Trainee doctors' views on mental illness among their peers and access to support services.

The mental health of doctors in training raises two major concerns, first that they are reluctant to, and have difficulty accessing, treatment, and second that undiagnosed and untreated doctors expose patients to unacceptable risks. Four 1-h focus groups were held, with participants' views explored on their observations about mental health as an issue amongst doctors, their personal knowledge of, and preferences for, sources of support, and other related factors. Transcripts were analysed using a thematic framework approach.

'If you're crying this much you shouldn't be a consultant': the lived experience of UK doctors in training with mental illness.

There is some disagreement in the literature whether doctors in training suffer more from mental illness than an age-matched population. However, mental illness among doctors in training is a cause for concern because of the dual problems of reticence about accessing help and the clinical risk of doctors practising while mentally ill. The belief that is widely held among doctors in training is that to disclose a mental illness would be seen as weakness and may damage their career. A biographical narrative interview technique was used that enables the informant to tell the story of a painful episode in their lives in their own way and in their own words. Interviews were transcribed, and a thematic framework developed by consensus and then used to analyse all of the narrative interview data. Four major themes were detected: (1) Doing the job while ill, (2) Sick leave (initiating, being on, returning from), (3) Interaction with the employer; and (4) Sources of support. Practising while mentally ill caused significant challenges. Interviewees did the minimum, hated having to make decisions, and failed to study for postgraduate exams. All interviewees took sick leave at some stage. However, most were reluctant to do so. Being on sick leave meant being absent from the career that identified them and running the risk of being perceived as weak. Returning to work from sick leave was often difficult. Back to work interviews and occupational health support did not always happen. This study demonstrates the suffering encountered by doctors in training with mental illness. The job becomes much more difficult to do safely when mentally unwell. A great deal of presenteeism exists, which inhibits doctors in training from getting the medical care they need. It is imperative that confidential medical care is made available to doctors in training, which is sufficiently distanced from their place of work.

Medical Student Beliefs about Disclosure of Mental Health Issues: A Qualitative Study.

In 2012 the United Kingdom's General Medical Council (GMC) commissioned research to develop guidance for medical schools on how best to support students with mental illness. One of the key findings from medical student focus groups in the study was students' strong belief that medical schools excluded students on mental health grounds. Students believed mental illness was a fitness to practice matter that led to eventual dismissal, although neither personal experience nor empirical evidence supported this belief. The objective of the present study was a deeper exploration of this belief and its underlying social mechanisms. This included any other beliefs that influenced medical students' reluctance to disclose a mental health problem, the factors that reinforced these beliefs, and the feared consequences of revealing a mental illness. The study involved a secondary analysis of qualitative data from seven focus groups involving 40 student participants across five UK medical schools in England, Scotland, and Wales. Student beliefs clustered around (1) the unacceptability of mental illness in medicine, (2) punitive medical school support systems, and (3) the view that becoming a doctor is the only successful career outcome. Reinforcing mechanisms included pressure from senior clinicians, a culture of "presenteeism," distrust of medical school staff, and expectations about conduct. Feared consequences centered on regulatory "fitness to practice" proceedings that would lead to expulsion, reputational damage, and failure to meet parents' expectations. The study's findings provide useful information for veterinary medical educators interested in creating a culture that encourages the disclosure of mental illness and contributes to the debate about mental illness within the veterinary profession.

Support for medical students with mental health problems: a conceptual model.

OBJECTIVE: Medical students experience higher prevalence of mental illness than age-matched controls and are less likely to access appropriate help when this happens. The aim of this study was to determine the range of strategies deployed by medical schools to support medical students with mental health concerns and to use this to identify distinct categories. METHODS: Websites and documents relating to all 32 UK medical schools were looked at, as were reports for quality assurance visits carried out by the General Medical Council (UK). A structured telephone interview was carried out with medical schools. Support services were examined by tracing the path that might be taken by a hypothetical student with mental health concerns of varying severity, seeing what was required and what was available at each stage. RESULTS: A range of support strategies is available to most medical students both from their medical school and from generic services in the university. Medical students will usually first contact a personal tutor or a senior member of faculty or be contacted by them as a result of concerns raised either via performance issues or by another student. While individual support interventions are mostly based on evidence of effectiveness, there is no unifying theory in terms of what constitutes effective support. To enable analysis of support interventions and comparison across providers, a six-stage conceptual model of prevention was developed. The six stages are the following: prevention, identification, referral, escalation, treatment, and reintegration. CONCLUSIONS: The staged model, derived from analysis of existing interventions, provides a framework for evaluation of current provision and comparison of different methods of delivery. Moreover, it provides a framework for future research.

Patchy 'coherence': using normalization process theory to evaluate a multi-faceted shared decision making implementation program (MAGIC).

BACKGROUND: Implementing shared decision making into routine practice is proving difficult, despite considerable interest from policy-makers, and is far more complex than merely making decision support interventions available to patients. Few have reported successful implementation beyond research studies. MAking Good Decisions In Collaboration (MAGIC) is a multi-faceted implementation program, commissioned by The Health Foundation (UK), to examine how best to put shared decision making into routine practice. In this paper, we investigate healthcare professionals' perspectives on implementing shared decision making during the MAGIC program, to examine the work required to implement shared decision making and to inform future efforts. METHODS: The MAGIC program approached implementation of shared decision making by initiating a range of interventions including: providing workshops; facilitating development of brief decision support tools (Option Grids); initiating a patient activation campaign ('Ask 3 Questions'); gathering feedback using Decision Quality Measures; providing clinical leads meetings, learning events, and feedback sessions; and obtaining executive board level support. At 9 and 15 months (May and November 2011), two rounds of semi-structured interviews were conducted with healthcare professionals in three secondary care teams to explore views on the impact of these interventions. Interview data were coded by two reviewers using a framework derived from the Normalization Process Theory. RESULTS: A total of 54 interviews were completed with 31 healthcare professionals. Partial implementation of shared decision making could be explained using the four components of the Normalization Process Theory: 'coherence,' 'cognitive participation,' 'collective action,' and 'reflexive monitoring.' Shared decision making was integrated into routine practice when clinical teams shared coherent views of role and purpose ('coherence'). Shared decision making was facilitated when teams engaged in developing and delivering interventions ('cognitive participation'), and when those interventions fit with existing skill sets and organizational priorities ('collective action') resulting in demonstrable improvements to practice ('reflexive monitoring'). The implementation process uncovered diverse and conflicting attitudes toward shared decision making; 'coherence' was often missing. CONCLUSIONS: The study showed that implementation of shared decision making is more complex than the delivery of patient decision support interventions to patients, a portrayal that often goes unquestioned. Normalizing shared decision making requires intensive work to ensure teams have a shared understanding of the purpose of involving patients in decisions, and undergo the attitudinal shifts that many health professionals feel are required when comprehension goes beyond initial interpretations. Divergent views on the value of engaging patients in decisions remain a significant barrier to implementation.

Why do clinicians not refer patients to online decision support tools? Interviews with front line clinics in the NHS.

OBJECTIVE: To assess whether clinical teams would direct patients to use web-based patient decision support interventions (DESIs) and whether patients would use them. DESIGN: Retrospective semistructured interviews and web server log analysis. PARTICIPANTS AND SETTINGS: 57 NHS professionals (nurses, doctors and others) in orthopaedic, antenatal, breast, urology clinics and in primary care practices across 22 NHS sites given access to DESIs hosted on the NHS Direct website. RESULTS: Fewer than expected patients were directed to use the web tools. The most significant obstacles to referral to the tools were the attitudes of clinicians and clinical teams. Technical problems contributed to the problems but the low uptake was mainly explained by clinicians' limited understanding of how patient DESIs could be helpful in clinical pathways, their perception that 'shared decision-making' was already commonplace and that, in their view, some patients are resistant to being involved in treatment decisions. External factors, such as efficiency targets and 'best practice' recommendations were also cited being significant barriers. Clinicians did not feel the need to refer patients to use decision support tools, web-based or not, and, as a result, felt no requirement to change existing practice routines. Uptake is highest when clinicians set expectations that these tools are integral to practice and embed their use into clinical pathways. CONCLUSIONS: Existing evidence of patient benefit and the free availability of patient DESIs via the web are not sufficient drivers to achieve routine use. Health professionals were not motivated to refer patients to these interventions. Clinicians will not use these interventions simply because they are made available, despite good evidence of benefit to patients. These attitudes are deep seated and will not be modified by solely developing web-based interventions: a broader strategy will be required to embed DESIs into routine practice.