      2.00   3.00   4.00   5.00   6.00


     Access Time                                                                                 Access Time                                                                                      Access Time




          Emotional                                                                         Depersonalisation                                                                               Personal
          Exhaustion                                                                        (Mean Diff                                                                                      Accomplishment
          (Mean Diff                                                                        T6-1, p<0.001)                                                                                  (Mean Diff
          T6-1, p<0.001)                                                                                                                                                                    T6-1, p<0.001)
Correlations

Females were more likely to become
 emotionally exhausted, while males were
 more likely to exhibit depersonalisation

The higher the degree of emotional
 exhaustion, the higher the “assessed” term
 performance !
3. Is Burnout bad for you?
Relationship between burnout and risk
of psychiatric disorder


            50




            40




            30

                                                                  Psychiatric Disorder

            20                                                       GHQ-28
                                                                       Bel ow 7/8 cut off

                                                                      G HQ-28
            10                                                          Above 7/8 cut of
             N=   91 10   89 14   79 16   68 15   68 15   67 18

                   1       2        3      4       5       6


                                  Access Time
What can you do to help?

Recognise the symptoms
Education for students
Realistic goals
Psychologist
Mentor / faculty independent support
 person
Lisa
Lisa is a locum at your practice. Practice
 and hospital staff have noticed that she is
 keeping to herself. She has lost weight
 and doesn’t talk at all in practice meetings.
Her clothes look dishevelled at times. A
 few patients have refused to see her.
 Sometimes she can be seen just sitting
 alone staring blankly.
                What could be happening to Lisa
       Depression                Anxiety
                                                          Incompetence



Financial problems                             Physical illness

                        Lack of support
                                                  Serious mental illness –
                                                bipolar disorder or psychosis
                                                          Anorexia
        Family problems
     Interpersonal problems                   Unhappy with career choice



   Substance use
                                          Stress and Burnout
Doctors and medical students are people
 too
  Physical Illness
  Psychological illness
Impairment

A doctor (or a student) is impaired if they
 suffer from any physical or mental illness
 which is likely to affect their capacity to
 work safely.
Impairment implies that the individual
 lacks insight into their own ability to work
 safely.
Illness likely to cause Impairment

Psychiatric illness
  Bipolar
  Depression
  Anxiety and OCD
  Eating disorders
Addiction
Physical illness and disability
Who would notice this behaviour?
How should we encourage doctors or
 students to report their concerns?
What can you do?

Remember what we are all here for –
 patient safety.
The key problem in impairment is lack of
 insight
Talk to someone – the person, your
 colleagues, DHAS, your indemnity
 organisation
DHAS
? Refer to the Medical Board
Sarah
 Sarah is a difficult student. She is unpopular with
  the other students and frequently complains
  about aspects of the course and the behaviour
  of other students. She often asks for ‘special
  consideration’ at exam time.
 When counselled by sympathetic Faculty
  members she appears to lack insight and
  blames external factors. She has failed her last
  assessment but she is complaining to the Dean
  that the test was unfair.
Another student has complained that
 Sarah emailed other students very
 unpleasant information about a tutor and
 told them not to bother attending tutorials.
Sarah has been to the Associate Dean
 crying and saying other students don’t
 include her in their group and don’t value
 her opinion.
                What could be happening to Lisa
       Depression                 Anxiety
                                                              Incompetence



                                                                 Physical illness
Financial problems     Lack of support


                                                         Serious mental illness –
                                                       bipolar disorder or psychosis
                                                                 Anorexia
                         ‘the Disruptive Doctor’
Personality problems


                                                   Unhappy with career choice
                    Family problems
                 Interpersonal problems
   Substance use
                                            Stress and Burnout
ISSUES

Separating competency from conduct
Separating support from progression
How can this student be assisted to gain
 competency
Whose responsibility is she?
Recognise the need for
  Behaviour management
  Performance and progression assessment
  Student support committee
  Documentation ++++
  Everyone should be aware of decisions

  Can one person do all of these roles?
Performance and support
The presenting behaviour is usually just
 the tip of the iceberg
        Summary - 4 Basic Tasks

1.   Diagnose the problem
2.   Appropriate support
3.   Manage performance
4.   Manage unprofessional behaviour
Taking care of BASICs


B ody
A ffect
S ocial
I ntellect        New Jersey Medical Assoc.


C osmos
                   Physician Health Program
  +
Selfless
            -
           Selfish
 B       is for Body


 Nutrition
    avoid dehydration
    minimise toxins
 Exercise
 Rest
    sleep is not a luxury
 Recreation - “rest for mind and spirit”
 Good Medical Care
 Boundaries and Balance
 A      is for Affect


 Mood
 Attitudinal and Emotional Health
 “Emotional Intelligence”
   self awareness
   ability to manage emotions positively
   empathy
   delayed gratification, but not indefinitely!
 Dealing with negative emotions
  Predictor Model of Psychological Distress

 Personality          Burnout           Distress

                    Depersonalisation           Disability

 Emotional             Emotional         Psychological
 Sensitivity           Exhaustion          Distress


 Dependent Type
   Personality       Personal
Low Confidence In    Accomplishment                Autoregression
  Coping Skills                                    p<0.0001
                                                   p<0.005
 S     is for Social


 Pay attention to your loved ones
 “In and through community lies the salvation of the
  world” (MS Peck)
 Trust and take risks
 Give and receive feedback
 Support each other
 Experience love and intimacy
 I      is for Intellect


 Hobbies
 Current events
 Reading
 Re-evaluate your worldview,
  belief systems, ethical and
  moral standards,
  ideals and expectations
 Deal with feelings of entitlement
 C      is for Cosmos


 A personal sense
  of meaning
  and purpose
 Spiritual Health
 It is easy to lose perspective in the rigours of
  daily medical practice
 We need to keep the ability to experience awe,
  wonder and surprise
BASIC

Into your 30’s   Into your 80’s
   B ody             Breathing
   A ffect           Awake
   S ocial           Satisfied
   I ntellect        Intelligible
   C osmos           Continent

				
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