Voluntary counseling could help doctors avoid burnout

Medical Tribune January 2009 P5
David Brill

Short counseling sessions can reduce burnout among doctors and encourage them to make positive changes to their working lives, a new study suggests.

Doctors who volunteered for an intervention program in Norway reported lower levels of emotional exhaustion, worked fewer hours per week and were less likely to be on full-time sick leave a year later.

They were also more likely to seek further professional help, with 53 percent having undergone psychotherapy at 1-year follow-up compared to just 20 percent at the time of enrollment.

Many had already reached high levels of distress and had considered attending the program for quite some time before actually doing so, according to Dr. Karin Rø of the University of Oslo, who led the study.

“The program legitimizes the need for doctors to take a step back for a while and think about their situation,” she said.

“A lot have come back to me and said that it was really important at that time in their life to have somebody to talk to, to get a different perspective on their own situation. Giving a little help, in time, is much better than having to give a lot of help when the situation is much worse.”

Volunteers at Villa Sana – the only center of its kind in Norway – chose between a single one-on-one counseling session of around 6 hours, or a week-long course involving daily lectures followed by group discussions. All sessions were confidential and no medical records were kept. A total of 227 doctors were included in the study, 185 of whom completed 1-year follow-up questionnaires. [BMJ 2008 Nov 11;337:a2004]

Dr. Sim Kang, a consultant psychiatrist at the Institute of Mental Health, Singapore, hailed the research as an important reminder of a timely issue.

“The healthcare profession is certainly susceptible to the onset of burnout if one is not careful about it. The demands of the job are changing and the expectations are quite high from the public nowadays,” he said.

“The symptoms of burnout encroach not just upon the sense of physical tiredness but also the sense that one is mentally wearied and emotionally drained. The message is that if prevention isn’t working and things are getting out of hand then they should seek help.”

Another BMJ study published this year reported that depressed pediatric residents made six times as many medication errors per month as non-depressed residents. [2008 Mar 1;336(7642):488-91]

Rø pointed to this finding as evidence that doctors need to take care of their own wellbeing in order to take care of others.

“When you fly on a plane and the oxygen masks come down you’re supposed to put your own one on before you help anyone who needs it. I think that’s a very good picture of doctors,” she said, adding that she hopes the study will prompt the creation of other similar centers in future.

A year on from the intervention the participants had reduced their mean working hours by an average of 1.6 hours per week. Just 6 percent were on full time sick leave, compared to 35 percent at baseline.

High rates of depression and suicide have been well documented among doctors. A recent study of Brazilian medical students found that as many as 38.1 percent had depressive symptoms, with females particularly susceptible. [BMC Medical Education, in press]

Rø noted that the Norwegian counseling intervention helped the doctors to normalize their situation, having previously felt that they were the only ones experiencing such feelings of distress. They often fail to seek help because they are used to focusing solely on the needs of their patients and do not realize when they are in need of help themselves, she said.

The exact prevalence of depression among the medical community in Asia is largely unknown.

However, Sim encouraged doctors to discuss their feelings of stress and anxiety in informal support groups with their peers whenever possible, adding that he would like to see longer-term data on the sustainability and generalizability of the Norwegian model before advocating the adoption of more formal, structured programs.



Seven tips for avoiding burnout

Dr. Sim Kang, a consultant psychiatrist at the Institute of Mental Health, Singapore, offers his advice on how to de-stress before it gets too late.

1 – Acknowledge and accept that we are all equally vulnerable and can feel trapped and overwhelmed like anyone else. Medical professionals are not superheroes.

2 – Be willing to communicate with others, particularly through informal networks of colleagues, family and friends.

3 – Clarify your responsibilities within the job and resolve any ambiguities that may be causing additional stress.

4 – Determine your own strengths and weaknesses and play to them.

5 – Educate yourself about the symptoms of burnout.

6 – Find time off to unwind and relax.

7 – Group together with your peers to discuss the difficult issues and identify any problems you may be experiencing.

Patient access to online health records helps doctors shake inertia

Medical Tribune November 2008 SFXIV
David Brill

Online personal health records can not only empower patients but also galvanize their physicians into action, a new study suggests.


Type 2 diabetics who used an online system were significantly more likely to have their medications adjusted during clinic visits, the randomized trial in US primary care practices found.

The system, which was directly linked into the electronic medical records used by the physicians, provided users with clinical information and enabled them to create their own diabetes care plan for discussion during consultations.

Patients were also encouraged to ask more questions and take an active role in their disease management.

Dr Richard Grant, who led the study, said that clinical inertia on the part of physicians can often contribute to patients failing to reach their targets.

“The study is very encouraging and underscores the point that the more patients know about what ought to be done, the more likely it is that medical management changes are made. If you empower patients, good things happen,” he said.

Associate Professor Thai Ah Chuan, a senior consultant and endocrinologist at National University Hospital (NUH) said that the system was interesting in principle but would be very difficult to implement in Singapore at present.

“First you’d have to improve the whole electronic medical records system, then you’d have to look into the medico-legal issues, and then there are the questions of motivation, training and money,” she said.

Phone consultations have proved popular for diabetes patients in Singapore, she said, but noted that online healthcare systems would only benefit a small proportion of people.

“My impression of local patients is that they use the internet for pleasure but never for health. To them health is the responsibility of their physician, so having a system like that … it’s providing information and some kind of empowerment but beyond that, whether it will then improve and benefit control is yet to be seen.”

Many hospitals in Singapore do not have fully electronic records and could not therefore adopt such a system yet, Thai added. NUH, for example, is still in the process of upgrading but hopes to be completely paper-free by next year.

Diabetes medication was changed in 53 percent of consultations among the study intervention group compared to 15 percent among controls (P<0.001).>Arch Intern Med 2008 Sep 8;168(16):1776-82]

There were no significant differences, however, in the control of diabetes-specific risk factors after 1 year – an effect that the authors attribute to low enrollment rates. Just 244 patients – 4 percent of the overall diabetes population – took part in the study.

Grant, who is based at Harvard Medical School, said that many diabetics are elderly and may not feel comfortable with using the internet.

He also noted, however, that there is a large population of younger people with computers who are simply reluctant to engage with health information systems. More research is needed to understand the reasons for these barriers, he added.

A sympathetic ear: The best medicine for irritable bowels

Medical Tribune November 2008 SFIX
David Brill

Listening to your patients could be an effective treatment for irritable bowel syndrome (IBS), a recent study has suggested.

Researchers from the US and UK found that 62 percent of patients reported adequate symptom relief when their doctor spent more time with them and asked questions in a warm and friendly manner, in addition to providing placebo acupuncture.

Forty four percent of patients showed the same improvement when acupuncture was given without the extra attention, and just 28 percent when no placebo therapy was given at all.

Professor Ted Kaptchuk, who led the study, said that it was one of the most important demonstrations of the placebo effect in the literature and the first to look at long-term outcomes in the clinical setting.

“The important implication is that the power of the placebo effect, and specifically the patient-doctor component of the placebo effect, was huge. The magnitude of that effect is comparable to any drug that’s ever been tested for irritable bowel,” said Kaptchuk, who is based at Harvard Medical School, US.

He added that the same principles could apply to situations such as chronic pain and depression, which also have a strong “subjective component” whereby the context of the healthcare situation can influence a patient’s interpretation of their condition.

“We’re not treating something that is defined biologically, say a tumor or a blood assay or something you find on an X-ray. We’re treating a complaint that’s very real, and the interactions of that complaint with the person’s sense of well-being and health is probably where the placebo effect is very important,” he said.

The study involved 262 patients who were randomized to receive one of the two placebo interventions or simply to remain on a waiting list. The effects were recorded at 3 weeks and remained similar after 6. [BMJ 336(7651):999-1003]

Dr. Gwee Kok Ann, a Singapore-based IBS specialist and president of the IBS Support Group, was not surprised by the study’s findings.

“I’ve always felt that IBS patients respond very well to treatment if you just make the effort to talk with them and explain things to them,” he said.

“A lot of times it’s just helping the patient first of all to understand what’s going on because I think that’s the main worry in a lot of them. They worry is it cancer, is it colitis, and that in itself reinforces the symptoms because anxiety drives the symptoms too,” said Gwee, an adjunct associate professor at the National University of Singapore and a consultant gastroenterologist at Gleneagles Hospital.

Addressing the diagnosis of IBS in a tactful way can also improve outcomes, he said, noting that doctors should take time to explain the condition thoroughly and convincingly so that the patient is comfortable with the diagnosis.

Patients view pain as a warning that something is wrong, he explained, so if their doctor can’t find an explanation for it then adrenaline and anxiety can rise, prompting the patient to demand more and more tests in the expectation that something has been missed. This situation can be avoided by introducing the diagnosis of IBS early rather than leaving it as a last resort for when everything else has been ruled out, he said.

Breast cancer recurrence stressful for docs and patients alike

Medical Tribune July 2008 P4
David Brill

Telling a patient that her breast cancer has returned is traumatic for doctors too, according to a Singapore survey.

Nineteen out of 20 physicians interviewed said that breaking this news was harder than delivering the initial diagnosis of cancer, while half described this as the most stressful part of their job.

The study, designed to explore patient-doctor relationships, also revealed that trust between the two parties can be eroded when breast cancer recurs.

“Patients start asking themselves what’s gone wrong: ‘I trusted this doctor, why has it recurred?’” said Dr. Wee Siew Bock, a consultant breast surgeon at Mount Elizabeth Medical Centre, Singapore, who participated in the survey.

“Almost one in three doctors feels that when [recurrence] happens the patient will lose a bit of
trust in them. And I think that doctors in general see it more like an issue of failure – not because you have failed to treat the patient adequately but because you have not been able to meet the expectations of the patient, which is cancer-free survival after the first episode,” said Wee.

The patient arm of the survey comprised 68 Singapore residents who were assessed by questionnaire. The physician group – made up of nine breast cancer surgeons and 11 oncologists – was interviewed face-to-face.

The study also found that while 84 percent of patients said that they trusted their doctor to
recommend the best available treatment, 79 percent admitted to wishing that they had been given a more detailed explanation of why that treatment was chosen.

These findings underscore the need to empathize with patients when breaking the news of a recurrence, according to Wee, who presented the results at the recent inaugural Breast Cancer Survivors’ Conference.

“I think that being able to make the patient understand her condition better means that you
are likely to get a more engaged patient when it comes to treatment. And a patient who is more
engaged is likely to be more positive and generally able to handle and cope with their illness a lot
better,” he said.

Wee also advised doctors to consider the importance of a patient’s support network, and to try
to encourage family members or friends to accompany the patient for consultations.

“It’s exceptionally traumatic if the patient just breaks down and falls apart in front of you and there’s nobody to support them, because at the end of the day you’re still the doctor … you have been delivering good news all along, now you tell her the bad news. I don’t think she will turn to you for support,” he concluded.

The survey was jointly commissioned by the Breast Cancer Foundation and AstraZeneca Oncology, and was conducted by German market research company, GfK.


Tips for communicating bad news to patients

Dr. Wee Siew Bock, consultant breast surgeon at Mount Elizabeth Medical Centre, Singapore, offers tips on breaking bad news to patients.

1. Be patient with your patients: “The most important thing is to sit down and listen … giving the patient time to express her fears and concerns will actually go a long way in helping you communicate better.”

2. Speak the same language: “One of the things that we must try to do is use more lay terms. Sometimes even using the dialects or languages that the patient is conversant in helps a lot.”

3. Be creative: “Sometimes I feel that using little analogies is very useful. It helps the patient … grasp the situation a bit better.”

4. Wait for the right moment: “It might be easier to get the message across with another relative of the patient around. Usually this happens with older women: if you have the younger relatives around, they can explain it better.”

5. Do your research: “I find it may be useful to just review the patient’s medical history: how she was when you first diagnosed her a few years ago, who came with her, how she coped – just to try to refresh how it was that she handled that situation. That gives you an additional dimension to how to break this bad news to that patient.”