Emotional exhaustion and distress after a counselling intervention for physicians : a three-year prospective longitudinal cohort study

Background: Doctors have a relatively high degree of emotional distress, but seek help to a lesser degree and at a later stage than other academic groups. This can be deleterious for themselves and for their patients. Prevention programs have therefore been developed but it is unclear to what extent they reach doctors in need of help. This study describes doctors who participated in a selfreferrral, easily accessible, stress relieving, counselling program in Norway, and compares them with a nationwide sample of Norwegian doctors. Methods: Two hundred and twenty seven (94%) of the doctors, 117 women and 110 men, who came to the resort centre Villa Sana, Modum, Norway, between August 2003 and July 2005, agreed to participate in the study. Socio-demographic data, reasons for and ways of help-seeking, sickleave, symptoms of depression and anxiety, job stress and burnout were assessed by self-reporting questionnaires. Results: Forty-nine percent of the Sana doctors were emotionally exhausted (Maslach) compared with 25% of all Norwegian doctors. However, they did not differ on empathy and working capacity, the other two dimensions in Maslach's burnout inventory. Seventy-three percent of the Sana doctors could be in need of treatment for depression or anxiety based on their symptom distress scores, compared with 14% of men and 18% of women doctors in Norway. Twenty-one percent of the Sana doctors had a history of suicidal thoughts, including how to commit the act, as compared to 10% of Norwegian doctors in general. Conclusion: Sana doctors displayed a higher degree of emotional exhaustion, symptoms of depression and anxiety as well as job related stress, compared with all Norwegian doctors. This may indicate that the program at Villa Sana to a large extent reaches doctors in need of help. The counselling intervention can help doctors to evaluate their professional and private situation, and, when necessary, enhance motivation for seeking adequate treatment. Published: 16 March 2007 BMC Public Health 2007, 7:36 doi:10.1186/1471-2458-7-36 Received: 7 October 2006 Accepted: 16 March 2007 This article is available from: http://www.biomedcentral. com/1471-2458/7/36 © 2007 Rø et al; licensee BioMed Central Ltd. This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. BMC Public Health 2007, 7:36 http://www.biomedcentral. com/1471-2458/7/36 Page 2 of 8 (page number not for citation purposes) Background Emotional distress and impaired function among doctors can be deleterious for patients, as well as for the doctors themselves, their colleagues, other co-workers and families [1-3]. Doctors have a relatively high prevalence of depression, as well as higher suicide rates compared to other academic groups [4-8], and possibly also an increasing prevalence of burn-out [9]. Whereas these facts should lead to early helpseeking, doctors seem to seek help to a lesser degree, and later in the course of disease than do other groups [10,11]. Doctors do not easily adapt to the patient role and they also have problems being professional when treating a colleague [12,13]. Especially regarding mental health problems, doctors tend to be passive, embarrassed to seek help and worried about lack of confidentiality [2,14]. The term "hazardous heroes" has been used about doctors going to work with symptoms and problems for which they would have given their patients sick-leave [15]. Internationally it has been observed that doctors obtain treatment late in the course of emotional distress; many have been prompted by third parties such as insurance companies, police and review boards, which indicates that job performance has been impaired [16,17]. Treatment programs have with some success tried to lower the threshold for seeking treatment by letting the doctors use pseudonyms [16,18], offering treatment at one centralized national hospital in order to avoid the local environment [19], and by ensuring complete confidentiality, easy access and offices not identifiable with psychiatry [20,21]. The conditions described above have also led to the establishment of preventive programs. Primary and secondary preventive interventions for doctors have focused on developing appropriate stress management and coping skills [22-24]. Possible effects of such programs on emotional distress need further documentation. It is also important to explore the characteristics of the doctors recruited to such programs. Do the programs really reach doctors in need of help? To answer this, one needs to compare the help seeking group with the general doctor population. Few studies of this kind have been performed, and none in Norway. In 1998, the Norwegian Medical Association (NMA) established a short-term counselling program for doctors, called Villa Sana. The declared aims for this effort were to enhance health and life quality, strengthen professional awareness and identity and prevent burnout. A prospective study of sociodemographic and clinical characteristics of doctors entering this program over a two-year period from August 2003 was initiated. The questionnaires were chosen in order to make the data comparable to those from a nationwide sample of Norwegian doctors. In this paper, we have raised the following research questions: 1. What characterizes doctors who seek help at Villa Sana with regard to gender, age and speciality compared to all Norwegian doctors? 2. a) How do doctors apply for help at Villa Sana, and what reasons do they give for seeking help? b) To what degree did they seek help before coming to Villa Sana? 3. Do doctors seeking help at Villa Sana differ from Norwegian doctors concerning degree of job stress, burnout and symptoms of depression and anxiety? The Villa Sana program The program offers two kinds of interventions for doctors or doctors with partners, who feel the need to reflect on their situation, related either to professional or private matters or both. One is a single day counselling session with one counsellor if the doctor comes alone, or two counsellors when there is also a partner or a spouse. The session lasts for 6–7 hours, aiming to give time and possibility to discuss the doctor's life situation and to suggest steps needed to handle the situation. This can include advice on seeking formal medical treatment including psychotherapy. The other type of intervention is a groupbased, week-long course with boarding, dimensioned for eight individual doctors or four couples. There are daily lectures, group discussions and physical activity. One individual counselling session is offered during the week. Themes for the lectures are: possibilities and restraints in working life, the individual's resources and personality, concepts of identity, family relations, communication, team work and prevention of burnout. The group discussions are based on the participants' own experiences, providing the possibility to share these issues with colleagues. The idea behind Villa Sana was that the program should be easily accessible. This includes making contact procedures as simple as possible, having readily available times for counselling appointments and having few restrictions as to reasons for contact. Doctors can contact Villa Sana directly on the phone, by post or by e-mail for an appointment. No referral is needed. All applicants are welcomed, except when need for immediate medical treatment is obvious, like serious risk for suicide or psychotic breakthrough. The program has been presented in the Norwegian Medical Journal and is announced twice a year in the same Journal. There are internet links to Villa Sana from the Norwegian Medical Association's web pages, as well as from Modum Bad's web pages. Members of the staff at BMC Public Health 2007, 7:36 http://www.biomedcentral. com/1471-2458/7/36 Page 3 of 8 (page number not for citation purposes) Villa Sana are also invited to different physician meetings to inform about the program. The Norwegian Medical Association covers all expenses, including travelling costs, making it possible for doctors from all parts of Norway to use Villa Sana. Since the program is defined as a preventive and not a clinical intervention, no medical records are kept. Methods Of 242 eligible doctors, who participated in the Villa Sana programs between August 2003 and July 2005, 227 doctors (94%) gave their informed, written consent to participate in the study. Eighty-two percent (n = 187) came for a counselling session and 18% (n = 40) took part in the course program. The Sana doctors are compared with data from a survey of health, work conditions and life quality of Norwegian doctors from 1993 [25], comprising from 1009 – 6600 doctors depending on the object of inquiry. Specialities are grouped into non-specialist, general practice (GP), internal medical specialities, surgical specialities, psychiatric specialities, public health and laboratory medicine [25]. Ways of help-seeking There are five dichotomous categories (0-no, 1-yes). If more than one category is marked yes, only one is chosen, ranking "referral" highest, "prompting by a colleague" second, "the doctor's own initiative" third, "coming because partner asked them to" fourth and "other reasons" fifth. Reason(s) for help-seeking are defined as one or more of the following areas: health and life quality, exhaustion/burnout, professional identity (meaning identification with the role as a doctor) [26], work-related conditions, private relations and "other reasons" with an option for free text. Specified reasons under "other" were all, except one, possible to categorize under one of the first five areas – hence "other" is in the following omitted. Reasons are scored on a five-point scale (0not decisive for help-seeking to 4-decisive for help-seeking). Sco