A knock on the door

30 years ago, a young doctor in overwhelm had planned to kill himself. He is now the President of a specialist College and wrote recently of his despair and the difficulties and loneliness he experienced in accessing the care he so desperately needed. At the time, he described how he had “a pervasive sense of failure”; a patient had died and he had felt responsible and felt “overwhelmed with inadequacy”. A timely knock on the door prevented him from taking his life as he had planned, so he did not end up as yet another statistic of doctor suicide. (1)

In response to this story in MJA Insight, a GP wrote explaining that this had not been a random knock at the door. Instead, colleagues who worked with him at the time and had heard reports of him taking, as he described “hospital supplies”, feeling very concerned about his safety, followed him home and knocked on the door. (2)

If they were anything like me at that stage in their training, they were all very young and inexperienced in life and at the time did not know how to discuss these difficult personal questions, so it was not until 30 years later when Steve shared his story that they felt able to share theirs.

These stories have evoked many memories for most, if not all of us.

I think about the time I did not knock on the door, along with others wanting to respect her privacy, when our colleague and friend’s lover flew away to return to his wife. If only? We are still asking that question so many decades later.

Helen Schultz, an Australian psychiatrist with an interest in physician health, recently wrote that while it is hard for us to do, we need to talk about physician suicide. (3)

She described a meeting she had been asked to chair, when the widows of doctors who had suicided spoke out. These courageous women put aside their personal suffering in the hope that others would not have to go through the same experience.

“We find ourselves shackled and silenced by guilt, by shame and by an intense fear of being judged. But there comes a point when you need to transform the wounds into wisdom and the pain into purpose.” (4)

If we can identify the problems behind physician suicide, we may find answers as to how we can work to prevent them. Doctor suicide has been a taboo subject until recently, but now thanks to voices like Helen Schultz, Pamela Wible and Michael Myers, and stories like Steve Robson’s we are at last, as a profession, facing this reality.

Mike Myers says:

“Advocacy is basic to our clinical work as health professionals. The more we speak out about ways in which the culture of medicine both nurtures and traumatizes physicians we will make a difference. We cannot remain silent. Broken physicians cannot speak for themselves – certainly not when they feel the most shattered or busted – maybe later.”

Pamela Wible, an American physician, in response to the death by suicide of 3 colleagues, started to investigate mental health problems in doctors, and published her findings in Physician Suicide Letters – Answered. (5)

Reasons why doctors suicide

Through listening to the stories of partners, family and friends of over 1000 physician suicides, Dr Wible felt she could see a pattern emerging and identified 13 reasons why doctors have suicided. (6)

Her list included:

• untreated depression
• shame
• loneliness
• total exhaustion
• sleep deprivation
• the misery of Medicine
• assembly line Medicine
• bullying
• whistle blowing
• being investigated by registration bodies
• perfectionism and
• OCD

And finally, perhaps a common category – “unknown” – we just do not know.

For the interviewed family, who had lost a partner/parent/daughter or son/sibling, in many cases their view was that Medicine was the chief cause.

While we know that the reasons behind a decision to end life can rarely be brought down to a single factor, rather each situation has its own unique complexity with several factors interacting, contributing to that final state of hopelessness, it may be helpful to explore these individual causes further.

Untreated depression

Depression has many causes and being constantly bullied and undermined is one of these. The main factor here is that doctors are people too and deserve to be able to access the best of care when they need it. Steve Robson, talking about his experience 30 years ago, remembers being told by his GP not to tell anybody or to see a psychiatrist. (7)

Thirty years later some of these beliefs still hold. Doctors are told and believe that their jobs are in jeopardy, that they will not get on training programs, that any record of having a mental health disorder or being on antidepressants could mean being deregistered.

It is of vital importance to address the issue of untreated depression in doctors, and that we fight for reform of the existing mandatory reporting laws, which form a barrier to doctors accessing care. While I am told that mandatory reporting results in doctors being supported, many doctors and students do not believe this to be true, and believe they cannot access treatment without jeopardising their careers. We have to make sure that any doctor with an episode of depression is given access to the best care possible and that the law is changed to make this possible. In a recent article the President of the RACGP has said that the current mandatory reporting laws are a form of “regulatory bullying”. (8)

As a doctor commented at the meeting run by the group of doctors’ widows and chaired by Helen Schultz:

“Doctors are not impaired, or weak, or deficient because of an episode of mental illness. Remy (An ED physician, husband of a GP) was a brilliant doctor.” (4)

Shame and stigma

Shame is for everyone, not only doctors, a potent catalyst for suicidality and can be both a risk factor for and a symptom of clinical depression. In all of us shame can arise from past traumas, social behaviours, substance abuse, relationship breakdowns and as a result of bullying, amongst many other causes.

It is a hidden emotion, insidiously eroding self-worth and self-belief, not something we talk about, rather something we hide. Perhaps as doctors we are too used to being high achievers, being seen as resilient, to being admired and respected. So, when things go wrong, or we perceive things have gone wrong or we are to blame, shame is an emotion we cannot cope with.

Unfortunately, depression or anxiety may be seen not as illnesses but rather as failings, and bring with them a fear of being seen as incompetent or losing our job and livelihood. So there is shame around mental illness itself. The standards in medicine are high and when errors or misjudgements are made, the consequence for the patient may be very severe.

In general, we are unsympathetic towards one another when things go wrong and public scrutiny brings further shame. The nature of many doctors is that they put very high demands on themselves, demand perfectionism in all they do and feel ashamed and down if they do not achieve this.

Loneliness

Loneliness has been identified as a risk factor for both mental health and physical disease. Medical students and doctors are often moved from place to place. I lived in 5 different cities in my years as a junior doctor. The demands of working as a doctor and studying for post graduate exams leave little space for developing friendships. Family, long term friends and personal GPs are left behind, so there is often little support when things go wrong, at work or in personal lives.

It is so important for us to look out for one another, to be aware that doctors new to the area may feel isolated, to encourage young doctors to register with a local GP and to simply ask: RUOK? Setting up mentoring systems for young doctors in all hospitals and identifying in each hospital a person and a place troubled doctors can find support and understanding, are vital to their wellbeing.

Severe fatigue and lack of sleep

All of us need and deserve adequate sleep especially if we are making vital and complex decisions about patient care, often under duress. Severe fatigue and chronic lack of sleep are recipes for disaster.

While it is less usual now to have the awful shifts we had when I was a junior, they still exist in some areas of medicine – surgeons working all night caring for emergencies and then doing routine surgery the next day. I remember after that kind of shift reading an article that found after sleepless nights there was a significant difference in doctors’ ability to do mental arithmetic, and wondering why anybody ever needed to do that research when the answer was blindingly obvious.

Keep an eye out for colleagues who are working impossible hours either through work or study or a combination of both. Work to educate and change any health service that puts these demands on doctors. While it is not always easy for women in Medicine to talk about it, combining hospital shifts with child raising can be totally exhausting, so enabling women to work and train part time is vital to their health.

Disappointment in Medicine

Pamela Wible talks of the misery of Medicine, and assembly line Medicine.

It has often taken high levels of commitment to train as doctors and the cost has been high in terms of years of not earning, loans to repay, relationship stresses, personal lives put on hold. We do it because we have dreams of how Medicine will be and how we can personally contribute. Sometimes the reality of Medicine is overwhelming. The vision of a caring doctor role model offering every patient, whatever their circumstances, as much time as they need in a compassionate and supportive environment may be quickly squashed.

Bullying of and by staff, lack of compassion, rushed and inadequate care and all the wrongs we witness in Medicine can be bitterly disappointing. We see the development of cynicism in medical students entering clinical phases before they even qualify. Altruism is lost and there is a deep disappointment that medicine does not live up to their dreams, is hard work and lacks the rewards they were working towards.

We should not give up on restoring the Medicine we know is true, where doctors are fully supported and patients receive the care they deserve. The first step towards compassionate care will always be developing self-compassion and we need to support our medical staff to do that.

Medical Regulation

Medical regulators are needed to ensure high levels of patient care, but they should never do so at the expense of a doctor’s wellbeing. Regulation should involve a high degree of sensitivity to the needs not only of patients but of doctors themselves.

Dealing with complaints or having registration threatened are high risk times for doctors and this should always be taken into account. Can our medical regulators be kinder and more insightful into the effect their behaviour may have on doctors?

Suicide is more preventable than not

There is a great complexity behind suicide, an interplay between a myriad of factors which together may lead to a sense of complete hopelessness. However, if we look at Pamela Wible’s list, there are more factors that are preventable than are not.

To address them we need absolute honesty and transparency; we can no longer hide suicidality and pretend it does not exist. The price for these doctors, for their partners and families, for Medicine and for the community is far too high. Doctors cannot be the collateral damage in a system which does not seem to care.

We can and should develop a system which supports all doctors. We can and should create compassionate and caring workplaces. We can and should change the culture of Medicine so that it becomes all it has the potential to be.

Now is the time to knock on the door, caring for one another. Now is the time to knock on the door of the health service. Now is the time to knock on the door of the government.

Now is the time, as Carmel Sullivan said, to transform the wounds into wisdom, the pain into purpose.

Now perhaps too is the time to knock on our own doors, to deeply value ourselves as people, to be honest about where we are at, to ask for help from other people we trust if we are struggling, and to reach out to others if we can see and feel that they are struggling, for we are not designed to do this alone.

References:

1. https://www.doctorportal.com.au/mjainsight/2018/41/learn-from-me-speak-out-seek-help-get-treatment/
2. https://www.doctorportal.com.au/mjainsight/2018/42/doctors-mental-health-a-heartfelt-reply-to-steve-robson/
3. https://beta.australiandoctor.com.au/views/its-hard-we-need-discuss-doctor-suicide
4. https://www.australiandoctor.com.au/news/gp-widows-speak-out-suicide-emotion-charged-meeting
5. http://www.physiciansuicidelettersanswered.com
6. http://www.idealmedicalcare.org/1103-doctor-suicides-13-reasons-why/
7. https://www.doctorportal.com.au/mjainsight/2018/41/learn-from-me-speak-out-seek-help-get-treatment/
8. https://insightplus.mja.com.au/2019/5/mandatory-reporting-regulatory-bullying-racgp-president/