Returning to training after time taken off due to stress
There is no working environment as uniquely stressful as that as a hospital. Though it is well known the NHS as an institution is under strain, often many forget how that is shared by every employee within it. As morbidity increases but spending declines, it is the staff that are pushed to make up the shortfall. Junior doctors often go entire shifts without eating or drinking and inconsistent rotas makes sleep hard to come by. Report by The King’s Fund suggests as many as 80% of Junior Doctors feel ‘excessively stressed’ whilst training. This figure makes both the huge decline in those progressing to speciality training and rise in those taking time out due to stress unsurprising.
When the daily grind causes nerves to fray, space from the clinical environment can make all the difference. It is essential to remember that taking time away for yourself is not an act of selfishness. It is far better to do this and return to your training than to allow self-doubt and stress to escalate until you lose your passion for practice, and even self-worth, altogether. This time away is an opportunity to develop coping techniques and deepen empathy, essential for any successful career in medicine. This time out is a sign of personal development, not of failure.
Remember, there is absolutely no reason that history should repeat itself upon return. Indeed, it is important to remember that taking the time now to learn how best to manage stress could make you an asset in supporting others in the future. See below a compilation of resources available to you during, and after, time spent away:
The DSN was set up in 1996 to provide physicians and medical students alike with peer-based support for any concerns with their own, or another’s, mental health. This service is entirely confidential and provides an opportunity to find support within your own community. Only a doctor can appreciate the immense expectation that comes from training or practicing within the medical field. The benefit of sharing your experience and struggle with a like-mind is two-fold: it can provide a long-term source of support but also keep you feeling integrated, and up to speed, with your profession whilst away from training. Recovery and resilience need not be done alone; research shows peer support to be invaluable for both, with self-disclosure being a key part of lasting improvement. The DSN site provides resources, blog material and signposting to relevant events and meetings.
The PHP was designed to facilitate access to counselling services for medical professionals who, due to the inconsistency of their work, could not do this via conventional routes. This service guarantees absolute confidentiality – often difficult when a medical professional yourself. However, be assured your information goes no further than the PHP service itself. This service has seen and successfully treated thousands of practitioners (both fully qualified and in training), though it is important to add that whilst in training you will only have access to 4 sessions of treatment before being signposted onwards if appropriate. Furthermore, if you live outside of the London area, only NHS referrals will be accepted for this service as self-referrals will not be accepted.
Social media has been taking on an increasingly pastoral role of late, with many preferring to self-disclose on these platforms than face-to-face. This is particularly true of experiences of mental illness that still remain highly stigmatised. The Facebook group ‘Tea and Empathy’ is a national, peer-to-peer support network specifically designed for NHS practitioners, though is also accessible to any other medical practitioner. This site allows for anonymous posting via administrators and includes closed regional groups. Peer-to-peer support can be offered through private messenger and is completely confidential. This site has branched out internationally, especially valuable if you are currently on or are planning an Out Of Practice Experience.
This organisation provides a variety of opportunities to obtain and provide support for doctors in training or currently practicing. This website specialises in both emotion-focused and problem-focused support, providing opportunities to receive psychological care, financial support and advice on a range of topics. This site is by far the most pragmatic available with resources on everything from how to handle a difficult landlord to considering whether an alternative career might be right for you. This site is helpful in good times and in bad, as useful in preventing emergencies as responding to them. Content here is produced by medical professionals from all specialisms and levels of seniority – you’re certain to find something relevant to you.
If you believe more regular, face-to-face support might be best for you, this site is best able to signpost you to counselling and psychotherapy professionals within your area. When it comes to mental health, there really is no substitute for intensive, professional, one-to-one treatment. Taking time out of your training means you can dedicate yourself fully to regular therapy without fear of conflicting work demands.
DocHealth is similar to The Royal Medical Benevolent Fund described above, however it provides either face-to-face support from senior clinicians for those within the London area or skype consultations for those further afield. This service offers up to six sessions, though if further support is required, DocHealth will assist in finding you the best care possible. This service is exclusively by self-referral and, as such, shares no information with your employer. Fees are salary-dependent and services are set to expand within the coming year.
Meditation isn’t something that may have crossed your mind, however the research supporting the efficacy of as little as 10 minutes of mindful breathing a day is staggering. This app (mostly free of charge though subscription options are available) provides detailed guides on how to make mindfulness work for you – you may find their stress management guide particularly useful. Headspace has been demystifying mindfulness for millions of subscribers and for a price of just 10 minutes a day, you have so much to gain in terms of mental resilience and effective stress-management, even in the most difficult of circumstances. If right for you, Headspace stands as an opportunity for you to explore and strengthen your stress response both during and after your leave.
Case study: Kate
‘I was worried that if people knew I had been off work with a mental health problem that they might judge me in some way or consider me to be “weak”. I was anxious about how other junior doctors would feel about me as I had left a rotation short of medical cover. I was worried that my performance would be judged if people knew why I had taken leave. At the time, I did not feel well supported on returning to work by personnel or by senior staff.
I was protected from working nights for my first couple of months back at work which was a decision taken by occupational health. Whilst this was beneficial in terms of my recovery it was sometimes criticised by other junior doctors on the rota who were asked to cover for me. The biggest challenge was caring for dying patients following the death of my step-daughter, I do not feel that this was given due consideration by my seniors on certain placements.
I have gradually become used to dealing with patients needing palliative care again although there are always going to be patients who affect you more than others. When this happens, I take time to reflect on it and make sure I do some “housekeeping” so that I am fresh for seeing the next patient. I have spoken to everyone who works in my practice about my bereavement and they are supportive and sympathetic if I ever have to break bad news.
I had a support group separate from work which I attended while unwell and during my bereavement leave. This was a charity run group who support anyone with the same mental health issue as myself. I found it helpful to have people outside of work that I could talk to about the work situation knowing that it would all be kept confidential.
I think supervisors should arrange additional meetings with people returning to work and occupational health need more resources to be able to offer tailored support for people returning to work. I think bereavement counselling should be available through hospital occupational health departments given that hospital employees will often have to deal with death and dying patients and their relatives which can be very distressing after a significant bereavement.
I would probably advise to wait until [you] feel ready to return and then wait for an additional month. I felt I was straight back to needing to be completely well and on form as no consideration was given to my recent return.’
As you can see from Kate’s experience, the transition back into training is far from challenge-free. When self-doubt and stress are at the root of why time has been taken away, it’s essential to manage this throughout your return. But remember, this as much a responsibility of your Deanery as it is you.
What your Deanery can do for you
It is possible your Deanery may fund counselling services for Junior Doctors directly. Remember, any concerns about confidentiality are unfounded – you will be treated like any other patient. Furthermore, the ability to have counselling nearby your own Trust shouldn’t be underrated – this will be an asset for ongoing support. Enquire with your educational supervisor if your Deanery funds such support.
Organising ‘top-up’ training and CPD-approved learning during time away and return
Though formal ‘Keep In Touch’ (KIT) days are primarily only available to those on paternity leave, opportunities do exist to ensure you feel prepared to return to the workplace after time spent away due to stress. Online resources are incredibly valuable in this; see below some relevant examples taken from the British Medical Journal Learning Portal.
Contact your Deanery to enquire if any in-person learning is available (such as ‘bootcamps’ or accelerated learning schemes’) or if a KIT day could be arranged during your time away. Additionally, consider enrolling on London School of Medicine’s ‘Springboard’ Course. This is one-day course offered twice each year for those looking for both practical and pastoral support prior to returning to training. Details on this can be found here.
Provide a designated mentor/ coach
In 2016, The Advisory, Conciliation and Arbitration Service (ACAS) agreement within the Junior Doctors Contract committed the Secretary of State to fund mentorship for junior doctors when returning to training. Though this service is not yet universally accessible, it is worth contacting your Deanery as to whether a Senior Consultant with experience of stress-related leave during training could be made available for advice and ongoing support. This may also be available in a group setting.
Arrange a supernumerary period or phased return
This refers to a period of intensive and supervised practice whilst coming back into training, including a variety of focused learning activities under direct observation. Contact your educational supervisor to see if any such opportunities exist, perhaps alongside other returners. Such support will be most beneficial on your first on-call rotas. It is important to be honest about your needs in this, particularly the level of intensity you need in this support. Asking for help saves your confidence and, in turn, helps you keep saving lives. It may also be worth considering Less Than Full Time Training – at least initially – upon returning after stress-related leave.
Ensure first patient lists are as straightforward as possible
The life if a junior doctor is notoriously changeable, with every patient seemingly more unpredictable than the next. However, if you feel comfortable doing so, make sure your educational supervisor is aware of the nature of your stress-related leave and see whether your patient lists can be tailored to your needs at this time. At least in the beginning it may be useful to respond to routine cases to build your confidence back within the clinical setting. Make sure you treat yourself with compassion at this time – work up to more challenging cases rather than over-stretching yourself at the beginning.
Signpost to centralised support in local HEE office
Check in to locate your local HEE office. They may be able to provide more mental health specific assistance or advice relevant to your area, both geographically and your medical specialism.
Remember, The Hippocratic Oath to ‘first, do no harm’ is as much about you as your patient – do not put yourself, and your mental wellbeing, second.