Our aim in this review was to improve understanding of how, why and in what contexts mental health services and support interventions can be designed in order to minimise the incidence of doctors’ mental ill-health. We summarise our main findings here, in relation to the four research questions. Findings for research questions 2 and 3 are presented together in view of the close interactions between the identified mechanisms and contexts. A summary of the four main clusters of CMOcs has been presented in Chapter 3, Summary of the 19 CMOcs in four main groupings (see Table 3).
Research question 1
What are the processes by which mental ill-health in doctors develops and leads to its negative impacts and where are the gaps that interventions do not address currently?
Our findings suggest that the development of mental ill-health in doctors results from the interaction of a significant and complex workload, organisational management and the professional culture of medicine. Doctors experiencing heavy workloads, together with a diminished level of control over their work, are unlikely to be able to perform at the high standards that they expect of themselves and their profession. In a professional culture which doctors experience as discouraging the sharing of vulnerabilities, in which professional regulation is perceived by doctors as likely to judge mental ill-health as potentially making a doctor unfit to practise, and in an organisational environment that promotes individual rather than collegial responsibility, doctors are unlikely to take steps that could prevent the development of mental ill-health. Although interventions that target individual doctors (e.g. to prevent doctors’ mental ill-health or ameliorate it once established) may address parts of these processes, the way in which individuals and the wider context interact suggests that interventions that address multiple organisational and professional issues simultaneously are more likely to be successful. In other words, the gaps in intervention targets tended to be more associated with ‘level’ (e.g. individual and/or team and/or employer), rather than ‘stage’ of the process.
Research questions 2 and 3
What are the mechanisms, acting at individual, group, profession and organisational levels, by which interventions to reduce doctors’ mental ill-health at the different stages are believed to result in their intended outcomes?
What are the important contexts which determine whether the different mechanisms produce the intended outcomes?
Our second and third research questions focused on the mechanisms, which may operate differently in different contexts, by which it is believed that interventions reduce doctors’ mental ill-health. We interpreted ‘reducing mental ill-health’ as either preventing the development of mental ill-health or ameliorating mental ill-health once it is established, and identified how professional and organisational culture could shape the operation of mechanisms.
We found that doctors’ working relationships, with other doctors and health-care staff as well as with the organisation in which they work, explained a key part of how mental ill-health could be prevented and reduced. Although not operating in a linear fashion, facilitative contexts, such as meaningful workplace relations and functional working groups, enabled the protective mechanisms of a sense of belonging and an ease with vulnerability to function. These mechanisms could interact with (or provide the context for) other protective mechanisms to operate, such as identifying with colleagues and finding meaning in work. Relationality, recognising the importance of meaningful human relationships in the workplace, provides an overarching explanatory concept here.
We also found that the tone set by organisations about a medical career could have important implications for mental ill-health. Constructive workplace feedback on performance, as well as an organisation’s demonstrable valuing of employees’ health and well-being, could provide the context for doctors to contribute to and benefit from an upwards cycle of interacting mechanisms, such as legitimating their own well-being, acknowledging vulnerability and valuing colleagues. A professional culture that recognises both the positive and negative aspects of a medical career could play a role by preventing feelings of inadequacy and helplessness in doctors. Finally, when doctors are affected negatively by significant life events, the provision of timely support in the workplace is crucial for hope to play a role in recovery.
In relation to costs, limitations in reporting meant that we were unable to link cost data to CMOcs. Even when this cost information was reported, there was a lack of methodological detail about how costs had been calculated. A minority of included sources quantified costs and there was a lack of methodological detail about how estimates of direct or indirect costs had been reached and a paucity of detail about direct, indirect or total costs that we could meaningfully extract. No included sources reported a health economic analysis (either cost–consequence modelling or prospective comparative evaluation), but it should be noted that our search strategy was not explicitly designed to locate such studies.
Research question 4
What changes are needed to existing and/or future interventions to make them more effective?
This review has identified how social identity, group membership and the ‘humanising’ of doctors’ work (in contrast to a reductionist view of clinical encounters) can play an important role in the prevention and reduction of mental ill-health in doctors. We noted earlier in this report (see How does existing substantive theory link with our findings?) how approaches drawing on aspects of theories of biopsychosocial health and well-being (the social identity approach243) can be used in tandem with our more specific CMOcs to underpin the refinement of strategies to reduce mental ill-health in doctors. Taken together, this has enabled us to articulate recommendations about strategy development for different audiences (). We also worked iteratively with the stakeholder group, experts and policy-makers to develop and refine the recommendations (consistent with our protocol; see also Chapter 2, Stakeholder group). Although these recommendations are presented separately to aid comprehension, the interdependency of these levels should be acknowledged in intervention design (e.g. doctors prioritising relationships at work may not be feasible if there are no organisational structures to support this at the level of team leaders and senior management). We have also developed 10 CUP principles to refine interventions, for those who deliver interventions, which draw out the interdependence of the different levels (Box 3).
Key recommendations and principles for refining/developing strategies to reduce mental ill-health
Principles for use for those refining/designing interventional strategies to tackle doctors’ mental ill-health
