Wounded healers

Myers is one of that rare breed — a doctor’s ­doctor. A professor of clinical psychiatry at SUNY Downstate Medical Centre in Brooklyn, he treats the profession’s walking wounded every day. In these doctors come, often at the very edge of the abyss. More than once, he’s failed to stop the leap.

Counsellor and confessor, a mapper of the strangest of topographies, his knowledge extends in all kinds of arcane, sad ways. He can tell you the trends in modes of death, the substances and methods his colleagues use to end their lives. He knows why so many doctors choose to die in their scrubs, in their offices. He knows the specialties with the highest rates of burnout — a 2016 study identified hot spots in emergency medicine, anaesthesiology and family medicine, among ­others. He can tell you the number of doctors who kill themselves in the US — at least one a day, on average.

“This,” he says mildly, “is the dirty little secret embedded into the culture of medicine.”

In 2015, building on his parallel career as an author of more than 150 books and papers, Myers began work on a new book, Why Physicians Die by Suicide. For months he worked the phones and trekked across the country in search of answers to this question. Slowly, over 100 interviews with the families of those who’d suicided, along with their friends, teachers, students, therapists and colleagues, he built a map of an ill physician’s mind.

Across the world, in another clinical practice in suburban Richmond, Victoria, Dr Helen Schultz is tapping away at her laptop, painstakingly compiling statistics, case studies and stories. Schultz also counsels doctors in distress — those facing the country’s peak medical tribunal Australian Health Practitioner Regulation Agency (AHPRA), those battling mental illness or struggling with substance abuse. Over time, she’s become a kind of Antipodean Michael Myers, a detective of doctor suicides. When we first chat, she is laying the foundations of an ambitious clinical project — to build a national database of doctor suicides based on so-called “psychological autopsies”, the same kind of intensively detailed interviews with family and friends that Myers conducted for his book. Tell your stories, she urges the bereaved.

She scours newspapers, finding potential case studies buried between weather reports and traffic stories. She emails me these stories, a slow drip-feed of tragedy — most recently a popular local doctor and father of four, Frith Foottit, in Rockhampton, Queensland, who ended his life on New Year’s Day. Look, another one, she writes.

Both Schultz and Myers have a personal connection to this grim field of study. Myers was 19 back in 1962 when a roommate killed himself in his first year of medical school. Schultz counselled the shell-shocked friends and colleagues of three young Victorian trainee psychiatrists and one intern who killed themselves in a grim few weeks of a dreadful summer in early 2015.

The dead take their reasons to their graves

The dead often take their reasons to their graves. But Schultz and Myers both believe that the testimonies of the living might be the biggest key to unlocking those reasons — and hopefully preventing others from taking the same path.

I have found Myers and Schultz while on my own search for answers. Like them, I have a ­personal connection to medicine: my parents and maternal grandfather were all doctors. Medicine to me was heroic, its practitioners the gatekeepers of life and death, but underneath the glamour and heroism there was another side. I knew that ­difficult surgery — or worse, the loss of a patient — took a big toll on my father, who would sit morose, chain-smoking, silent; I knew of whispers of divorce, depression, drinking and outbursts of rage among other doctors in our social network.

Memories of this underworld surfaced recently with news of the death of Chloe Abbott, 29, one of at least three doctor-in-training suicides in NSW over the four months to January last year. Based at St Vincent’s Hospital in Sydney, Abbott, by all reports, was bright, well-liked, a champion swimmer and politically active; she would be later hailed by the Australian Medical Association as a “champion of young doctors” for her passionate advocacy work. But medicine “ate her alive”, according to her grieving family, who watched as she gradually succumbed to the crippling stress and pressure of training and exams.

Abbott’s story gripped my thoughts. I wanted to make sense of this darker side of medicine I’d intuited as a child: a world divided, in US writer Susan ­Sontag’s elegant dichotomy, into the kingdom of the sick and the kingdom of the well. And so I went looking, speaking over six months to GPs, psychiatrists, cardiologists, the heads of local health ­networks, college deans, registrars, medical students and government ministers. A picture emerged of a long tail of doctor suicides stretching back for decades, a story that connects a web of doctors across Australia. Everyone, it seems, knows someone who has succumbed. Figures are hard to come by but Georgie ­Harman, CEO of mental health advocacy group beyondblue, cites the group’s 2013 report that found doctors reported substantially higher rates of psychological distress and attempted suicide than both the general Australian population and other professionals, with 21 per cent having been diagnosed with or treated for depression.

My email pings with case studies. Names pour out. A recently divorced partner in a ­private practice. The son of another doctor emails me the eulogy he gave at his dad’s funeral. One evening I am emailed a suicide note from a specialist who pulled himself back from the brink, but kept this note as a kind of postcard from the edge.

“I have lost the will to fight and this is it,” it begins.

Schultz tells me about a workshop on suicide and grief she ran last year for the Royal Australian and New Zealand College of Obstetricians and Gynaecologists at their conference following the suicide of an obstetrician. “Every attendee there knew at least one, if not two, colleagues or peers who have suicided … It was pretty awful.”

I speak to Dr Anne Malatt, an ophthalmologist in Bangalow, NSW, and an advocate for ­medical reform, who experienced depression and substance abuse herself as a young doctor. Her best friend suicided during their surgical training after struggling with depression and alcoholism. “She was a great doctor, and a beautiful person, but she found the pressures of training just too intense, and she didn’t feel she could leave medicine and do something else, so she chose this way out.”

I hear from Dr Mukesh Haikerwal, GP, former federal president of the AMA and chair of beyondblue’s National Doctors’ Mental Health Program advisory committee, who says, almost matter-of-factly, that:

“of course, from third-year medical school, we started losing people”.

I speak with current AMA president Dr Michael Gannon, who says wearily that “there would be a very, very small number of doctors who haven’t been touched by the suicide of a colleague, either at medical school or as a doctor … sadly, I do know of doctors who have died prematurely because of mental health issues, and I also know doctors who have completed suicide during that time.”

And I consult Schultz and Myers, who urge me to go to the best sources: the families left behind. Eventually, with the help of a mediator — a Sydney journalist who as a child lost her own doctor father to suicide — I find a family willing to talk. And so I find myself, in the foyer of a Sydney hotel, scanning the room. Carmel Mezrani, a GP from NSW’s Central Coast, has travelled down to meet me with her two teenage daughters Ellen and Olivia. I spot them in a corner banquette — a frieze of three pale figures as still as statues.

It has been said that extreme grief is like the sun: impossible to look at directly. As waiters ­bustle around us with porcelain teapots and petit fours, Carmel and her girls seem caught in a void of shock. Carmel wants to — and doesn’t want to — talk. The internal struggle is painfully obvious: she is so tense, I feel she’ll shatter under the pressure of a single question. I tell her I’m nervous, too. She smiles — yes, she says, so are they. Ice is broken.

On an iPhone, she shows me a photo of her late husband Ramy and the girls on holiday in Queenstown, New Zealand, in 2016. “It was our first holiday with just the three of us together,” Olivia says. We had a good time.”

Ramy Mezrani was 51, charismatic, larger than life and “exceptionally social”, according to ­Carmel; a man who raised $20,000 for charity by climbing Mt Kilimanjaro, and who was deeply interested in the world around him. His Facebook photos depict a life of travel, parties, people, his family, caught in holiday snaps around the world: Rome, London, Paris. He killed himself six months after the holiday snap was taken, in October 2016. I stare at it, ­perplexed. I think of the strange dissembling that often surrounds suicide when Carmel tells me that at Ramy’s memorial service, attended by more than 800 people, “his family told people he’d had a heart attack”. This is why Carmel is here this morning — to break the silence, shame and stigma that still exists around suicide.

At the time of his death, Ramy and Carmel had been separated for 18 months but the relationship was amicable, Carmel says. She had coffee with him at her house the night before he died. They talked: about the kids, their relationship, changes in his life. At the time, Ramy was living alone and had recently resigned from his post at Wyong Hospital, one he’d held for 20 years. She didn’t know why; it seemed puzzling.

“His identity was very much tied up with his work as a doctor.”

Ramy had a history of depression and was on antidepressants at the time of his death. “He was also seeing his general practitioner, and he had just started seeing a psychologist three days before he died,” says Carmel. “I had asked him on a ­number of occasions about his medication but he ­obviously didn’t want to engage in that discussion. I had seen him depressed before … [but] he functioned to all intents and purposes very, very well.”

How did he seem that night? “He seemed sad and quite introspective but also very insightful, about life in general, the ups and downs of our relationship. But it was very cordial … He seemed to be dealing with the separation and was [in a better place] in terms of his relationship with the kids.”

It proved an illusion. Carmel found him dead at his home the next morning. The shock was profound. “I had no inkling he was going to do what he did.” She is stalked by the question: What did she miss? He had lost weight, “but he told me he was on a diet; that he was trying to get fit and change his life”. Mostly, she says, it was just a subtle withdrawing. The mistake many make is to expect outward distress and drama; the reality of suicide is quieter, subtler, a whisper rather than a shout. Ramy’s girls say he seemed “his usual generous self” on the Queenstown holiday. But looking back, there was a quietness. Only in retrospect, Olivia says:

“You see it if you’re looking for it.”

It raises the question: can you stop someone? After leaving ­Carmel’s house, something made Ramy decide to take that final step. Later, after his death, she found he had plans for the following week. Maybe he was ruminating all night and then made an impulsive decision, she says. “I look back and think, ‘How did I not see it? Was it something I did or said?’ We’ll never know.”

The warning signs

Quietness — a slow erosion of the soul, a ­corrosive but quiet husking of the self — emerges as a commonly cited warning sign when I talk to ­families. There were no dramatic manifestations of inner cracks, widening mental faultlines, they say. No harbingers of moorings wrenching free. Just a slow erasure, like an eclipse.

One evening I speak to John Bryant, a ­university student. Last May, his father Andrew, a respected Brisbane gastroenterologist, killed himself in his office. The parallels between Andrew Bryant and Ramy Mezrani stretch from glowing professional careers to a love of the outdoors. They mirror each other, too, in the shocking unexpectedness of their deaths.

John tells me his father was “deeply engaged with the world around him. He sang in choirs, cycled, swam, climbed mountains and sailed oceans.” Father and son were meant to compete in the 110km Great Brisbane Bike Ride just before Andrew died.

“Dad was a good man,” he says quietly. “A good doctor.” His eulogy, which John later emails me, is a map of achievement, of a big life well lived. Like Ramy’s photo, it is a ­baffling, depressing artefact. Masks again, it makes you think; a kind of hiding in plain sight. How could a man so valued feel such despair?

Like Carmel Mezrani, John says there were no indicators of terminal despair. “He was a bit flat, but as far as we could tell he was just tired from work, and that wasn’t too unusual. He was never someone to complain but he didn’t reach out for the help he obviously needed. Maybe the signs were there. But at the time it wasn’t enough for us to really take notice, unfortunately.”

One sunny winter’s morning, I meet Ramy’s eldest child, Daniel, 21, at a Sydney cafe. Bright, passionate and articulate, he is studying science at the University of Sydney. He shared a rented home with his father and uncle in Sydney; Ramy moved between the city and the Central Coast. Over breakfast, Daniel speaks with keen insight on a range of things: the impact of vicarious trauma on doctors, a lack of kindness and ­collegiality in the medical profession, the neuro­biology of fatigue, the importance of destigmatising ­suicide and speaking out, the power of therapy, the role of depression in suicide. Later he emails me the summary of a paper on the topic by Tasmanian psychiatrist and academic Saxby Pridmore.

Daniel cannot bring himself to talk much about the day his father died. “It was the most horrible, life-changing thing that has ever happened to me,” he says flatly. His slim hands form a church steeple. He spent months, he says, obsessively looking for answers, trying to read the tea leaves of his father’s life. But recently, he decided to stop. No more digging. The elusive, tormenting “why” will end up destroying him otherwise.

“My advice to those in my situation? Move on. I have. Eventually you have to let go.”

At 21, his life is already divided into before and after. Suicide has cleaved a family tree and singed all its branches like a lightning bolt. “I know I have been changed forever by this. And I wonder — who would I have been if this hadn’t happened?” He doesn’t know.

One of suicide’s most painful legacies is dealing with this void — of knowledge, of answers, of reasons why. There are obvious occupational factors, says Myers — access to lethal drugs, the knowledge to use them, learned fearlessness, exposure to vicarious trauma. Then there’s the practice of medicine itself: an epidemic of burnout fuelled by everything from long shifts and huge, complex caseloads to what many doctors say is a punitive and unsupportive regulatory culture.

This is exemplified by Australia’s mandatory reporting laws, under which a doctor seeking treatment from a GP or psychiatrist can be reported to AHPRA and face suspension or deregistration. Schultz knows of at least one case in which a notification from the ­regulatory watchdog has triggered a suicide. Add to this a culture of dog-eat-dog competition, ­harassment and bullying in the hospital ­environment. “It has to stop,” says the AMA’s NSW president Brad Frankum.

For young doctors such as Nishanta Tangirala, 27, a third-year basic physician trainee at Sydney’s Royal Prince Alfred Hospital (whose husband, a cardiology registrar, is also “spinning out a little” with stress) this is the daily reality: gruelling 16-hour shifts on top of an already overwhelming study load, social isolation, the constant crippling pressure of exams and the fear of humiliation if you fail. “You give pieces of yourself away,” ­Tangirala says. That 2013 beyondblue study found that female doctors are particularly vulnerable.

Ben Veness, a Victorian psychiatry registrar and advocate for junior doctors, who worked alongside Chloe Abbott as a medical student, points a finger at the specialist medical colleges. NSW Health Minister Brad Hazzard warns that the colleges urgently need to reform their “very stressful”, all-or-nothing exam system, among other things. “Doing nothing is not an option.”

All of these are environmental stressors and play a role, says Myers. But as he outlined in an interview with LitMed magazine last year,

“it’s an oversimplification to say that medicine alone is demanding and exacting. Many professions are like that and don’t have suicide rates like we have.”

The psychological makeup of doctors

So what then? Is there something unique in the psychological makeup of doctors that puts them at higher risk of mental illness and suicide? Yes, Myers concludes. Go deeper, to the level of ­biology. Look to personality traits that amplify the trauma of failure and setbacks that exist in all high-stress, high-stakes professions.

First, there’s what he calls the “wounded healer” hypothesis of psychoanalyst Carl Jung. People drawn to medicine, Myers says, are often simultaneously the right people and the wrong people for the role. Many, he told LitMed, are ­“survivors of childhood trauma, loss and ­family dysfunction. [They] make great doctors but can be vulnerable to psychiatric symptoms either genetically or from their early environment.”

The traits that help them excel in their profession — altruism, empathy, sensitivity to the pain of others — can prove to be pitfalls, says Myers. “We look for sensitivity in applicants to medical school and residencies and it is frightening to think that so positive an attribute can be part of the volatile mix that leads to suicide in distressed doctors.” Add to this a tendency to perfectionism. “Medicine attracts and selects for bright, hard-working, ambitious and perfectionistic people. Some are also highly competitive and don’t accept defeat or failure easily. They can be very hard on themselves.” This perfectionism can interact, sometimes disastrously, with the messy reality of medicine.

Dr Kym Jenkins, former medical director of the Victorian Doctors’ Health Program and ­president of the Royal Australian and New Zealand College of Psychiatrists, which lost the four doctors in 2015, says that a study of doctors who attended the VDHP and died by suicide found that factors included everything from “social ­isolation/dislocation to losing identity as a partner, or as doctor, rejection by loved one(s), struggling for too long and a sense of loss, grief at not being able to be a ‘good doctor’”.

In a sense, medicine is a victim of its own exalted status in our culture, Myers says. We regard doctors as a special tribe, high priests of healing. Any crack in this veneer is unacceptable, even to themselves.

It is a hostile culture with which Melbourne cardiologist Geoffrey Toogood is painfully familiar. A crippling bout of depression, fuelled by a messy divorce and work stress, saw him in 2013 “freefalling” into the abyss. He would watch the clock, minute by minute, using it as his life raft. “I sort of learnt how to hang on. It was like, ‘OK, it’s 11am, I won’t do anything bad until 12.’ You’re in extraordinary emotional pain.” Recovered now, he looks back with some bitterness at the reaction of former colleagues and superiors. Supportive? Hardly, he says bluntly. He felt shunned, an outcast in the macho culture of cardiology, where “you don’t want to be perceived as weak. There’s also the double thing of being a doctor and being male”.

Myers sees the end result: physicians who are physically broken, mentally fragile and angry. “They are furious that they have worked so hard, given so much to ­others, put their own needs on the back burner, and instead of receiving thanks or appreciation or even commiseration they find themselves miserable and often shunned by their colleagues.” This is often tragically reflected in the prevalence of doctors who commit suicide in their offices, often in their scrubs. As he’s heard from fellow physicians, for some it is “the ultimate ‘f..k you’ to medicine. That is his/her way of saying that medicine has worn me down and killed me.”

Resilience is a dirty word

To Helen Schultz, resilience is a dirty word because it implies that doctors who need help or proceed to suicide are simply not tough enough. And that’s not the case, says the AMA’s Michael Gannon. Conditions in medicine now are far more stressful than in the past, from workplace conditions to uncertain career pathways. Gannon says the issue of supporting medical students needs to be looked at. But it must be part of a holistic approach. “We need to look at how we support doctors in private practice, how do we identify those doctors who are struggling, how do we manage performance issues in hospitals, both public and private, and in general practice.”

So what can be done? I turn to the families. Carmel, Daniel and John support measures such as the reform of the college exam process and amendments to mandatory reporting laws, along with more doctor-focused counselling services and hospital-based wellness programs. An ­example is the physical and mental health program for doctors called BPTOK, co-founded by Dr Bethan ­Richards and implemented at Royal Prince Alfred Hospital after three basic physician trainees in NSW took their lives early last year. Dr Teresa ­Anderson, chief executive of Sydney Local Health District, which oversees more than 11,000 medical staff, says new measures on the table include a review of rosters, greater supervision of trainees and ­sessions on stress relief.

Daniel Mezrani is keen to take on an advocacy role in schools and medical colleges, as are his ­sisters. Toogood is pushing ahead with his doctor wellness project CrazySocks4Docs and writing on advocacy issues in the medical press.

Change is slow

But change is slow, says Dr Leanne Rowe, a past chairman of the Royal Australian College of General Practitioners and a GP who counsels doctors. “There has been a lot of talk about the problems and very little commitment from any medical organisation to a comprehensive strategy across prevention, early intervention and crisis intervention for the whole profession.”

Victorian psychiatry registrar Ben Veness agrees. Nine months after we first chat, he tells me there have been meetings and focus groups but “little change in the environmental determinants of doctors’ health, and of course, more suicides”. He has new names to add to the grim roll-call: he’s got wind of the deaths of a medical student, an ENT registrar, an obstetrics and gynaecology registrar and a professor of surgery, among others.

Carmel has a similar story: she knows of at least two other doctors who have killed themselves on the Central Coast since Ramy’s death, and both fit the at-risk profile of a middle-aged male dealing with personal trauma such as marriage breakdown. Ultimately, she believes, true reform of the medical culture will only come through compassion and openness. Speak out, she urges. Let the sunlight in, let it disinfect the shame and stigma around suicide, make it easier for the struggling to swim to life rafts. Keep the issue alive, she beseeches — don’t let the dead be forgotten when the caravan of public interest moves on.

Geoffrey Toogood, the cardiologist saved by the clock, concurs. You can throw taxpayers’ ­dollars at the problem but ultimately it is simple human support that is sorely needed. Toogood credits friends reaching out to him as being as vital for his ­survival as therapy and medication.

He emails to tell me that one ­morning, while walking the dog with his young daughter, she asked if he would be worried if she became a ­doctor, given what he went through. “I told her I would be proud if she did, and that I am going to make sure the system is better by then,” he writes. “I promised her that.”

This article was first published on 05 May 2018 on sharonvergis.com and in the The Weekend Australian Magazine, May 5th, 2018.

Reprinted here with the kind permission of Sharon Verghis.