Beyond the call of duty

A recent inquest into the death of a consultant paediatrician concluded that his 100-hour weeks played a significant part in his death. His is not an isolated case - doctors increasingly suffer from stress-related illnesses, writes Kate Craven

We will never know precisely why he did it. But what is certain is that the family and colleagues of Dr Sid Watkins are still reeling from the shock. In March this year, during an evening shift at Southampton General Hospital, the talented consultant paediatrician went into the toilets and injected himself with a dose of anaesthetic that proved fatal.

A recent inquest into his death heard that the doctor, who was married with two daughters aged eight and four, was regularly on duty for between 80 and 100 hours a week. The night before he died, he had worked a full night shift before flying to Germany to oversee the airlifting of the daughter of a British serviceman to Edinburgh, a private matter that had been arranged with the Ministry of Defence. The 44-year-old then flew back to Southampton, arriving only 30 minutes before his next night shift was due to start.

A biochemist told the hearing that the drug that Dr Watkins used could provide the same euphoria and state of relaxation as many opiates, and that he may have taken it to escape from the pressures of work. Recording a verdict of accidental death, the coroner Keith Wiseman said that he was satisfied that Dr Watkins had not contemplated taking his own life. "Eighty to 100 hours a week seemed to be normal and his widow puts the figure a lot higher than that. It is far from normal and must, I think, carry with it a significant risk of over-tiredness. These hours seem to be crazy." His widow, Camille, is expecting their third child.

A BMA survey of almost 11,000 consultants found that 77 per cent worked more than 50 hours a week for the NHS, and 46 per cent more than 60 hours a week. A spokeswoman blamed striving to meet the Government's waiting-list targets, as well as having to perform normal clinical duties. And the pressures may well worsen. "We have got junior doctors' hours coming down because of their new contracts and because the European working time directive, which applies to them next year, will legally restrict their hours to 48 a week," she says. "There is a fear that the rising workload will transfer to consultants, who are already covered by the directive but it's not as vigorously imposed as it is set to be for junior doctors."

But that fear has already become reality, according to Dr Venkat Reddy, a consultant paediatrician: "It used to be that a lot of consultants didn't come in for emergencies, but now, with the reduction of the junior-doctor service, a lot of them are in during the middle of the night. Most paediatricians I know have opted out of the European working time directive, which limits their workload to 48 hours a week, mainly because the service would not function if they all worked to those limits. They feel that the children would suffer."

Harvey Marcovitch, spokesman for the Royal College of Paediatrics and Child Health, says that the introduction of shift work had also dramatically pushed up workloads. "There isn't anyone around any more among the juniors who really knows what's going on with individual children day by day. They each see snippets and the consultants are left as the people responsible for keeping an eye on the whole course of the child's hospital admission.

"If you have people working on shifts, you don't see much of them - you might not see them for a week if they're doing a night shift. You don't get to know their strengths and weaknesses, and you may not think you can rely on somebody. What do you do? You end up coming in and doing it yourself," he says.

With more procedures available for patients to make complaints, many consultants also feel the threat of possible litigation. "Doctors are very much looking over their shoulders nowadays," he adds.

According to a report published in the BMJ in March this year, psychiatric problems were the most common reasons for doctors taking early retirement. The most widespread were depression, anxiety and alcoholism. The study, How Many Doctors Are Sick?, by Dr Judith Stanton, a consultant in public-health medicine at Brent Primary Care Trust, and Woody Caan, professor of public health at Anglia Polytechnic University, found that doctors exhibited higher levels of psychological disturbance than people found in equivalent professional occupations.

"Health problems range from anxiety through to emotional exhaustion, clinical depression, substance misuse and suicide," it said. "Depression, alcoholism and anxiety neuroses (including post-traumatic stress disorder, obsessive-compulsive disorder, phobia and panic disorder) are the most common mental illnesses." Figures from the BMA's working group on the misuse of alcohol and drugs showed that in a lifetime, about one in 15 doctors in the UK may suffer from some form of dependence on alcohol or other drugs.

Dr Stanton believes that the findings of her report may well be just the tip of the iceberg. "There are a lot of mental-health problems in the profession, the true extent of which are not yet known," she says. "Doctors often act in superhuman ways, working superhuman hours to the nth degree to try to achieve the almost impossible, which can, of course, lead to burn-out," she said. "They do not suffer from absenteeism, they suffer from 'presenteeism'."

Doctors can find it difficult to admit that they have a problem, she explains. "They may fear seeking help because they're scared of being deemed unfit to practise. There's a huge argument against admitting that you are stressed. You can't go off sick because the patients are unwell and they need you, and you can't lay extra work on your colleagues. There's a culture of just carrying on. You sign your patients off work, but you might be at work with the same condition yourself."

Doctors in their late thirties, early forties were the largest group of users of the BMA's confidential counselling service, the research found. "Most of the calls were for stress," says Dr Stanton. "When you are in your forties, you are still a relatively new consultant - the buck stops with you. You have family demands at that age and you might perceive yourself as being isolated."

Doctors are three times more likely to commit suicide than the national average. Many agree that the figure is so high because of access to means and knowing what method will be effective. Dr Duncan McDonald (not his real name), a consultant anaesthetist, was 49 when he decided to kill himself. "I would get home at night after a terrible day, and have a couple of gins, then it got to be three, then four, then I started hiding the bottle and it got worse. I averaged a bottle of spirits a day," says Dr McDonald.

"My wife said that she was going to leave me. I knew that I couldn't carry on without her, and I knew that I couldn't carry on as I was, so I decided to commit suicide." He made sure his family was out for the day, changed all the locks on the doors, and inserted an intravenous drip into his arm containing drugs. "The thing that saved me was that instead of lying down, I sat on the edge of my bed thinking, 'Thank God that's all over', and as I became unconscious I fell to the floor, which pulled the drip into the tissues. I had a coronary."

He was discovered by his family and woke up in his own casualty department with his most disliked colleague leaning over him and tutting. "I've never been so angry in my life," he remembers. "I was in charge of the intensive-care unit at the time, and they put me in there. It was on the seventh floor and I tried to jump out of the window, so they sectioned me." He spent a week in a psychiatric hospital. All 14 of his consultant colleagues voted that he shouldn't return, but his regional boss gave him another chance as he had started attending AA meetings. Now 62, he no longer drinks, and he works part-time.

"There was a tremendous amount of pressure," says Dr McDonald, who helps run the helpline of the British Doctors' and Dentists' Group, a support network for recovering alcoholic and drug-dependent doctors, dentists and students, which has about 800 members. It is one of numerous help groups available to the medical profession, including the National Counselling Service for Sick Doctors, the Doctors' Support Network and the Sick Doctors' Trust.

Not all, however, believe that doctors are under any more stress than the rest of us. Dr Richard Caplan, a consultant psychiatrist at the Southern General Hospital in Glasgow, who has an interest in stress in the medical profession, says: "Doctors tend to complain a lot about the stress they're under. I think they're actually quite good at dealing with it, it's what they're trained to do. They moan about it a lot, but they are probably handling it better than many people are. It is in their interests to present the job as being stressful and difficult, and therefore needing more resources.

"The job for most people is doable, and I don't think the stress levels are any greater than they were 10 years ago."