Pain Medicine Practitioners and Wellbeing

Transference - Counter transference
Action
“Burnout”
Red Flag Conditions
DHAS

“What do you do?”

“I am a Pain Medicine Specialist. I see pain patients.”

“How on earth do you do that? Don’t you find it really stressful, and depressing?”

It is widely considered, especially within the medical fraternity, that Pain Medicine practice is unpleasant, unrewarding, with special pressures which make it unattractive. Some are puzzled as to how someone could actually choose to work in the area.

To sustain a high standard of practice and personal wellbeing, including being able to enjoy and be stimulated by one’s involvement, it is necessary to skilfully manage the many stressors and strains for Pain Medicine practitioners. Most do have a very satisfying professional and personal life.

These pressures concern issues related to:

• General living
• Medical practice in general
• Pain Medicine specifically

• The style of patients’ presentations
• Recurrent confrontation with others’ pain and suffering
• Working with people with “incurable” disorders
• Administrative complexities
• Medico Legal issues

Patients’ Presentations

Particular aspects of pain patients’ presentations include:

• Multi-system disease with complicated and perhaps unusual disorders
• Multiple failed treatments
• Their disillusionment, hopelessness, anger and fear along with dependency, desperation and unrealistic expectations
• Problems with communication, trust, and respect
• Differing opinions including that of “the patient’s role

Transference - Counter transference

The finding that witnessing the suffering of others is a very powerful source of distress, for the observer as well as the individual involved, is increasingly recognised in studies of Post Traumatic Stress Disorder.

This stress is amplified when the observer has accepted a duty of care, and even more so when it seems as though they are unable to fulfil this duty of care. This might seem to be the case when the pain and suffering continues. (It is important to note however that this is not necessarily true, depending upon how the practitioner has defined the duty of care which they have accepted).

This situation stimulates reactions within the practitioner which at times has a very powerful influence on their perceptions, judgement, decision making, clinical and personal behaviours, even without this effect necessarily being apparent to the practitioner.

This can lead to changes such as excessive preoccupation with providing a successful treatment, withdrawal and subsequent under-treatment, or distortions of the treatment activities, such as responses that are not usually considered part of a therapeutic relationship – extending the boundaries.

The effects of increased stress are well documented in pain patients, with a higher than usual rate of emotional and psychiatric disorders and a higher than usual rate of suicide. This is also found in patients with cancer, depression and substance abuse.

The effects on Pain Medicine practitioners per se has apparently not been well studied, although the increased incidence of difficulties for anaesthetists, psychiatrists and those involved in Medico Legal conflicts, patient complaints, and difficult patients has been well documented. 

Action

It is necessary therefore that, if intending to continue working in the field, Pain Medicine Practitioners learn to look after themselves, as well as their patients.

An important early issue to consider is the moral and ethical aspects of devoting such precious resources (time, effort, finances etc) to oneself. Such an approach implies that at times a practitioner will be using resources for their own benefit, gratification and personal development, rather than to directly improve the wellbeing of their patients.

To be successful and to maintain one’s wellbeing, such an allocation must be given a sufficient priority. If not considered carefully, this can present a moral dilemma, as in our society the focus and encouragement is more on giving to others rather than taking for oneself, especially for health practitioners.

It is implied in the term “Professional” that the practitioner will put the interests of the patient before their own. But it is important to also be able to define appropriate boundaries. The moral dilemma may be resolved when it is considered that the personal care of the practitioner is in the patients’ interests as well. It is not advisable to have a general anaesthetic from a very tired or distracted Anaesthetist (similarly for any other discipline).

A practitioner must be able to develop a professional approach of putting the patients’ needs before their own in many circumstances, but should also develop a balanced approach, being able to correctly judge when it is appropriate to say “no”. Conspicuous occasions arise when a patient’s requests (demands) are inappropriate, unwise or unwarranted.

On other occasions it will be necessary for the practitioner to decline on the basis that they do not have the resources to provide adequately for the patient’s requirements. This may be the result of such practical issues as insufficient finances, equipment or service time for procedures, interventions and medications.

It may be however that the resources in short supply are time and energy, or sufficient emotional reserves to be able to retain composure when the practitioner is fatigued or distressed. It is a moral responsibility and professional requirement for the practitioner to develop the skills necessary to identify, and preferably prevent, but at least manage these situations so that harm will not occur to either the patient or the practitioner.

It is useful for a practitioner to have a good understanding of the means by which they might develop a satisfying and healthy lifestyle, individually, within their families, and within the general and medical community.

The ingredients of a good lifestyle are generally well known– a well-balanced diet, regular sleep and exercise, involvement in a range of stimulating and satisfying activities and interests. Although this approach appears, and essentially is, simple, it is one of the great paradoxes of modern life that success in achieving these objectives is remarkably elusive, complex, difficult and frustrating, especially for medical practitioners.

Perhaps it is because these goals are so simple that they are so elusive, as if the obsessional traits that are so common in successful professionals do not allow less than “perfection”, and then even some more, with satisfaction, reward and merit too often linked with degrees of difficulty and amount of effort rather than the quality of the result.

There is a special excitement and sense of challenge, associated with a release of adrenaline and hyper-arousal that comes from working close to the margin between success and failure. It is exhilarating and satisfying if a favourable result is achieved. This style is more likely to be seen as requiring personal attributes such as courage, fortitude, and ability to persevere despite adversities such as fatigue, fear, doubt, criticism, fear of failure, and personal hardship.

These examples are much more conspicuous and likely to be rewarded by the community than well worthwhile outcomes achieved in a more mundane manner. In a manner that is not always logical, the degree of danger and risk is often associated in the community mind as being equivalent with value.

Perhaps this is because on some very notable occasions, these personal attributes are required to produce a result that is necessary. However the converse is often accepted i.e. by working in such a style therefore the result must be valuable. Even though this is not necessarily the case, the notion is seductive.

A medical culture has developed which has a considerable impact on the lives of the practitioners. In earlier times, medical resources were less available and doctors worked longer hours to service community needs.

In recent times it is apparent that medical working habits have not kept pace with changes in community standards, particularly with regard to working hours or the balance between work, personal and family life. Conflicts of interest abound. Change is likely to continue, requiring a corresponding process of continuing adaptation.

There are too many casualties that can reasonably be attributed to practitioners failing to adequately manage the stresses of medical practice. The development of a major physical and psychiatric disorder is most obvious although the manifestations are by no means limited to these phenomena.

Less obvious but also important are the casualties in terms of relationship and family breakdowns, dysfunctional families, financial failures, limitations on professional practice and, importantly, the loss of capacity to enjoy a satisfying life. The latter is not merely a matter of personal indulgence but an important early indicator of loss of health and well-being.

Such developments at times have an impact on patients, as the result of impaired clinical judgements and perhaps by impaired personal judgement with respect to relationships, such as with boundary violations.

Consistent with good medical practice, a preventative approach is the ideal, closely followed by early intervention. Awareness of the process by which these predicaments develop helps. The development of “burn out” is an example.  

“Burnout”

Medical practitioners enter the profession after successful academic careers following an increasingly rigorous process of selection, with many able applicants not included. Thus, from a very early stage of professional life, intense competition is required, even if this is not intended by the organisers.

Medical practitioners are well regarded in the community and have a reputation for being keen, enthusiastic, altruistic, self-sacrificing, generous, hard working, interested, self-motivated, with high personal and professional standards, leaders and community advocates, tolerant, uncomplaining, enduring and persevering.

They are selected for their intelligence, academic prowess and learning ability. Especially in more recent times there is an expectation for practitioners to have high levels of communication skills, good relationships, and balanced activities – as long as all patients are seen promptly and comprehensively!

The orientation into medical practice of the intern year is almost synonymous with anxiety, humiliation, mistakes, rapid learning, confusion and fatigue. Unfortunately many also have traumatic experiences. The degree of trauma depends on the actual events and the consequences, but also their expectations and the quality of subsequent support.

Even without a traumatic “index event,” when considerable pressure persists without a break for recovery, it is common for there to be a gradual waning of the initial enthusiasm and excitement.

Effort is required to continue when it may have previously been easy. The “adrenaline” drive which stimulated energy – the higher level of arousal experienced when one is willing, keen, excited and expectant of a good return for effort - has gone. This varies with the situation, but more specifically with their perception of their situation, their circumstances, and the environment in which they live and work.

For some, when it seems that rewards are not going to be forthcoming, disillusionment sets in. Helplessness, hopelessness and “losing” are followed by disappointment, despair, anxiety and anger – a grief reaction that accompanies loss of something important.

The cause-effect relationship between the Beliefs Systems of our pain patients and their Outcomes is almost certainly the same for attending Pain Practitioners. Their sense of achievement and actual well-being are likely to be determined by the goals they accept for themselves in their interactions with their patients. Skilful Goal–setting is as essential for the practitioner as it is for the patient – “Take your own medicine.” This includes accepting limits to their own abilities, no matter how much they may want to do more for their suffering patients.

If a practitioner has been drawn into setting targets for themselves based on what they want rather than what can actually be achieved, they are at risk. If they do not achieve these goals, the effort to maintain the energy to persevere is much greater, without the optimism and enthusiasm that comes from success to drive it along.

Without some intervention, the process of burnout continues and the risk of developing more conspicuous emotional disorders increases considerably. There is an associated risk of complications from attempts to avoid these consequences, for example by the inappropriate use of alcohol, illicit drugs, therapeutic medications, or other clumsy measures to seek pleasure, satisfaction, a sense of calm and a peace of mind.

Medical practitioners, with the emotional distancing and suppression that is a feature of the obsessional traits which are desirable and encouraged, often ignore such developments, even the presence of disorders which they would actively treat in patients presenting to them. These include Major Depression, Anxiety Disorder, common fatigue, Post Traumatic Stress Disorders, Panic Disorder, alcohol and drug abuse. 

Red Flag Conditions

Some practitioners, who are usually acting with integrity and good intentions but very poor insight and judgement, may only come to attention for the first time after development of a “red flag” condition. In this context, a red flag condition can be defined as one in which an actual impairment has developed which prevents safe practice. When red flag conditions are present, patients are at a level of risk which is unacceptable from a professional point of view.

These conditions (e.g. severe depression, anxiety, substance abuse, cognitive impairment, severe fatigue) require the practitioner to immediately cease practice. They may need to obtain effective treatment, and to enter a rehabilitation program before they can resume practise, although some problems, such as fatigue may simply need a good sleep.

When undertaken voluntarily in an appropriate manner, with compliance with proper recommendations, this does not require notification to authorities such as a Medical Board. When a practitioner is not willing to undertake such an approach, a more coercive approach involving authorities such as the Medical Board should be arranged. This may require the active intervention of a colleague who is skilled, experienced, and confident with respect to management of such difficulties and interventions on behalf of professional colleagues.

Red Flags (immediate leave)

• Gross Incompetence
• Professional Misconduct
• Substance Abuse (current)

Intervention Who?

• Skilled
• Experienced
• Independent 

Intervention When?

Earlier rather than later.

DHAS

Confidential advice regarding such difficult situations can be obtained from the Doctors Health Advisory Services (DHAS). These are services in each State and Territory, provided at no cost, established by medical practitioners acting in a voluntary capacity, whose sole function is to assist medical practitioners that may be having difficulties getting assistance with a problem that has arisen with their health.

Doctors are more reluctant than many to consult their colleagues. The services operate by contact with colleagues who take turns in an on call roster, who are interested, trained and skilled in treating other medical practitioners, and who provide advice, usually by telephone initially. (In some cases, services are also available for use by Pharmacists, Dentists, and Veterinary Surgeons) DHAS recognises the importance of maintaining very strict confidentiality. They are independent of other agencies (Health Departments, Medical Boards, AMA) although they operate with their knowledge and strong “in principle” support. (See attached list of contacts for DHAS in each State and Territory.)

Many of the colleges, hospitals, and other professional organisations have similar organisations which provide support to colleagues experiencing difficulty.

DHAS

• confidential
• independent
• advisory
• voluntary
• no charge
• 24/7 On-Call Page
• G.P. on call phone assessment
• Specialist on call panel
• “3 wise men” visit
• recommendations, referral

Other Organizations

• Professional - (Colleges)
• Directors of Clinical Training
• Medical Education Officers
• Medical Indemnity Insurers
• Health Rights Commission
• Drugs of Dependence Dept
• Medical Board
• Health Insurance Commission

Yellow Flag Conditions

Prevention is preferable. If not, early intervention is desirable. Consider this when “yellow flags” are present. Yellow Flags are indicators of a risk of developing disabling problems, or an early stage of development. No actual impairment or unacceptable risk has yet become apparent.

The presence of a risk is not the same as an impairment. A practitioner may be actually be functioning quite well, even while the likelihood of impairment occurring is high. For example, someone who is severely fatigued, worried or even intoxicated may still be able to perform routine, well known activities successfully, but if they are required to take an unfamiliar decision or action they may lack the required skill and may even be dangerous in this situation.

Being aware of these factors allows monitoring and early intervention. A single risk factor (or Yellow Flag) or one that is relatively minor may be tolerated, depending on the situation. Judgement is required as to when the accumulation of these risks is approaching an unacceptable overall degree of risk, necessitating intervention.

Situations in which problems may occur include:

a. Common stressors of usual practice

b. Critical incidents

c. Life adversities unrelated to practice

d. Concurrent but independent medical and psychiatric disorders 

A common yellow flag situation exists when there is not a good basic healthy lifestyle. This includes adequate balanced diet and eating habits, sleeping patterns, a balance of work, rest and leisure activities.

Increasing isolation is a frequent feature of doctors in difficulty. This occurs with geographical isolation, but even in busy metropolitan cities or within a busy hospital, by the failure to maintain professional and social networks. This can be overcome by membership of professional organisations, attendance at seminars and educational activities, as well as informal occasions during the working week. Geographically remote practitioners can minimise their isolation by attendance at conferences, as well as by the skilled use of communication techniques, particularly telecommunication.

Most medical practitioners have not had specific training with respect to modern management practices and yet are required to organise and administer complex organisations with substantial financial budgets, and responsibility for many staff and large patient populations. Time management becomes an issue and one that is frequently noted to be a problem for those in difficulty.

An important professional responsibility is developing good judgement as to the limit of one’s own ability, when to accept responsibility for ongoing care in relation to particular conditions and when to obtain assistance, such as by referral.

The acquisition of skills and high levels of confidence in clinical work by obtaining high quality training is a most important factor in reducing subsequent professional stress. It is also important for the practitioner to arrange appropriate support, both within their clinical work and with colleagues. Particularly with respect to highly developed skills, a “critical mass” of several people with similar skills is required to be able to successfully manage challenging complex problems over a long period of time without undue personal and professional risk.

A major development in Pain Medicine was the practice, instituted by John Bonica, of having meetings of those involved in the clinical care of the patient on a regular basis. Meetings offer the joint wisdom of the multidisciplinary approach with respect to the clinical problems at hand, as well as mutual support in the context of challenging problems, educational opportunities for all and stimulation for professional development. They continue to be a hallmark of good Pain Medicine practice and a requirement to be satisfied by those seeking to be regarded as Pain Centres.

Along with the acquisition of particular clinical skills, a certain aptitude and attitude to the commonly presenting issues and patients is required to avoid difficulty.

Good practitioners will recognise the occasions when seeking a second opinion, extra support, or discussion about a clinical situation will add to the patient’s care, as well as to the practitioner’s wellbeing. This is much easier when it is part of routine practice, with well developed lines for reciprocal communication between colleagues.

Established practices minimise the stress of having to decide whether to take such action on many occasions, and become even more useful when there has been a “critical incident.” The potential for embarrassment, nervousness, and humiliation do not become an issue which might inhibit the practitioner from obtaining or providing help in such important times. The development of peer review groups contributes significantly to disclosure and acceptance of personal uncertainties as being understandable, reasonable aspects of practice, detracting from the inappropriate, unhelpful, and unhealthy development of a concept that a doctor has to be perfect.  

Yellow Flags – attitude

• Late
• Untidy
• Disorganized
• Poor documentation
• Poor communication
• Incomplete work
• Avoids supervision
• Inflexible, rude, aloof
• Anxious
• Inattentive
• Inappropriate behaviour
• Inappropriate relationships
• Conflict
• Mistakes

Yellow Flags - personal health

• Tired
• Poor concentration, memory
• Sleep disorder
• Difficulty relaxing
• Disillusioned, demoralized, cynical
• Sick leave
• Self prescribing
• Physical illness
• Psychological illness
• Personality dysfunction
• PH illness/abuse/ disadvantage 

Yellow Flags - clinical

• Difficult patients
• Critical incidents
• Support failures
• Work load

(right doctor, patient, place, time)

Yellow Flags – life style

• Balance - work, interests, social, spiritual
• Personal care, diet, physical activity
• Substances - nicotine, caffeine, alcohol, illicit
• Isolation –rural, professional, social
• Financial
• Relationships
• Legal
• Family/social - illness, expectations 

Yellow Flags – practice issues

• GP
• Private Health Insurance
• Disability Insurance
• Superannuation
• Professional development, accreditation
• Professional membership, support (AMA)
• Medical Defence
• Regulation Authorities
• Safe hours
• Recreation Time
• Workload
• Prioritization
• Emergencies
• Response time
• Staff concerns, morale
• Practice Health -numbers, remuneration
• Complaint management
• Debt management

The Specific Issues of Pain Medicine

Involvement in the field of Pain Medicine can be particularly challenging in regard to stress. The patients themselves have undergone a series of stressful disappointments, their lives have been seriously disrupted and are likely to never be the same and they are likely to endure at least some form of continued suffering, even if this is significantly reduced by the interventions of the practitioners.

The demographic profiles of those attending Pain Clinics demonstrate that the patients attending are distinguishable from those in the general community with pain by being significantly predisposed to having difficulties dealing with the adversities they are presented with.

The risk factors for development of depression, anxiety, substance abuse and other significant sources of dysfunction are significantly over-represented in the populations of Pain Clinics when compared with the general population. They more frequently have histories of neglect, abuse, illness, substance, illiteracy, limited education, personal and family dysfunction.

This is particularly important because, while there is a significant psychosocial workload for pain practitioners, there continues to be a serious problem in the lack of adequate psychological services to provide for our pain patients. This is particularly an issue when the patients themselves are more likely to use a somatic focus of attention, to be reluctant to accept psychological intervention and to have expectations of physical medicine and the Pain Medicine practitioner which are unlikely to be satisfied. They are very often irritable, and with limited social support in their usual environment. Their usual treating practitioners will often be stressed and having difficulty with persisting problems.

There is continuing debate in many areas of Pain Medicine practice, such as the role of opiate medication, of interventions, the use of scarce resources, and limited funding, complicated by tension with third party payers and those involved in the litigation process.

Consistent with the general measures that have been found to be useful in minimising stress for medical practitioners in general, it is useful for those involved in Pain Medicine to be sure to establish and maintain healthy styles of living

• Ensure they have obtained and continue high levels of training, and high standards of medical practice
• Monitor and be prepared to intervene early with the development of “yellow flag” features either personally or with colleagues
• Develop and maintain useful stress management strategies, individually and with colleagues
• Develop and use specific responses in the advent of critical incidents
• Be aware of and use resources available in the event of manifest disorders
• Be aware of and use appropriate rehabilitation strategies in recovery
• Be aware of and use the resources of those with expertise and experience to advise and assist those once such disorders have presented as a problem

Prognosis - excellent

• Intelligent
• Educated
• Experienced
• Independent
• Motivated
• Valued 

References

In Sickness & in Health. Ed John O’Hagan, John Richards. Publ DHAS (NZ) 1997.

12 Steps for Medical Professionals. Dr M Kaufmann, OMA Physician Health Program Ontario Medical Review 11/99, 66(10) p40-41

The Student & Junior Doctor in Distress – Our Duty of Care. MJA, Vol 177, Supplement, 1/7/02.