Psychological PPE: do we need to start fit testing earlier in medical training?

As we exit another covid-19 peak and start to ease out of a third UK lockdown, concerns are being raised about the resilience of the medical workforce and ability of individuals to cope with the anticipated practical and psychological strain of the months ahead.

Thinking back to the hurried preparations during the first peak in March, valid concerns were raised about the ability of the NHS to cope with the expected influx of patients and the public stayed at home to “protect the NHS.” As doctors faced stress and moral injury, intensified by the pandemic, some sort of psychological reaction was inevitable, but concern about how doctors as individuals would cope psychologically was not widely discussed.

In the public eye, healthcare professionals, and doctors and nurses in particular, were seen as “heroes” and rewarded with weekly rounds of applauselittle public consideration was given to the question of whether the “hero” label sat comfortably with them. It might be difficult for a doctor acting in a “hero” role to admit both to themselves and others that they feel stressed or unwell. This may lead to a delay in them seeking appropriate support or help.

While the government was scrabbling to secure sufficient personal protective equipment (PPE) for the workforce, Nightingale Hospitals were ahead of the curve in equipping all their staff with a proactive response to emotional wellbeing—”psychological PPE.” But medical training has given the current workforce little preparation about how to don “psychological PPE.”

As psychiatry trainees we are privileged to attend reflective groups, but even as self-selected trainees with an interest in psychology, reflecting on our own emotions and psychological responses at work can feel alien and difficult, particularly in the early stages of training. Trainees in other programmes have no such dedicated time and space for reflection, and doctors ordinarily only access wellbeing initiatives or psychological support if they are having difficulties in their training and/or work. 

The experience of working as a doctor, even outside a pandemic, provides encounters with death, trauma and distress as daily occurrences. Of course doctors support each other with informal conversations, cups of tea and typical NHS gallows humour. The experience of having feelings validated and normalised can provide emotional relief. But some doctors’ social circumstances mean they will not be able to access these informal medical support networks, and others will find they have become more isolated since the pandemic.

Even before the current situation, evidence has shown that doctors who receive appropriate emotional support are able to provide better care for their patients. Surgeons with worse self-reported mental health reported more major medical errors than their colleagues and burnout has been strongly associated with self-reported suboptimal patient care practices across specialties and grades. Emotional regulation can be taught and results in a reduction in burnout, which is crucial because doctors’ occupational wellbeing is significantly associated with patients’ adherence to treatment and even with lower rates of hospital-borne infections. We must provide doctors with strategies to prevent burnout and allow them to provide the best patient care.

In a terrible way, the pandemic may finally be giving mental health “parity of esteem” with physical health, something which has been sought for so long. The conversation has changedpoliticians are attempting to weigh up the risk of covid-19 transmission against the risks of further lockdown, a large part of which is the anticipated mental health burden. Perhaps psychological elements of life as a doctor will also get increased recognition in medical training and doctors will be taught to identify and reflect on their emotional responses. Space and infrastructure may also be introduced so doctors are able to have important conversations about wellbeing as a matter of routine. Normalising “psychological PPE” will be of benefit to patients and doctors alike. 

Sophie Behrman is an ST7 trainee in general and older adult psychiatry in Oxford Health NHS Foundation Trust, UK.

Sophie Roche is a final-year medical student at Oxford University, UK.

Gerti Stegen is director of medical education and a consultant psychiatrist in medical psychotherapist, Oxford Health NHS Foundation Trust, UK. 

Competing interests: none declared