From the Editor
Governments in Canada and across the west have committed themselves to spending more on mental health care. But how should we spend this new money? Should we focus on people earlier in the illness experience? Should we fund evidence-based treatments like CBT? Should education campaigns aimed at reducing stigma be the priority?
UK Prime Minister Theresa May recently announced new mental health reforms. She explained: “It’s time to rethink how we tackle this issue, which is why I believe the next great revolution in mental health should be in prevention.” In this week’s first selection, we look at Prime Minister May’s announcement, and we ask: should Canadian policymakers look to 10 Downing Street for mental health ideas?
10 Downing Street
Also, this week, we consider an interview with Dr. Treena Wilkie, CAMH’s Deputy Physician-in-Chief for Medical Affairs and Practice, who talks about physician burnout. Dr. Wilkie closes with a few words of advice for our colleagues: “There’s help available.”
And, in our third selection, The New York Times investigates deaths in an American hospital. The article isn’t about psychiatry (it’s about health care). But could it be about the problems in your hospital?
This will be the last Reading of the academic year. To my young colleagues who have just graduated: I hope you enjoy your careers in psychiatry as much as I have.
There will be no Reading next week. Should you fall off the distribution list of these Readings, please don’t hesitate to pop me an email.
Selection 1: “PM launches new mission to put prevention at the top of the mental health agenda”
Gov.uk, 17 June 2019
It’s time to rethink how we tackle this issue, which is why I believe the next great revolution in mental health should be in prevention.
In the waning days of her premiership, UK Prime Minister Theresa May focuses on mental health. She has an ambitious goal: prevention.
The wide-ranging package of measures will make sure people have the confidence and skills they need to identify mental health issues before they become critical, particularly in young people.
The speech (and the press release) goes into detail. “Today’s announcement means schools, social workers, local authorities and healthcare services will receive extra support to make sure people know how to promote good mental health in the same way that they look after physical wellbeing.”
The government proposes several measures:
- “training for all new teachers on how to spot the signs of mental health issues, backed up by updated statutory guidance to make clear schools’ responsibilities to protect children’s mental wellbeing
- “all 1.2 million NHS staff encouraged to take suicide prevention training from the Zero Suicide Alliance, which we have already committed to support with £2 million of government investment
- “support for school mental health leads so they can help children struggling with self-harm and risk of suicide
- “access to world-class teaching and training materials for all teachers to use in classrooms to meet the new requirements for mental health education for all primary and secondary pupils
- “extra funding to support local authorities to strengthen and deliver local suicide prevention plans so that they better meet the needs of the people they serve
- “updated professional standards for social workers across England to increase their knowledge and skills when helping those with mental health issues…”
The effort has received positive feedback, including from psychiatrists. Of course, there is the larger question of whether this announcement results in much change. Prime Minister May is leaving 10 Downing Street, and her successor may choose not to follow through on any of her commitments.
Still, we can mull the proposals themselves. Prevention is an ambitious goal – we clinicians are all too familiar with the impact mental illness has on patients and their families, and prevention is a worthy goal. Strip away the rhetoric, and the emphasis of May’s ideas is on school-aged children, and educating educators to spot problems after they may have started but before they have progressed (secondary prevention, to use the public health term); she also proposes more funding for suicide prevention. It’s difficult not to like these ideas, but without a strong commitment for measurement and outcomes, is Prime Minister May’s last big announcement destined to be a big bust (like, say, ThriveNYC)?
Selection 2: “What all physicians should know about physician burnout”
Treena Wilkie and David Gratzer
Quick Takes Podcast, 19 June 2019
I started watching the clock during the day, and thinking more about, well, how many more patients? How much time is left in my day? I knew I could get through it, but I didn’t know how I would feel at the end of the day. And then that just started getting earlier and earlier in the day. Five minutes into the day… I was thinking ‘oh boy, it feels like I’ve been here a while already, and I have a long day to go and how am I going to do this?’
For my latest podcast, I talk with Dr. Treena Wilkie about burnout. I also interview Dr. Murray Erlich (quoted above), who discusses his own experience with burnout.
A few highlights from the conversation with Dr. Wilkie –
On defining burnout:
Physician burnout is a syndrome that is characterized by three things: emotional exhaustion, depersonalization, and a reduced sense of personal accomplishment.
Emotional exhaustion is usually described as feeling used-up at the end of the day. So, at the end of the day, a physician doesn’t have anything more from an emotional perspective that they can offer to patients… Depersonalization is described as starting to view patients as objects rather than human beings. And the reduced sense of personal accomplishment is really feelings of ineffectiveness. So, feeling as though you can’t be helpful to other people – even though you may be doing the same things that you were always doing.
On the difference between burnout and depression:
Depression is a defined mental disorder in the DSM, with defined criteria, that may have multiple different factors which could be related to the precipitation of an episode. I think, again, burnout is a very specific description related to prolonged exposure to occupational stress.
On the impact on the system:
Physicians who are experiencing burnout exhibit changes in their professionalism or professional behaviour, have more medical errors, there’s decreased quality of care at times. And I think another thing which has been noted: changes in work efficiency. So, there seems to be more physician turnover. Physicians tend to work less hours if they’re more burnt out. So, there are a number of impacts on the system which have been more identified in recent years.
These last few comments may be the most interesting, as Dr. Wilkie argues that physician burnout is something of a public health problem.
The main podcast can be found here, and is just over 11 minutes long; there is also a podcast with Dr. Erlich:
Selection 3: “Doctors Were Alarmed: ‘Would I Have My Children Have Surgery Here?”
The New York Times, 31 May 2019
Tasha and Thomas Jones sat beside their 2-year-old daughter as she lay in intensive care at North Carolina Children’s Hospital. Skylar had just come out of heart surgery and should recover well, her parents were told. But that night, she flatlined. Doctors and nurses swarmed around her, performing chest compressions for nearly an hour before putting the little girl on life support.
Five days later, in June 2016, the hospital’s pediatric cardiologists gathered one floor below for what became a wrenching discussion. Patients with complex conditions had been dying at higher-than-expected rates in past years, some of the doctors suspected. Now, even children like Skylar, undergoing less risky surgeries, seemed to fare poorly.
So begins a long article on a hospital and its controversial paediatric surgery program. The writing is compelling, as is the investigative reporting – Gabler taps secret recordings from meetings. One specialist comments: “‘Would I have my children have surgery here?’ In the past, I’d always felt like the answer was ‘yes’ for something simple. But now when I look myself in the mirror, and what’s gone on the past month, I can’t say that.”
The article documents concerns raised by physicians and nurses, administrators who wonder about the bottom-line, and patients who have bad outcomes. (Skylar, for the record, dies long before her third birthday.)
The full essay is worth the read. It’s about a cardiac surgery program in another country. But could it be about any health care program in any country? The UNC story raises good, if unsettling, questions: Why don’t we use more data (such as outcomes data) to identify problems in health care? Are we overly concerned with budgets? Are physicians too eager to turn a blind eye to problems because of a guild mentality?
Reading of the Week. Every week I pick articles and papers from the world of Psychiatry.