In my early teens, when on a walking safari, we were charged by an elephant.
We lived then in Zambia and this family trip was faithfully recorded on my mum’s Box Brownie, the results being of the “find the elephant” variety. We had been walking with an African game guard who was intimidated into going far too close to a herd of elephants by a bullying and over-zealous American. I ran faster than I have ever run before or since, heart pounding, hyperventilating and scared silly. Anxiety disorders feel exactly the same – but there is no elephant and you cannot run away.
Anxiety amongst doctors
As doctors, we respect the fact that for patients, mood disorders are seen as an illness, a disorder for which we can suggest treatment. We accept that there is a high incidence of anxiety and depression in our community. However, this is not necessarily how we feel when confronted by a colleague with symptoms or even when we suffer ourselves.
There seems to be a belief that as doctors we are omnipotent, infallible and that somehow we avoid the problems our patients present with, particularly issues of mental health. In truth there is a high prevalence of anxiety disorders amongst the general population and this is reportedly even higher among doctors and medical students.(1) We need to talk about it because by not talking about it, the problem remains hidden and this is isolating and may discourage doctors from accessing treatment.
The Beyond Blue survey asked whether the respondents would trust a colleague they found out had a mental health disorder, many said they would have reservations. It is small wonder that many medical students and doctors are reluctant to discuss their problems with other medical professionals. Those who do are sometimes met with judgement or at times with a complete lack of understanding for the profound effect anxiety and depression may have. Those with symptoms of anxiety often suffer in silence, fearing their competency will be in question or worse, that their licence to practice could be withdrawn. The unfortunate consequence of delaying care is that the disorder may become more severe, they may develop more complex symptoms and worse, may have thoughts of self-harm, and there is evidence their performance may be affected, possibly compromising patient care.
In some cases, it can be severe and overwhelming:
“I can’t seem to get it across that my stress is constantly 1000% of what I feel able to manage and it absolutely rules my life; I don’t go out, I don’t socialise and I feel on the verge of a mental breakdown constantly. I can’t even watch medical themed programs on TV because I find them stressful! It’s ridiculous and makes me feel pathetic and weak because I know I’m capable of more and this just isn’t me. Every single moment of my life (I even dream about it) is spent obsessing about work.” (Young doctor, blogging)
Why are anxiety disorders higher in doctors?
Our profession is very demanding and there is little room for error. Even to reach the starting block, to gain medical school entrance requires a high level of dedication and commitment to studying. Medicine attracts high achievers and perfectionists. Those very traits which allow them to be high achievers both pre- and post-graduation are the traits that may lead to anxiety during their career.
“What helped me become successful (being self-critical and a perfectionist with high expectations) later became the source of my problems.” (Surgeon, blogging)
It is almost impossible now for one individual to hold the breadth of medical knowledge. Medicine is not an exacting science, so that for each of the enormous number of diseases we have identified, each may have several ways of presenting and may present differently in the disease’s different phases. How therefore can any one individual have an infallible sense of safety in their own resources? When stressors are high for doctors both within and outside the work arena, a relationship breakdown, being sued, an error of judgement, a stressful clinical encounter, symptoms of anxiety may arise for the first time or escalate, affecting their ability to cope.
Transition times create a vulnerability to anxiety which may not have previously manifested – students moving into the clinical phase of training, starting work as a junior doctor, sitting exams which dictate whether you can progress or not, taking full responsibility as a specialist, where the buck stops here. These are really important times to practise self-awareness and self-care, to create support networks and find ways of supporting your work/life balance.
As a profession we are tough on ourselves, often having completely unrealistic expectations of ourselves. We expect ourselves to be superhuman, perfectionist and on top of that to be altruistic and compassionate towards our patients. Couple that with a curious intolerance of lack of toughness in colleagues and we have created a monster for ourselves. Small wonder doctors developing anxiety disorders judge themselves.
It is quite natural to have a high level of concern about our clinical reasoning and medical management, about our practical skills, our inter-professional relationships. Medicine asks this of us. It is when these concerns and fears become overwhelming that we need to consider whether we are developing an anxiety disorder.
“I have become more reclusive having been very social in the past and I fear for my future career. My biggest problem seems to be performance. I am very comfortable taking care of patients but having to get up in front of crowds for presentations and even sometimes during surgery I find myself dizzy, nauseated and on the verge of vomiting. It is becoming too much me for me to handle, and unfortunately I have attempted to seek help but discovered my concerns will not be so well understood by my superiors.” (Surgical trainee, blogging)
My own experience with anxiety
My own experience with anxiety happened 40 years ago and thankfully never recurred.
It did, however, change my career path. It is still difficult for me to talk about because at the time it was consuming, hidden, undiagnosed, untreated and painful. As I put pen to paper there are still the remnants of concern about being judged, about feeling ashamed.
I was in my mid-twenties, newly returned from working and travelling overseas, (from walking the Kokoda trail to working to save the airfare to working in a neonatal unit in the uncompromising city of Birmingham). There was illness in my family, relationship issues, Part 2 Fellowship to be studied for and I developed an anxiety disorder.
When I read about psychological disorders amongst physicians I found that my story was very similar to what has been reported:
- Psychological disease may be self-diagnosed incorrectly
- The doctor may feel too ashamed or fearful about their career to seek help
- Doctors often do not have their own GP
- When help is sought, the severity is often underestimated
- Doctors with psychological problems often do not receive the care they need
- Other doctors are generally unsympathetic.
I did not really understand what was happening to me and thought I was mad, inadequate and incompetent. After months of angst I told my boss I needed to resign, though I was not completely honest why. He thought this was exam stress and suggested I saw his friend, a psychiatrist in the hospital I worked in. Of course I did not tell him what was really going on. In the end after a year, I passed my exam and to be honest I ran away. No patient was harmed. As I discovered later, doing paediatrics and anaesthetics in a small hospital in Papua New Guinea, I was completely competent – it was as they say: “all in the mind”.
When I look back in compassion for my younger self, I see a young woman overwhelmed by stress, not knowing how to get help. It could have been so very different if I had accessed the care I needed.
If you think you are suffering from anxiety
If you think you are suffering from anxiety, there are ways you can help yourself; you do not need to suffer unnecessarily.
- Whether you have an illness or not, whenever you move to a new area, identify and register with a GP you trust and are comfortable with.
- Identify strategies which help you deal with the stress of medicine in appropriate ways, be this through exercise, breathing exercises, relaxation techniques, finding time to do the things you love – make this a part of your life.
- Find a physician friend or mentor with whom you can be completely honest. Best put this in place before there is a real need.
- Seek help early rather than later and do not try to self-diagnose or worse to self-treat.
- Access a psychologist whom you trust to teach you the psychological strategies to understand and reduce anxiety.
- Access on line programs to support your care.
- If you are concerned about a clinical competency and this is causing anxiety, ensure that you are properly trained in the area. Feeling appropriately confident and competent can greatly reduce anxiety
- If you feel your work is compromised, consider taking time off until you are better.
- Support colleagues who are distressed – they need our love and support, not our judgement.
My own anxiety condition passed and fortunately the experience was not repeated over the rest of my career, though I never worked in a neonatal unit again. Distressing as it was, my personal “charging elephant experience” was thankfully relatively short lived, but gave me an understanding of myself and of others working in Medicine which I will not forget.
- Beyond blue study
I saw her dressed in black—
the wife of my patient.
My diagnosis had been
Why do I feel guilty?
Could her husband have died?
I could not go and ask;
“you’ve killed him’ she might say.
I scan the news papers;
the columns of the dead.
Good; his name is not there.
But he still could have died.
Heart attacks often strike
undetected, don’t they?
When had I seen him last?
A month ago perhaps.
palpitations he had,
oh yes. ‘Reduce coffee
and cigarettes’, of course.
What else my God, what else?
Oh yes. He was worried
about brain tumor. Yes!
That’s it! Need not worry;
the wife’s father had it.
And terminal they’d said.
‘My sympathies Madame;
he rests in peace at last.’
‘Oh no! He was so young,
you have killed him Doctor!’
Boghos L. Artinian MD