– The doctor may be severely depressed, but he will get up in the morning, go to work, perform his duties flawlessly, then come home and lie down, he will not be able to do anything else. It works similarly with addiction. The moment when the doctor ceases to cope with work is the last – says Dr. Magdalena Flaga-Łuczkiewicz, psychiatrist, health plenipotentiary of doctors and dentists at the Regional Medical Chamber in Warsaw.
- - COVID-19 made us talk loudly about the mental health of doctors, understanding that when you work with such a load, you can not deal with it. This is one of the few pluses of the pandemic - says Dr. Flaga-Łuczkiewicz
- As the psychiatrist explains, burnout is a common problem among doctors. In the USA, every second doctor is burned out, in Poland every third, although this is data from before the pandemic
- – The most difficult emotional thing is powerlessness. Everything is going well and suddenly the patient dies – explains the psychiatrist. – For many doctors, bureaucracy and organizational chaos are frustrating. There are situations like: the printer has broken, the system is down, there is no way to send the patient back
- איר קענט געפֿינען מער אַזאַ אינפֿאָרמאַציע אויף די TvoiLokony היים בלאַט
Karolina Świdrak, MedTvoiLokony: Let’s start with what is most important. What is the mental condition of doctors in Poland at the moment? I suppose COVID-19 made it a lot worse, but it also made a lot of people talk about doctors and take an interest in their well-being. How are the doctors themselves?
Dr. Magdalena Flaga-Łuczkiewicz: COVID-19 may have worsened the mental health of doctors, but most of all it made us talk about it out loud. It is a question of a general attitude and the fact that journalists from various mainstream media are interested in the topic that books are being created that show this profession in a sympathetic light. Many people began to understand that when you work in such a load, you can not cope with it. I often say that this is one of the few pluses of a pandemic: we started talking about doctors’ emotions and how they feel. Although the mental condition of doctors in the world has been the subject of research for decades. We know from them that in the USA every second doctor is burned out, and in Poland every third, although this is data from before the pandemic.
The problem, however, is that while there is still talk of doctors’ burnout, more serious problems are already surrounded by a conspiracy of silence. Doctors are afraid of stigma, problems such as diseases or mental disorders are very stigmatized, and even more so in the medical environment. It is also not only a Polish phenomenon. Working in medical professions is not conducive to speaking out loud: I feel bad, something is wrong with my emotions.
So a doctor is like a shoemaker who walks without shoes?
This is exactly what it is. I have a medical treatment manual from an American psychiatric publishing house in front of me a few years ago. And there a lot is said about the belief still lingering in our environment that the doctor is to be professional and reliable, without emotions, and that he cannot reveal that he cannot cope with something, because it may be perceived as a lack of professionalism. Perhaps, due to the pandemic, something has shifted slightly, because the topic of doctors, their mental condition and the fact that they have the right to be fed up comes up.
Let’s look at these problems one by one. Professional burnout: I remember from psychological studies that it concerns most professions that have direct and constant contact with another human being. And here it is hard to imagine a profession that has more contact with other people than a doctor.
This applies to many medical professions and occurs mainly because doctors get to know and deal with many people’s problems and deal with their emotions every day. And the fact that doctors want to help, but cannot always.
I imagine that burnout is the tip of the iceberg and that doctors probably have many more emotional problems. What do you encounter most often?
Burnout is not a disease. Of course, it has its number in the classification, but this is not an individual’s disease, but an individual response to a systemic problem. Support and assistance to the individual are of course important, but they will not be fully effective if they are not followed by systemic interventions, for example a change in work organization. We have detailed studies on the fight against burnout by doctors, such as the American Psychiatric Association, that propose dozens of possible individual and system-specific interventions at various levels. Relaxation and mindfulness techniques can be taught to doctors, but the effect will be partial if nothing changes in the workplace.
Do doctors suffer from mental disorders and diseases?
Doctors are human and can experience whatever other people experience. Are they mentally ill? Of course. In our society, every fourth person has, has or will have mental disorders – depression, anxiety, sleep, personality and addiction disorders. Probably among working physicians with mental illnesses, the majority will be people with a “more favorable” course of the disease, due to the phenomenon “healthy worker effect». This means that in occupations that require years of competence, high immunity, work under load, there will be fewer people with the most severe mental disorders, because somewhere along the way they “crumble”, leave. There are those who, despite their disease, are able to cope with the demanding work.
Unfortunately, the pandemic has made many people feel overwhelmed by mental health problems. The mechanism of the formation of many mental disorders is such that one may have a biological predisposition to them or those related to life experiences. However, stress, being in a difficult situation for a long time, are usually the stimulus that causes you to exceed a tipping point, for which coping mechanisms are no longer sufficient. Before, a man somehow managed, now, due to stress and fatigue, this balance is disturbed.
For a doctor, the last call is the moment when he is no longer able to cope with his work. Work is usually the last stand for the doctor – the doctor may be severely depressed, but he will get up in the morning, he will go to work, he will perform his duties almost flawlessly at work, then he will come home and lie down, he will be unable to do anything anymore. more to do. I meet such doctors every day. It is similar in the case of addicts. The moment when the doctor stops coping with work is the last. Before that, family life, hobbies, relationships with friends, everything else collapses.
So it often happens that doctors with severe anxiety disorders, depression, and PTSD work for a long time and function decently at work.
- מענטשן און פרויען רעאַגירן צו דרוק דיפערענטלי
What does a doctor look like with an anxiety disorder? How does it function?
It doesn’t stand out. He wears a white coat like any doctor found in hospital corridors. This is usually not seen. For example, Generalized Anxiety Disorder is something that some people who have it don’t even know it’s a disorder. It’s the people who worry about everything, create dark scenarios, have such an inner tension that something can happen. Sometimes we all experience it, but a person with such a disorder experiences it all the time, although it does not necessarily show it. Someone will check certain things more meticulously, will be more careful, more precise – it’s even better, a great doctor who will check the test results three times.
So how do these anxiety disorders make themselves felt?
A man who returns home in constant fear and tension and is not able to do anything else, but keeps ruminating and checking. I know the story of a family doctor who, after returning home, constantly wonders if he has done everything right. Or he goes to the clinic an hour earlier, because he remembered that he had a patient three days earlier and is not sure if he missed something, so he may call this patient just in case, or not, but he would like to call. This is such self-tormenting. And it’s hard to fall asleep because thoughts are still racing.
- «We close ourselves in solitude. We take the bottle and drink it in the mirror »
What does a depressed doctor look like?
Depression is very insidious. All doctors had classes in psychiatry in a psychiatric hospital during their studies. They saw people in extreme depression, stupor, neglected, and often delusional. And when a doctor feels that he does not want anything, that he is not happy, that he gets up hard to work and does not want to talk to anyone, works slower or gets angry more easily, he thinks that “this is a temporary bluff”. Depression does not start suddenly overnight, it only smolders for a long time and gradually worsens, making self-diagnosis even more difficult.
It is getting harder and harder to focus, the person is unhappy or completely indifferent. Or furious all the time, bitter and frustrated, with a sense of nonsense. It is possible to have a worse day, but when you have worse months it is worrying.
- זענען די פאָרענסיקס דאקטוירים וואָס באַהאַלטן די מיסטייקס פון אנדערע דאקטוירים?
But at the same time, for many years, he is able to function, work, and fulfill his professional duties, while the depression worsens.
This is exactly what it is. A Polish doctor statistically works in 2,5 facilities – according to the report of the Supreme Medical Chamber from a few years ago. And some even in five or more places. Hardly any doctor works one-time job, so fatigue is associated with stress, which is most often explained by worse well-being. Lack of sleep, constant on-call duty and frustration lead to burnout, and burnout increases the risk of depression.
Doctors try to cope and look for solutions that will help them. They engage in sports, talk to a colleague psychiatrist, assign themselves drugs that sometimes help for a while. Unfortunately, there are also situations in which doctors resort to addictions. However, all this only increases the time before they go to a specialist.
One of the symptoms of depression may be difficulty sleeping. Professor Wichniak examined family doctors for sleep. Based on the results obtained, we know that two out of five, i.e. 40 percent. doctors are unhappy with their sleep. What are they doing with this problem? One in four uses sleeping pills. The doctor has a prescription and can prescribe the drug himself.
This is how often the addiction spiral begins. I know cases when someone comes to me who is addicted to, for example, benzodiazepines, i.e. anxiolytics and hypnotics. First of all, we have to deal with addiction, but under it we sometimes discover a long-term mood or anxiety disorder.
The fact that the doctor heals himself masks the problem for many years and postpones its effective solution. Is there any place or point in the Polish health care system where someone can tell this doctor that there is a problem? I do not mean a doctor’s colleague or a caring wife, but some systemic solution, for example periodic psychiatric examinations.
No, it doesn’t exist. An attempt is underway to create such a system in terms of addiction and severe diseases, but it is more about detecting people who are already malfunctioning enough that they should not be practicing as a doctor, at least temporarily.
At each district medical chamber there should be (and most of the time there is) a plenipotentiary for the health of doctors. I am such a plenipotentiary at the Warsaw Chamber. But it is an institution established to help people who may lose the possibility of practicing their profession due to their health condition. Therefore, it is mainly about doctors struggling with addiction, who are inclined to treatment, otherwise they risk losing the right to practice. It can be helpful in extreme situations. But this action is aimed at the negative effects, not at preventing burnout and disorder.
Since I am the health plenipotentiary for doctors in the Warsaw Medical Chamber, i.e. from September 2019, I have been trying to focus on prevention. As part of this, we have psychological help, 10 meetings with a psychotherapist. This is emergency aid, rather short-term, to start with. In 2020, 40 people benefited from it, and in 2021 many more.
The system is built in such a way that a doctor who would like to use the help of our psychotherapists first reports to me. We talk, we understand the situation. As a psychiatrist and psychotherapist, I am able to help choose the optimal way of helping a given person. I am also able to assess the degree of suicide risk, because, as we know, the risk of doctors’ suicide death is the highest among all occupations in all statistics. Some people go to our psychotherapists, some I refer to addiction therapists or to consult a psychiatrist, there are also people who have used psychotherapy in the past and decide to return to their “old” therapists. Some people attend 10 meetings within the chamber and that’s enough for them, others, if this was their first experience with psychotherapy, decide to find their own therapist and longer therapy. Most people like this therapy, find it a good, developing experience, encouraging their friends to take advantage of it.
I dream of a system in which doctors are taught to take care of themselves already during medical studies, they have the opportunity to participate in therapeutic groups and ask for help. This is happening slowly, but still not enough for what you need.
Does this system work all over Poland?
No, this is a proprietary program in the Warsaw chamber. During the pandemic, psychological assistance was launched in several chambers, but not in every city. I sometimes receive calls from doctors in distant places.
– The point is that in a situation of strong emotions – both himself and the other side – the doctor should be able to take a step back and enter the position of an observer. Look at the screaming mother of the child and not think about her pissing him off and touching him, but understand that she is very upset because she is afraid of the baby, and the recorder yelled at her, she could not find a parking space or go to the office – says Dr. Magdalena Flaga-Łuczkiewicz, psychiatrist, health plenipotentiary of doctors and dentists at the Regional Medical Chamber in Warsaw.
When I was studying psychology, I had friends in medical school. I remember that they treated psychology with a grain of salt, laughed at it a bit, said: it’s only one semester, you have to survive somehow. And then, years later, they admitted that they regretted the neglect of the object, because later at work they lacked the ability to deal with their emotions or to talk to patients. And to this day I wonder: why does a future doctor only have one semester of psychology?
I finished my studies in 2007, which is not so long ago. And I did have one semester. More precisely: 7 classes of medical psychology. It was a lick of the subject, a bit about talking to the patient, not enough. It’s a little better now.
Are doctors now taught during their studies such things as dealing with difficult contacts with patients or their families, dealing with the fact that these patients are dying or are terminally ill and cannot be helped?
You talk about dealing with your own powerlessness is one of the most difficult things in the medical profession. I know that there are psychology and communication classes at the Medical Communication Department at the Medical University of Warsaw, there are classes in communication in medicine. There, future doctors learn how to talk to a patient. There is also the Department of Psychology, which organizes workshops and classes. There are also optional classes from the Balint group at the disposal of students, where they can learn about this great, and still little-known method of expanding medical competences with the soft ones, related to emotions.
It is a paradoxical situation: people want to be doctors, to help other people, to have knowledge, skills and thus control, no one goes to medicine to feel helpless. Yet there are plenty of situations in which we cannot “win”. In the sense that we cannot do anything, we must tell the patient that we have nothing to offer him. Or when we do everything right and it seems to be on the right track and yet the worst happens and the patient dies.
It is hard to imagine anyone coping well with such a situation. Or differently: one will do better, the other will not.
Talking, “venting” these emotions, helps to shed the burden. It would be ideal to have a smart mentor, a senior colleague who has gone through it, knows what it’s like and how to deal with it. The already mentioned Balint groups are a great thing, because they allow us to see our experiences from different perspectives, and they refute in us the terrifying loneliness and the feeling that everyone else is coping and only we are not. To see how powerful such a group is, you simply need to attend the meeting several times. If the future doctor learns about the group’s operation during his studies, then he knows that he has such a tool at his disposal.
But the truth is, this physician support system works very differently from place to place. There are no nationwide system solutions here.
- א מידלייף קריזיס. וואָס איז עס ארויס און ווי צו האַנדלען מיט עס?
Which elements of a doctor’s work do doctors perceive as the most stressful and difficult?
Difficult or frustrating? For many doctors, the most frustrating thing is the bureaucracy and organizational chaos. I think anyone who has worked or works in a hospital or public health clinic knows what they are talking about. These are the following situations: the printer broke, the paper ran out, the system does not work, there is no way to send the patient back, there is no way to get through, there is a problem with getting along with the registration or management. Of course, in the hospital you can order a consultation from another ward for the patient, but you have to fight for it. What is frustrating is what takes time and energy and does not concern the treatment of the patient at all. When I was working in the hospital, the electronic system was just beginning to enter, so I still remember paper documentation, medical histories for many volumes. It was necessary to accurately describe the treatment process and the patient’s disease, stitch it up, number it, and paste it in. If someone wants to be a doctor, he becomes a doctor to heal people, not to stamp stamps and click on a computer.
And what is emotionally difficult, burdensome?
Helplessness. Often this helplessness is due to the fact that we know what to do, what treatment to apply, but, for example, the option is not available. We know which medicine to use, we read about new methods of treatment on an ongoing basis, we know that it is used somewhere, but not in our country, not in our hospital.
There are also situations where we follow procedures, get involved, do what we can, and it seems that everything is going well, but the patient dies or the situation gets worse. It is emotionally difficult for a doctor when things get out of hand.
- פּסיכיאַטראַסץ אויף די יפעקץ פון סאציאל דיסטאַנסינג אין אַ פּאַנדעמיק. די דערשיינונג פון "הויט הונגער" איז ינקריסינג
And how do contacts with patients look like in the eyes of a doctor? The stereotype says that the patients are difficult, demanding, they do not treat the doctor as partners. For example, they come to the office with a ready-made solution that they found on Google.
Perhaps I am in the minority, but I like when a patient comes to me with information found on the Internet. I am a supporter of a partnership relationship with the patient, I like it if he is interested in his disease and looks for information. But for many doctors it is very difficult that patients suddenly want to be treated as partners, they no longer recognize the doctor’s authority, but only discuss. Some doctors are offended by this, they may simply feel humanly sorry. And in this relationship, emotions are on both sides: a frustrated and tired doctor who meets a patient in great fear and suffering is a situation that is not conducive to building friendly relationships, there is a lot of tension, mutual fears or no culpability in it.
We know from the campaign conducted by the KIDS Foundation that what is very difficult in dealing with patients are contacts with patients’ families, with parents of treated children. This is a problem for many pediatricians, child psychiatrists. The dyad, i.e. the two-person relationship with the patient, becomes a triad with the doctor, patient and parents, who often have even greater emotions than the patient himself.
There is a lot of fear, horror, resentment and regret in the parents of young patients. If they find a doctor who is tired and frustrated, they do not notice the emotions of a man who has a sick child, but only feel unjustly attacked and start to defend themselves, then both sides break away from the real situation, emotional, debilitating and unproductive begins . If the pediatrician experiences such situations with many patients daily, it is a real nightmare.
What can the doctor do in such a situation? It is difficult to expect a parent of a sick child to control his anxiety. Not everyone can do it.
This is where techniques for de-escalating emotions, e.g. those known from transactional analysis, come in handy. But doctors are not taught them, so it varies depending on the psychic make-up of a particular doctor and his abilities.
There is one more difficult aspect that is little talked about: we work with living people. These living people can often remind us of someone – ourselves or someone close to us. I know the story of a doctor who started specializing in oncology but couldn’t stand the fact that there were people his age dying on the ward, identified too much with them and suffered, and eventually changed specialization.
If the doctor unconsciously identifies himself with the patient and his problems, experiences his situation very personally, his involvement ceases to be healthy. This harms the patient and the doctor himself.
In psychology there is a concept of the “wounded healer” that a person who is professionally involved in helping, often experienced some kind of neglect, injury himself in childhood. For example, as a child, she had to care for someone who was sick and in need of care. Such people may tend to look after others and ignore their needs.
Physicians should be aware – though not always the case – that such a mechanism exists and that they are susceptible to it. They should be taught to recognize situations in which they exceed the limits of commitment. This can be learned during various soft skills trainings and meetings with a psychologist.
The KIDS Foundation report shows that there is still a lot to be done in the doctor-patient relationship. What can both parties do to make their cooperation in treating a child more fruitful, free of these bad emotions?
For this purpose, the “Great study of children’s hospitals” of the KIDS Foundation was also created. Thanks to the collected data from parents, doctors and hospital employees, the foundation will be able to propose a system of changes that will improve the hospitalization process of young patients. The survey is available at https://badaniekids.webankieta.pl/. On its basis, a report will be prepared, which will not only summarize the thoughts and experiences of these people, but also propose a specific direction for the transformation of hospitals into places friendly to children and doctors.
In fact, it is not the doctor and not the parent that can do the most. The most can be done systemically.
When entering into a relationship, the parent and the doctor experience strong emotions resulting from the organization of the treatment system. The parent is resentful and furious, because he waited a long time for the visit, he could not hit, there was chaos, they sent him away between the doctors, there is a queue in the clinic and a dingy toilet that is hard to use, and the lady at the reception was rude. The doctor, on the other hand, has the twentieth patient on a given day and a long line of more, plus a night shift and a lot of documentation to click on the computer, because he didn’t have time to do it earlier.
At the beginning, they approach each other with a lot of luggage, and the situation of the meeting is the tip of the problems. I feel that most could be done in the area where this contact takes place and how the circumstances are organized.
Much can be done to ensure that the contact between the doctor and the parent is friendly to all participants in this relationship. One of them are system changes. The second – teaching doctors to cope with emotions, not to allow their escalation, these are specific competences that would be useful to everyone, not only doctors. The point is that in a situation of strong emotions – both himself and the other side – the doctor should be able to take a step back and enter the position of an observer. Look at the screaming mother of the child and not think about her pissing him off and touching him, but understand that she is very upset because she is afraid of the baby, and the recorder yelled at her, she could not find a parking space, she could not find Cabinet, she waited a long time for a visit. And say: I can see that you are nervous, I understand, I would be nervous too, but let’s focus on what we have to do. These things are learnable.
Doctors are people, they have their own life difficulties, childhood experiences, burdens. Psychotherapy is an effective tool for taking care of yourself, and many of my colleagues use it. Therapy helps a lot in not taking someone else’s emotions personally, it teaches you to take care of yourself, pay attention when you feel bad, take care of your balance, take a vacation. When we see that our mental health is deteriorating, it is worth going to a psychiatrist, not delaying it. Just.