In February this year a young Sydney doctor wrote:
“In the year it has taken to complete my training as a junior doctor 3 of my colleagues have killed themselves. These are just the ones I know about.”(1)
He went on to heavily criticise a system which fails to support its junior staff.
The family of one of these young doctors is reported as saying the “brutal” and “completely unsustainable” expectations of her job, which she juggled while studying 40 hours a week, contributed to her death.(2)
Recently when a young English doctor suicided, she was reported to have implicated the British Secretary for Health in her suicide note.(3) In America the annual number of doctor suicides in equivalent of a whole medical school.(4) In Victoria in 2015, four young doctors took their lives.(5)How many more suicides are needed before we as a community act?
Brad Hazzard, the NSW Health Minister, has recently announced an investigation. Why did we wait so long?
In fact, what happened to the inquiry that was launched in response to the 2015 deaths?
We should all be asking questions. Is there not something wrong in a profession proud of its ethics and its caring which allows this to happen without there being a national inquiry that is acted upon; a profession which hides these statistics; a profession unwilling to deeply review the culture of Medicine which is perhaps the underlying cause of these untimely and tragic deaths?
Our young doctors are the backbone of our hospital workforce. They are the future of our profession. Our community has invested highly in their education. Medicine needs them to form the reliable, compassionate and competent workforce our patients need and want. They are the future of medicine. We should value and nurture them and provide all the support they deserve.
As doctors, we can no longer stand back and blame the “system” which is contributing to this tragedy, we need to stand up and challenge it.
Studies of physician mental health and suicide
When I look at the pictures accompanying reports of doctor suicide I see not a statistic, but a young and beautiful man or woman, in the prime of their lives. I see a young doctor who has studied hard and made sacrifices to join the profession they dream will bring life fulfilment. I see a beloved daughter or son, sister or brother, partner and friend. I read of passion and commitment, of dedication, of selflessness. I feel a deep sadness that our profession has let them down and a rising frustration that we have been unwilling or unable to address the issues within our profession that have brought us to this place.
A meta-analysis of physician suicides found a1.4x increase in male physician suicides and 2.2x increase in female physician suicides compared to the general community. Kolves and De Leo found that 59% of physician suicides were attributed to a mental health disorder, unipolar depression being the commonest cause. Work related issues were identified in 18.5 %.(6)
A 1996 review of published articles on doctor suicides found the estimated relative risk varied from 1.1 to 3.4 in male doctors, and from 2.5 to 5.7 in female doctors, respectively, as compared with the general population, and from 1.5 to 3.8 in males and from 3.7 to 4.5 in females, respectively, as compared with other professionals. The crude suicide mortality rate was about the same in male and female doctors, whereas in the general population it is 4 times higher in men.(7)
The Australian Beyond Blue figures looking at medical student and doctor mental health found 3.4% reported a high level of psychological distress. 1 in 4 had milder psychological distress including depression and anxiety. Young doctors and women doctors were at highest risk. Males were at higher risk of overuse of alcohol. 1 in 10 had suicidal thoughts in the last year. The tragic suicides are but the tip of the iceberg of a very distressed population of young doctors.(8)
Barriers to seeking care
Doctors’ stories of their own journey with mental health issues follow similar patterns. This from a young doctor studying for his fellowship exams:
“I was studying for the second part of my fellowship exams and I developed an anxiety disorder. Prior to this I had always been considered competent, now I became terrified I would not be able to intubate one of the tiny babies we cared for. It was a nightmare. I did not go to a doctor, I did not have a GP. I did not understand the nature of anxiety or for that matter depression, I thought I was going mad. I felt ashamed to tell anyone in case I lost my job, my income, respect. When I admitted my stress to my specialist he sent me to see a colleague in the other hospital I worked in, I did not tell him what was happening because I was concerned about confidentiality and being ridiculed.”
Studies show that this is what happens to doctors with mental health issues. They may self-diagnose and even self-medicate, often misdiagnose and incorrectly medicate. They find it difficult to seek help – time factors, confidentiality concerns, fear of losing their job – and when they do the help is not always what they need.
Mandatory reporting is supposed to protect the public from doctors whose competency is in question. Unfortunately, it is having the effect of discouraging doctors from seeking the care they need, which in itself could be putting their patients at risk.
Following two suicides in Sydney, the Chairman of the NSW AMA, Prof Brad Frankum, wrote:
“It is clear to me that provisions such as mandatory reporting are stopping doctors and students from accessing care, or are making them fearful of the consequences if they do require support.We have to change this because it is not making our doctors or our patients safer.”(9)
In a recent media report an English GP registrar who had been previously named registrar of the year had voluntarily reported to the Medical Board about a drinking problem. Believing he was going to fail a urine test after a party he took his life.(10)
What can we do?
Many strategies have been shown to be successful in trials: all of them look at the support and treatment of young doctors. It is essential that we provide training and funding to incorporate these measures into our medical schools and hospitals. We should stop hiding from the fact that as a profession we have a problem and do our best to prepare our students and doctors for the stresses that they will face. We should encourage them to identify and engage with a local GP every time they move location, so this becomes automatic. Validated on-line CBT/ MBT programs should be designed specifically for doctors and offered at no cost. They should be introduced through medical school and advanced programs offered as they advance in their career and the stressors change. Hospitals should offer dedicated down time where young doctors, under the supervision of senior clinicians or psychologists, can learn the value of reflection, self-awareness and connectedness.
We believe a mentoring system could be offered through Medicare where each junior doctor is coupled with a GP trained in the management of mental health disorders and who is aware of mental health issues as they relate to doctors. For this to work there needs to be a review of the mandatory reporting system so that at the very least doctors are supported and cared for in a way every patient deserves.
Suicide is more common in women doctors(11) and in recent years, gender equity means there are now equal numbers of men and women entering medical schools. If we fail to address the causes behind these sad and tragic deaths, as the balance between male and female physicians changes we are likely to see more, not fewer deaths.
We have been aware of the mental health issues in doctors for many years.(8,12) Many strategies have been tried but there is no real evidence that they are really working and I believe this is because we are trying to treat the doctors but we are failing to address the fundamental flaws in the medical system and the medical training system which underpin these problems. Until we do this our young doctors will suffer and some will pay the most awful of prices. This demands the complete honesty and humility of our profession. We can no longer, in our collective arrogance, believe we are invulnerable, invincible and not open to scrutiny. We cannot blame our problems on “The System” without being willing to engage with the system to look for viable solutions.
If we truly believe that compassionate care is fundamental to Medicine, we must treat our students and junior doctors with the care we would like them to show us.
Quotes and references:
This article was originally published in MJA Insight 14, on 18 April 2017 as “Flaws in the system are killing young doctors.”