Doctors' Mental Health

Workplace scars

Author: Paul Hayes

Anxiety, depression, burnout, fear, anger – doctors experience the gamut of mental health issues. A recent cluster of suicides is shining some much-needed light on the often overwhelming pressures of a life in healthcare, as well as some of the options for help.

 

Chris*, a GP of five years who runs a successful group practice with three other doctors, recently visited the coroner’s court following the unexpected death of a child who attends his practice.

While he has debriefed with his peers about the incident and received medico-legal advice assuring him he was not at fault for the child’s death, Chris has been unable to shake strong feelings of guilt about how he handled the case. He has since become uncertain about clinical decision-making, leading to problems with time-management and a tendency to over-investigate patients. He is irritable, sleeping poorly and not enjoying his usual hobbies.

Chris recognises he is experiencing mental health issues that stem from his patient’s death and a number of other work-related pressures, but is unsure of the best way to access help and is hesitant to discuss the issue with his colleagues.

Stories such as this have become increasingly commonplace in Australian healthcare. An alarming rash of suicides within the profession in recent months has highlighted the fact that many doctors are not only struggling to cope with the burdens of their vocation, but also with how they can even acknowledge the issue and ask for help.

Long-time Brisbane gastroenterologist Dr Andrew Bryant, Sydney fourth-year doctor-in-training Dr Chloe Abbot, Sydney’s Dr John Moutzouris, who worked in renal medicine at Liverpool Hospital, and several more in healthcare all took their own life this year. Each of these suicides was attributed, at least in part, to the stresses and pressures of the life of a doctor and the fact they felt unable to discuss their issues.

‘Chloe said … that she was too scared to speak up to anybody about [a colleague’s recent suicide] in case she was put on suicide watch, too,’ Dr Abbot’s sister, Micaela, told the Australian Doctor Group.

The fact so many healthcare professionals are dealing with issues of mental health and find it so difficult to discuss begs the question: how can they get help?

There are options – their GP, psychiatrists, psychologists, professional support programs, etc. But a deeply-embedded professional culture in which doctors are often expected to ‘suck it up’ and build resilience, combined with an inability to do so often being seen as a sign of weakness, means accessing any mental health services, let alone acknowledging an issue, presents a range of problems.

Many in healthcare cite these issues of stigma, coupled with difficulties in ensuring privacy, fear of deregistration and the desire to continue helping patients, as major barriers in accessing care.

‘There is ample evidence that, as doctors, we are not good at taking care of ourselves and seeking appropriate professional help, whether for routine medical care or when we have a problem,’ Dr Joanna Flynn, Chair of the Medical Board of Australia (MBA), told Good Practice. ‘This is not good for us, for our patients or for the profession as a whole.’

 

Finally talking about it

Following Dr Bryant’s suicide, his wife Susan penned a powerful open letter in which she outlined his anxieties about ‘private practice, about being behind in his office administration, about his practice finances, about some of his patients, about his competence’ in the days and weeks prior to his death. Susan Bryant didn’t want her husband’s suicide to be a mystery, an issue people would be afraid to discuss because of fears that surround people in healthcare admitting to and seeking help for depression and other issues of mental health.

‘I don’t want it to be a secret that Andrew committed suicide,’ she wrote. ‘His four children and I are not ashamed of how he died.

‘If more people talked about what leads to suicide, if people didn’t talk about [suicide] as if it was shameful, if people understood how easily and quickly depression can take over, then there would be fewer deaths.’

News of so many doctor suicides hit Dr Eric Levi hard, and Susan Bryant’s letter – in which she also wrote that Dr Bryant took his life despite having access to help and no pre-existing mental health conditions – awoke more feelings. Dr Levi, an experienced ear, nose and throat surgeon, was moved to write a blog post, ‘The dark side of doctoring’, discussing his own negative experiences and how life as a surgeon has at times led to feelings of depression, anxiety, burnout, hopelessness, lethargy and worry.

‘When I carefully dissect my dark seasons, some common themes often emerge,’ Dr Levi wrote. ‘Work is often the critical exacerbating and perpetuating factor in those dark times.’

The blog proved to be something of a turning point in starting a more open dialogue, a genuine discussion, about doctors and mental health issues associated with their profession.

‘My blog post had about 260,000 views. Obviously, it is something that a lot of medical practitioners feel,’ Dr Levi told Good Practice. ‘That sense of loss of control of their practice, a sense of loss of support because they’re always moving, always having to go to different places during their training, and a loss of meaning in this world of modern medicine.’

The issue has since taken on a huge profile in traditional and social media, sparking not only myriad debates and conversations across social media and in multiple publications, but real-world campaigns like #Socks4Docs and #CrazySocks4docs, when healthcare professionals throughout Australia wore odd socks as a sign of solidarity for one another.

‘It’s absolutely devastating that this conversation was only generated after the loss of my sister, but we need to get these important changes in place,’ Micaela Abbot said at an Australian Medical Students’ Association conference earlier this year. ‘Chloe’s death can’t be a waste.’

Cardiac surgeon Dr Geoff Toogood is one of the most prominent voices in the discussion and the main driver of the #Socks4Docs campaign. He has been very open about his own experiences with severe depression and suicidal thoughts in 2013, saying he found the process of initially discussing his problem and accessing appropriate help a problematic one.

‘I faced issues of privacy, stigma – you can tick all the boxes,’ he told Good Practice. ‘More people knew about my illness than I’d told, so obviously the news spread. I had some discrimination.’

This discrimination was compounded when his many responsibilities were challenged by trying to take time away from work in order to address his illness.

‘There’s the roster, you’re on call, people are emailing you and asking, “When are you coming back?” You don’t need that, it doesn’t help,’ Dr Toogood said. ‘Applying guilt to someone who already feels guilty for taking leave for an illness – which most people think is in your head and you’ll be able to get up the next day and feel better – is not helpful for recovery.

‘That is a barrier, but it’s more of a long-standing cultural issue.’

Dr Toogood was ultimately swayed about not returning to work when discussing his issues with his own GP.

‘I remember my GP saying, “You can’t go back to work today or this week”, and I said, “I’ve got all these patients and procedures. What’s the hospital going to do?”’ he explained. ‘She told me, “It doesn’t matter. If you go back to work, then they won’t have you to look after them”. She was that blunt.

‘Then she said, “I’ll ring them to tell them that you can’t go”. I needed that.’

 

From all sides

Long hours and a heavy workload, fear of making mistakes, stresses of work and study, balancing work and personal responsibilities, burnout, less contact with patients, and many more factors rate as significant areas that contribute to mental health issues among doctors.

‘The increasingly bureaucratic, or industrialised, modernisation of health practice means you get a lot more clerical duties associated with being a doctor. The system is getting more complex,’ Dr Levi said.

‘It eats away at why I went into medicine in the first place.

‘I went into medicine to be a doctor but, here we are, only spending a third of our time actually physically with patients, talking to patients.’

According to Dr Mukesh Haikerwal, a long-time GP and mental health advocate, many of the pressures doctors face are present throughout their healthcare journey.

‘The levels of stress start from the very beginning,’ he said. ‘What underpins it all is a stressful upbringing, if you like, to get to a position of being fully ready or trained as an independent practitioner.’

Dr Levi described his training years as mentally and emotionally challenging.

‘As a resident and junior registrar, [my family and I] were moving from one country town to another every three months. With a young family, you can imagine the kind of social impact that has when you move every three months or every six months,’ he said.

‘Working after hours, working late, missing significant social events, birthdays, anniversaries, reunions. That chips away at your social network.

‘My traditional social network was essentially non-existent because for up to four years of my life I was being a nomad and moving around.

‘It takes away your sense of control over your own career. It’s all determined by other people.’

Dr Levi has found this type of personal stress, on top of the work itself, studying for exams and the driven nature of people who take on a life in healthcare, will often have a significant effect on the mental health of young doctors as they get a taste of their new lives.

‘I spoke to medical students recently and said, if you have an underlying mental health disorder and you walk into medical training, it’s a tough training … that will almost certainly exacerbate your pre-existing mental health conditions,’ he said. ‘If you don’t have a mental health condition, you actually might be predisposed to experiencing the symptoms of mental health conditions as you go through training.

‘[Medical students/practitioners] are often made up of high-achieving, goal-driven, intense individuals. Healthcare attracts that group of people, and the need to maintain a high level of performance is one of the things we often have as medical practitioners.

‘Therefore, letting our guard down, by allowing other people to know we have mental health conditions, is something that may be considered a negative thing.’

Doctors’ concerns about discussing their issues of mental health are often exacerbated by fear of Australian Health Practitioner Regulation Agency’s (AHPRA’s) mandatory reporting laws for healthcare professionals and the potential for deregistration. According to those laws, doctors must inform AHPRA ‘if they have formed a reasonable belief that a registered health practitioner has behaved in a way that constitutes notifiable conduct’.¹

Many in healthcare believe these rules to be restrictive and a key reason so many are reluctant to discuss their own issues. According to Dr Flynn, however, there is a widespread misunderstanding, or misinterpretation, within healthcare as to what doctors have to report when treating other doctors.

‘It is important all doctors realise that the threshold for requiring a mandatory report is high, and is only reached when an impaired doctor is placing the public at risk of substantial harm,’ she said. ‘It should not deter us from seeking help and support when we need it.’

Regardless, efforts to at least soften the laws – essentially exempting clinicians from having to report impaired colleagues – have gathered momentum in recent months, with Federal Minister for Health Greg Hunt supporting measures designed to better protect doctors. A spokesperson for Hunt told Fairfax Media earlier this year that the Federal Government was working with all states and territories to alter the laws and establish ‘a common national standard to protect the mental health of doctors’.

One of the keys to helping healthcare professionals discuss their issues with other doctors is a better understanding of the idea that most people experiencing mental health issues are usually perfectly capable of competently performing their professional tasks.

‘We know that one in five Australians in any 12-month period, and 45% of us in our lifetime, experience symptoms consistent with a mental illness. If every doctor didn’t work because they had a mental illness, we would be seriously short of doctors,’ Dr Caroline Johnson, a mental health advocate and GP who often treats other healthcare professionals, told Good Practice.

Dr Levi agrees that a mental health issue does not equal incompetence.

‘No doubt, if you’re an impaired medical practitioner something needs to be done to protect the practitioner and the patient, but that’s a different group,’ he said.

‘I’m talking about practitioners who are competent and safe, but have an underlying mental health condition, a group of essentially well-functioning medical practitioners who do have mental health issues, but who are afraid to report for fear of what restrictions will be put upon their practice.

‘These people are the ones who are not seeking help because of the fear of being reported.’

In her experience, Dr Johnson has found that doctors run a much greater risk to themselves and their patients if they avoid seeking help out of any underlying fear for their career or reputation.

‘Doctors should be careful not to put themselves above that professional responsibility, which is to be well enough to do your job well,’ she said. ‘If a doctor has a question in their own mind about whether they’re fit to practise, then it’s the responsible thing to do to have a conversation with someone else who is an expert in the matter as to what they think about your fitness.

‘In that setting, when someone is seeking help, acknowledging that they have a problem and doing something about it, I would say their likelihood of being safe as a practitioner is much higher than if they ignore it, put their head in the sand and don’t get help at all.’

 

General practice and other services

Dr Leanne Rowe, a GP and co-author of First do no harm: Being a resilient doctor in the 21st century, believes a vital first step for healthcare professionals being able to properly address any mental health issues is a seemingly simple, yet surprisingly under-utilised one.

‘I’m trying to encourage all doctors to have a regular preventive health assessment every year,’ she told Good Practice. ‘That is important for a number of reasons – everyone should have a health screening based on the RACGP’s Red Book [Guidelines for preventive activities in general practice], including mental health screening. If mental health screening is undertaken routinely, it is non-stigmatised.

‘Routine health assessments are also an opportunity for doctors to build a trusting relationship with their own GP, which makes it easier for them to access good care if they hit challenges down the track. It makes it easier to access confidential mental health care with a trusted person, particularly in a crisis. 

‘Around 50% of doctors don’t have their own GP. I think we as a profession should be pushing for a campaign for every doctor to have their own trusted GP. Not just someone you might see once in five years, but someone you see at least annually so you have some continuity of care.

‘It’s quite a simple strategy, but I think it’s very effective.’ It is important to note, however, that the ability to treat other doctors is a skill unto itself. Dr Johnson has found managing doctors the same as she would any other patient, with some caveats, can be an effective approach.

‘I say to doctors upfront that I’m going to assume you don’t know all the stuff that you probably do know, because it’s a bigger risk – for me – assuming that you do know something, but later finding you haven’t thought of it,’ she said.

‘The second part of that conversation is to say that you also bring a lot of expertise and knowledge and I would really encourage you to talk to me about that.

‘I expressly address things like the temptation to self-refer and self-prescribe, and talk about boundaries around that.

‘We then create a set of informal rules around how the doctor–patient relationship will work, which is not that dissimilar to what I would do with every patient.

‘Most of the time people say, “I’m really grateful for that. I don’t want you to treat me like a doctor, I want you to treat me like a patient”.’

Beyond their own trusted GP, Australian primary healthcare professionals can also access the RACGP’s GP Support Program. Designed to help maintain the wellbeing of doctors anywhere in the country, the program provides professional advice to help with a range of issues, including work pressure, anxiety and depression, traumatic incidents, grief and loss, alcohol and drug issues, and more.

Doctors can also make use of a number of expanded health services as part of the MBA’s national health program, which was rolled out in 2016.

The Doctors’ Health Services, or ‘drs4drs’, are designed to offer confidential health-related triage, advice and referral services; follow-up services, including support and advocacy in returning to work; education, awareness-raising and advice; training to support doctors to treat other doctors; and facilitation of support groups.

‘The [MBA] encourages all doctors to take care of themselves, and look out for each other and seek help when they need it,’ Dr Flynn said. ‘We fund the Doctors’ Health Services to make it easier to access health services, and to make sure that help and support is available in each state and territory.’

Dr Johnson believes the realities of a life in healthcare are such that these types of services must be expanded upon, and more should be established, in order to provide doctors and others in the profession the best possible help to competently undertake what will always remain a fundamental aspect of people’s lives.

‘To be honest, I don’t think we can make healthcare less stressful, inasmuch as people will have serious illnesses, people will die, bad things will happen. That’s the nature of a lot of acute healthcare,’ she said.

‘We have to work on supporting each other, supporting our young doctors to develop the skills to cope with that, and I think sometimes we fall short there.’

 

* Not his real name.

 

Reference

1. Australian Health Practitioner Regulation Agency. Mandatory reporting. Canberra: AHPRA. Available at www.ahpra.gov.au/Notifications/Make-a-complaint/Mandatory-notifications.aspx [Accessed 6 July 2017].