Are doctors-in-training in the UK aware of the current support services available to them?

Introduction: Stress and burnout amongst the medical profession is increasingly being recognised and acknowledged internationally. The problem is apparent; the solution is less clear. Tailored support services for doctors exist. Anecdotally, doctors comment that they are unaware of any confidential services available. In addition, stigma attached to admitting a problem remains and prevents doctors engaging in these services (Singh, 2003). It is evident that further support is required. However, the existing structures in place ought to be reviewed to assess whether they are reaching the target population and are being utilised appropriately. Method: An anonymous online questionnaire was sent to all doctors-in-training within the Imperial College NHS Healthcare Lead Provider and Northwest Thames Foundation School. Results: One hundred and fifty doctors-in-training responded to the questionnaire. Each stage of postgraduate training within the UK was represented in the results. 50% of the doctors-in-training were unaware of any support services for doctors locally or nationally. 70% of responders were unaware of any support for doctors with personal or professional difficulties within London. Participants reported a fear of potential stigma being attached to them if they disclosed any difficulties to senior doctors within their training programmes or to any of the potential services available. Discussion: The findings highlight that current support services are not well known and that doctors-in-training have struggled when they have tried to find information available. Signposting and increasing awareness, as well as information on the services, needs to be improved to increase accessibility for doctors-in-training. Conclusion: The stigma surrounding doctors asking for help is not unique to the UK. This study demonstrates that stigma remains prevalent within the medical setting and is a barrier to accessing the support services. Further education on the topic could tackle the stigma, increase conversations on health and wellbeing and increase knowledge and understanding of the services. Nash E MedEdPublish https://doi.org/10.15694/mep.2017.000209 Page | 2


Introduction
Stress and burnout amongst the medical profession is increasingly being recognised and acknowledged internationally. The many studies, conducted at various institutions globally, using the Maslach Burnout Inventory, demonstrates high levels of stress and burnout within the profession (Romani & Ashkar, 2014). Doctors have higher mental health problems compared to an age-matched population (Gerada, 2017). In South Africa, high levels of burnout and emotional exhaustion within the medical profession are reported (Peltzer, Mashego & Mabeba, 2003). Almost half of the newly qualified doctors in Australia describe the same problems (National Mental health survey of doctors and medical students, 2013). In Canada, at least a third of the residents report stress related problems (Cohen et al., 2008); whilst in America it is as high as 50-76% in medical and surgical residents (Shanafelt, 2009). Arabic and European countries are seeing similar levels (Al-Dubia & Rampal, 2010;Romani & Ashkar, 2014). In the UK, suicide rates in doctors rising, in particularly with females it is twice the average norm (Cole-King, Garret, Williams, Hines & Platt, 2013). Medical professionals are reluctant to seek support when it is required and by the time they do, they are frequently in a dire situation (Cole-King, et al., 2013).
Patients' welfare also suffers from a medical workforce that is stressed and burnt-out. The wellbeing of the healthcare professionals directly impacts the care the patient receives (Royal College of Physicians, 2015). A UKbased study identified that the hospitals with the highest levels of staff sickness have the highest patient mortality rates (Boorman, 2009). Burnt-out, stressed doctors are less compassionate and have less time and ability to support, empathise or manage patients appropriately (Gerada, 2017). This has a spiralling negative effect on the doctor's wellbeing, because job satisfaction decreases and stress and emotional exhaustion increase.
The problem is apparent; the solution is less clear. Tailored support services for doctors exist. Mindfulness courses, resilience training, counselling services and many others have been developed (Isaksson, Gude, Tyssen & Aasland, 2008;Romani & Ashkar, 2014;Shapiro, Astin, Bishop & Cordova, 2005). However, the stigma attached to admitting a problem remains apparent and prevents doctors engaging in these services (Singh, 2003). Success rates of interventions are much greater in the medical population than that of the normal population (Brooks, Gerada & Chalder, 2011). It demonstrates once engaged, a doctor is likely to benefit from any intervention. Doctors need to be able to access the necessary support services, when they require it, at the earliest stage possible. Anecdotally, doctors comment that they are unaware of any confidential services available. This further decreases engagement in crucial services. There is little benefit to increasing the number or type of services available to doctors, if doctors report they are unaware of existing organisations or support networks.
With increasing numbers of doctors with symptoms of stress and burnout it is evident that further support is required. However, the existing structures in place ought to be reviewed to assess whether they are reaching the target population and are being utilised appropriately. Knowing this information would improve the development and tailoring of the support structures and services for doctors.

Research question:
Are doctors-in-training aware of the services available that provide help and support for difficulties and problems they may encounter? Nash E MedEdPublish https://doi.org/10.15694/mep.2017.000209 Page | 3

Method
To answer this question, a mixed-method research approach was adopted. An anonymous online questionnaire was sent to all doctors-in-training within the Imperial College NHS Healthcare Lead Provider and Northwest Thames Foundation School; the organisations together include over 2,000 doctors-in-training within London. Doctors-intraining, in the UK, includes all doctors from newly qualified, up till completion of their specialist training. The minimum length of time this can take, working full time, is 5 years and can vary up to 10 years, depending on the specialty. London is sub-divided into areas (deaneries), each responsible for the doctors-in-training within that area. The Lead Providers are responsible for the postgraduate medical education and training of these doctors within each specialty within the deanery.
The questionnaire was subject to quantitative analysis. The free text section at the end of the questionnaire was analysed qualitatively through thematic analysis, and emerging themes identified. An example of the questionnaire is displayed in Table 1. • Nationally? 4. If you were experiencing personal or professional difficulties in any of these following categories, where may you find support? • Career • Work-place • Health problems • Addiction • Stress and anxiety • Exams 5. Many people will not look for these services until they need them. Where would be an appropriate place to advertise or signpost these services to be easily accessible to doctors-in-training when they need the information?
Ethical approval was sought and it was deemed not necessary, as patients or relatives were not involved in the study. One hundred and fifty doctors-in-training responded to the questionnaire. Each stage of postgraduate training within the UK was represented in the results, from Foundation Year 1 to Specialty Trainee level 8. Figure 1 depicts the range of specialties responding to the survey; with all the sub-specialties within medicine and surgery combined under their generic specialty.

Figure 1: Number of responses from each specialty
From the responses to the questionnaire, 50% of the doctors-in-training were unaware of any support services for doctors locally or nationally. 70% of responders were unaware of any support for doctors with personal or professional difficulties within London. Detailed analyses of the responses to each question are described.
Are you aware of any support services available, if you were experiencing professional or personal difficulties during training within: The Hospital Trust?
35% of doctors-in-training were aware of support services available within the Hospital Trust they were currently working in, identifying the consultant responsible for their training at that trust as the source of support. These consultants were either designated Educational Supervisors or Clinical Supervisors to the doctor-in-training. 12% of participants considered accessing Occupational Health or counselling services within their trust for support.

London?
Only 30% of the doctors-in-training were aware of support services available for doctors within London. Breaking down this figure into subcategories of the services they were aware of: 27% Professional Support Unit, 9% Practitioners Health Programme, 13% MedNet (replaced by Practitioners Health Programme -Health Education England London).

Specialty training?
32% of doctors-in-training identified available support within their medical specialty. From these doctors, 60% highlighted their consultant supervisors (Clinical Supervisors or Educational Supervisors) or the consultants responsible for their stage of specialty training (Training Programme Directors) as the source of support. Other answers included a designated mentor within the specialty or Heads of the Specialty Schools (for example, the Head of the School of Paediatrics).

Nationally?
Of the services available nationally, only 23% of participants were aware of any, with 51% of these responses citing the British Medical Association counselling service.

If you were experiencing personal or professional difficulties in any of these following categories, where may you find support?
The participants were provided with a series of options to select from and a free-text option. The potential areas of difficulties were work related (career uncertainty, workplace problems, exam struggles) or health related (stress, anxiety and addiction problems). The results are displayed in Table 2. Senior consultants, either in the roles of Clinical or Educational Supervisors or Training Programme Directors, were identified as the most likely first source of support except for health or addiction problems. Even for stress and anxiety, 41% of doctors-in-training stated they would seek consultant support. Occupational health was acknowledged as a source of support for 28% of participants with health problems, but less frequently for those with stress or anxiety problems.
The Professional Support Unit was rarely recognised as a source of support by doctors-in-training for any problem, with only 3% of participants acknowledging it as a support option in one category (exam stress), and its highest rating being 15% (in addiction problems).

Many people will not look for these services until they need them. Where would be an appropriate place to advertise or signpost these services to be easily accessible to doctors-in-training when they need the information?
Doctors-in-training suggested potential places to advertise and signpost for support services. Various websites were a popular option, as were Postgraduate Medical Education Centres (during attendance for teaching sessions) and within teaching sessions. The websites proposed include the Imperial College Healthcare Lead Provider; local hospital trusts; the medical specialty websites and the various Royal Medical Colleges. The e-portfolio, a source continually accessed by doctors-in-training to document their progression through training, was suggested as another option. Figure 2 displays a breakdown of the percentage for each possible source as a solution to signpost or advertise the support services.

Qualitative results
The thematic analysis from the qualitative section of the questionnaire, identified six main themes: Concerns of stigma attached if a doctor admits any problems Confidentiality and impartiality concerns regarding any form of support Long-term implications on career progression if a doctor discloses any difficulties Consultant supervisors are the main sources of support, but are not perceived as confidential support or capable of dealing with the difficulties Inaccessibility of current services Stress caused by training programmes The doctors-in-training report a fear of potential stigma being attached to them if they disclosed any difficulties to senior doctors within their training programme, or to any of the potential services available. Negative consequences from this stigma on their progression through training, or their future career were a further concern.
"There is still too much stigma attached to be able to discuss issues with clinical supervision" "It's difficult to access support without believing it will negatively impact on ones career or reputation" There was a lack of trust regarding confidentiality for the doctor-in-training regarding consultants and senior clinicians, as well as towards any services that maybe available. A call for support services fully independent from training programmes was suggested. The medical training programmes themselves were identified by the doctors-in- training as a source of stress and concern, due to lack of support from senior colleagues and the repeated compulsory relocations to new areas or hospitals.
For the doctors-in-training that tried to access support, there were multiple examples provided of doctors struggling to find any information about any support services or help that is currently available.

"I found it really difficult to get any information on sources of help and support"
If they did seek help, the inflexibility of the services that were accessed prevented the doctors-in-training from being able to utilise the services "I have tried to contact support agencies, but they could only make appointments several weeks in advance when I only had one weeks notice of my rota".

Discussion
There are dedicated support services for doctors-in-training within the UK, yet the doctors-in-training that contributed to this questionnaire demonstrated that over half were unaware of available support for them locally, within their specialty, regionally or nationally. The Professional Support Unit London, which has dedicated services to support doctors-in-training, does not appear to be utilised by these doctors-in-training. For example, only 11% of the participants stated they would access the Professional Support Unit if they were having career-related difficulties. This demonstrates that available services are either unknown or poorly understood. The support services available are independent and confidential to training programmes. However, these services are not perceived as such, as the participants were requesting independent support that is separate from the training. Mistrust in available services was evident; with concerns that confidentially would not be respected, or that in seeking support it would have adverse consequences on future training or careers. This prevents doctors-in-training seeking help or engaging in the services at times when they need help. For those doctors that tried to seek help, the additional barriers of inflexible services due to on-calls or rota commitments are a further deterrent. Services that are tailored specifically for medical professionals should be flexible to the availability of these professionals. A weekday service is not practical for doctors who work long hours, with on calls and long commutes. Such barriers will decrease engagement with the services.
Consultant supervisors were frequently identified as the initial source of support for the doctors-in-training. Nonetheless, the doctors-in-training expressed concerns regarding confidentially and impartiality of these consultants; with a concern that any problems disclosed might impact upon their future careers. Consultant supervisors are often involved in the annual appraisals and progression of doctors-in-training and this directly conflicts with a doctor-in-training's ability to trust the consultants. There is a concern and misconception that disclosing a difficulty may not remain confidential from the appraisal process. Further concerns were expressed that although consultant supervisors were the first-line of support, the consultants were inadequately trained and struggled to provide this support. Consultants themselves are potentially unaware of the additional services that they could signpost their junior doctors to.
The findings from this study highlight that current support services are not well known and that doctors-in-training have struggled when they have tried to find information available. Signposting and increasing awareness, as well as information on the services, needs to be improved to increase accessibility for doctors-in-training. The stigma surrounding disclosing any difficulty in the medical profession remains prevalent. Whether it is a perceived or actual stigma is difficult to determine. This stigma needs to be tackled to encourage doctors to come forward and access these services. Senior clinicians need to demonstrate their confidentiality and impartiality to any information disclosed.
The fear regarding the lack of confidentiality of the support services demonstrates a lack of understanding and knowledge of these services. This identifies a need for further education on this matter. A possible solution for this is by utilising teaching sessions to advertise the services and simultaneously educate the doctors on the topic. Sixty per cent of the doctors-in-training proposed the best way to signpost support services are in teaching sessions, this is a potential next step in engaging doctors on the topic.
With the number of doctors-in-difficulty increasing, confidential and impartial services must be available and accessible to support doctors. The current system for signposting and referring doctors-in-training to support services needs to be reviewed to help increase awareness and prevent misconceptions. Improving knowledge and understanding of such an important yet stigmatising subject, will benefit doctors and improve their wellbeing, which will ultimately benefit patient care.
These results only focus on support services within the UK and the NHS. Therefore, some of the findings may not be relevant for an international perspective. Nonetheless, the problems of stress and burnout, and the stigma surrounding mental health in the profession, are reported internationally (Gerada, 2017). The solutions to these difficulties and increasing the support services for doctors, is an international challenge for all healthcare professionals. Developing confidential, accessible support, that is tailored to medical professionals, and that can be accessed without concerns of stigma or unwanted consequences, is not a unique need of the UK. As this study has demonstrated, even if the services exist, poor awareness and stigma can prevent them being utilised appropriately. Increasing discussions and trying to decrease the taboo of stress and burnout in doctors, combining it with further education on doctors' health and wellbeing is applicable and relevant to doctors everywhere.

Limitations
This study only reflects a small portion of the opinion of doctors-in-training within the UK. Although there was a good response rate, it is relatively small in comparison to the number of doctors approached to participate, and it is difficult to extrapolate to reflect the view of all the doctors-in-training within the UK. A poor response rate could potentially be related to doctors' feeling overwhelmed and stressed, with limited free time to complete the questionnaire; it is more likely to be due to questionnaire-fatigue and lack of time by doctors-in-training, which will decrease participation.

Conclusion
The stigma surrounding doctors asking for help is not unique to the UK. This study has demonstrated that the stigma remains prevalent within the medical setting and remains a barrier to accessing the support services. This stigma needs to be tackled to improve the health and wellbeing of all doctors. There is little benefit in increasing For all junior doctors, interns or residents, senior clinicians are frequently viewed as mentors and role models. Within the UK, doctors-in-training are always assigned a clinical consultant supervisor, but not an independent mentor. An impartial senior clinician, within or separate to the specialty, may be an appropriate method of increasing support for doctors-in-training whilst decreasing misgivings surrounding impartiality and confidentiality.
Protecting a clinician's health and wellbeing is as important as the continued development of their skills and knowledge: without their own health, they will not be able to look after the health of others.

Take Home Messages
From the study results, the following recommendations have been developed: Aim to decrease the stigma surrounding support services Teaching sessions focused on support services and how and when to utilise them Promote the discussion of doctors' health and wellbeing Independent support from senior clinicians should be incorporated into a doctors' training Improve signposting of existing services Emails Leaflets Advertisements within hospitals Medical educators require additional training to have a good working knowledge of the availability of support services and be able to advise doctors-in-training how to access them

Notes On Contributors
Dr Eleanor Nash is a GP trainee in Lincoln, and was previously as Educational Research Fellow for the Imperial College NHS Healthcare Lead Provider.

Appendices
These are support services, locally and nationally, that are tailored specifically for doctors:

Occupational Health
Confidential advice and support available to all staff within the hospital trust, for work related issues.

NHS Practitioner Health Programme
A free and confidential NHS service for any registered medical practitioner living or working within the London Deanery, with issues that may relate to a mental or physical health concerns or addiction problems, particularly where these might be affecting work. It is a self-referral service. Appointments can be arranged through the PHP website www.php.nhs.uk or 020 3049 4505

Occupational Mental Health Service (PHP HEE London)
A short-term interventions service for doctors requiring help with mental health or addiction difficulties, with onward referrals to longer-term therapies if it is required. A strictly confidential service available for all doctors with a current London training number. All new referrals are assessed within 48 hours. It is self-referral service, either by: Phone: 020 3049 4505 Email: england.phpadmin@nhs.net

Professional Support Unit London
Provides help for the professional development of clinicians within London, throughout all stages of their career. Includes careers advice and individual coaching and mentoring. It is a self-referral service. Contact the PSU team by Email: PSU@nwl.hee.nhs.uk Phone: 0207 866 3271 Confidential support service for doctors concerned about their use of drugs or alcohol. Telephone advice line 24hours a day and is available to friends, family and colleagues as well as an individual requiring support.

444 5163 or www.sick-doctors-trust.co.uk
Psychiatrists' support service, Royal College of Psychiatrists A free, confidential support and advice service for members, trainee members and associates of the Royal College of Psychiatrists who find themselves in difficulty or in need of support personally or professionally. It is a dedicated phone helpline. Phone: 020 7245 0412 Email: pss@rcpsych.ac.uk

Royal College of Obstetricians and Gynaecologists Mentoring Scheme
For obstetricians and gynaecologists who are experiencing difficulties in relation to their work. Mentors are Fellows or Members of the College who have had mentoring training.

Royal College of Surgeons Confidential Support and Advice Services for Surgeons (CSAS)
A confidential telephone line as a point of personal contact between surgeons, which is intended to offer a listening ear and act as an informed signpost to appropriate sources of advice and support.

Declarations
The author has declared that there are no conflicts of interest.