THE well known 2013 beyondblue national mental health survey of about 14 000 doctors and medical students reported that over 10% experienced suicidal thinking in the previous year. Five years on, we have failed to address the scale of our problem and we continue to confront the tears behind the statistics of high levels of suicide in the medical profession in Australia and globally.
How can we prevent doctor suicide at a local and a national level?
We can destigmatise mental illness for doctors and medical students
First, we can change the negative attitudes to mental illness in our profession by accepting that doctors and medical students have the same risk factors as the general population. Unsurprisingly, we may have family histories of mental illness and alcohol and substance misuse, chronic illness or pain, negative life experiences and relationships, fractured family structures, family of origin histories of violence or suicide, and histories of child abuse. When patients with these common problems seek our help, we may experience “triggering” of our own histories.
In addition, we often have perfectionist, self-critical, hypervigilant and task-oriented personality styles that make us great doctors, but put us at risk of failing our own impossible expectations. Only by fully understanding our potential vulnerabilities can we be proactive in mitigating them.
However, instead of recognising our common risk factors, most doctors wear well developed emotional “masks” due to the damaging stigma of mental illness, and as a consequence, many of us fail to identify signs of distress in our colleagues, particularly when functioning well at work. Unfortunately, unhappiness, stress and burnout are often regarded as normal in medical workplaces, rather than as warning signs of mental illness.
In reality, disclosure of doctor distress often results in “career suicide”, the unfortunate term whispered in medical workplaces. Our harsh medical culture is intolerant of doctors who are “not coping”, “emotional”, “overly sensitive”, “not up to it” and “not pulling their weight”. The beyondblue study documented some of these common negative attitudes, with about 40% of doctors unfairly judging colleagues with a history of mental health problems as less competent than their peers.
In view of this systemic stigma, if we suspect a colleague is quietly suffering, we need to do more than ask “are you okay?” or send a superficial SMS. Making time to meet one on one for an informal coffee to connect and listen is an effective way to offer each other mutual support. Spending a 10-minute break with another doctor without our “masks” to destigmatise our common feelings, rather than withdrawing behind our computer screens, can be one of the most important parts of our busy day.
We can encourage all doctors and medical students to have their own trusted independent doctor
The systemic stigma and fears about career ramifications, breaches in confidentiality, having to take time off work, and mandatory reporting often deter doctors from seeking help for mental health issues. Only about 50% of us have our own treating doctor, and if we do, we tend to present late or in crisis, partially self-medicated, and with a poor prognosis, rather than for early intervention.
To manage these challenges, we can help encourage all our colleagues in our workplaces to have regular annual preventive health assessments with their own independent GP, including routine mental health screening. By building a trusted relationship with a treating doctor, we are more likely to also attend for routine debriefing, optimal early mental health intervention, and postvention after direct or vicarious traumatisation, particularly involving suicide.
As doctors, we are in a better position than most patients to use our networks to find the right help, including accessing independent GPs outside our geographical area of practice, doctors’ health advisory services or telehealth support for those of us who are working remotely or doing shift work.
As we know well, there are significant penalties for breaching patient confidentiality under the Privacy Act, which apply to doctor patients too. We need to dispel the myths of mandatory reporting by reminding ourselves of the high threshold for making a notification in the Medical Board Guidelines, which state:
“The intention is that practitioners notify [the Australian Health Practitioner Regulation Agency] if they believe that another practitioner has behaved in a way which presents a serious risk to the public. The requirements focus on serious instances of substandard practice or conduct by practitioners, or serious cases of impairment, that could place members of the public at risk”.
This is rarely the case.
We can provide early, optimal management of mental health problems in doctors and medical students
Like other patients, doctors do not always have insight into their own problems, and we should get better at the early recognition of the atypical symptoms of mental illness our colleagues may exhibit at work, such as uncharacteristic irritability or anger, difficulty concentrating or making decisions because of excessive worry, lack of empathy, social withdrawal and/or fatigue or low energy due to insomnia. However, we should never become a treating doctor to a colleague at work or a friend because we cannot offer them optimal comprehensive assessment or management, including relapse prevention, medication monitoring or suicide risk assessment.
In my experience as a GP treating other doctors, I have learnt to recognise that doctors may present with a mixed pattern of depressive disorder, anxiety disorder and post-traumatic stress disorder related to acute and chronic exposure to patient misery, violence, abuse and death, including suicide, which makes diagnosis and treatment challenging.
To add to these management challenges, I have found there are pitfalls in self-help strategies and psychological therapies for doctors, who tend to overthink due to having well developed negative mental filters and negative cognitive biases. Being risk averse is part of being a good doctor. It is not easy to overcome this strong trait by challenging negative thinking with the usual cognitive behavioural therapy techniques. Structured formal mindfulness-based cognitive behavioural therapy has been found to be one of the most effective treatments for depression, but how many doctors actually know what this involves?
As doctor suicide is more common than in the general population, doctors are frequently traumatised by a colleague’s death and then placed at risk of suicide themselves. For patients at risk, doctors are trained to respond: “Many people who are under extreme pressure feel like harming themselves. Have you ever felt this way?” This can be a difficult question to ask a colleague in distress, but it is an essential part of ongoing suicide risk assessment.
For all these reasons, doctors and medical students may require training to care for the special needs of medical colleagues.
We can change our medical culture
A medical career has never been more challenging or complex, and doctors, like all health professionals, require support. Although doctors tend to take very little sick leave, many medical workplaces fail to support doctors when they request a lower patient load or time off work because of skeleton medical staff levels, which is a major occupation and safety issue.
We can make our diverse clinical teams more effective by valuing, respecting and including every member, “disagreeing well” and encouraging peer review and healthy debate to continually improve our standard of patient care. While disagreements with our colleagues are inevitable in the complex world of medicine, we need to learn to be supportive and to give and receive feedback or criticism in a constructive and positive way.
Each of us can recognise our leadership role in nurturing the next generation of doctors, just as our teachers gave their time to train us. We must talk to our students and registrars about the tough issues and empower them with the skills to manage them.
To our shame, the families of young doctors who have died by suicide have recently described our medical culture as “soul crushing”. Systemic occupational health and safety issues predisposing doctors to mental health problems include bullying, harassment, discrimination, racism, and escalating patient complaints and medico-legal action. Recommending information about resilience to doctors for these complex issues is as foolish and harmful as trying to fix a displaced compound fracture by covering it with a dressing.
We can call out harmful biases, bullying, discrimination, racism and harassment for our colleagues and our patients. Colleagues who display these poor behaviours usually have insecurities, arrogance, anxiety disorders or personality disorders, and they need our help because they are sometimes reckless, unsafe and oblivious. Staying neutral and turning a blind eye are also unacceptable behaviours.
We can make our medical organisations work for us
Five years after the beyondblue survey results were released, a number of medical organisations have set up forums, conferences, websites, doctors’ health services, mentoring programs and other mental health initiatives, but these activities are yet to address the scale of our problem, our complex systemic issues and our challenging culture at a national level. Many programs are currently being evaluated and are yet to be promulgated across the country.
Each of us can engage with our fragmented medical organisations to make them work together and present a powerful united voice of advocacy for doctors at a national level. In addition, our often overlooked medical defence organisations can help us mitigate clinical risk and respond to patient complaints and legal action, which are the cause of much distress in doctors.
Medical organisations can also integrate doctors’ mental health solutions in national and state conferences; offer training doctors to care for the special needs of other doctors and medical students; provide resources and education on healthy organisational culture and how to address bullying, harassment and discrimination; and include mental health promotion and information more prominently in newsletters and websites on an ongoing basis.
Doctors’ health programs must also be tailored to address the special needs of groups of doctors more at risk, including young doctors, women, Indigenous doctors and doctors trained overseas.
We “are doing” or “have done” doctors’ health is not enough. Many doctors and medical students are not “okay”, and their quiet suffering is affecting their standard of patient care and their ability to stay in the medical workforce. While we have many competing priorities in medicine, the poor mental health of doctors and medical students, which reflects global trends, deserves ongoing urgent action by the whole medical profession and all medical organisations.
Most importantly, together, we can all celebrate the great aspects of being a doctor, such as the joy and satisfaction in making a difference to people’s lives, the deep insights into life, working with people from diverse backgrounds and learning about amazing advances in medicine.
None of this is easy, but we can prevent the tragedy of doctor suicide – together.
Clinical Professor Leanne Rowe AM is a GP and co-author of Every Doctor: healthier doctors = healthier patients. Her MD is on the topic of cognitive behavioural therapy, and she served on the Victorian Premier’s Suicide Prevention Taskforce. She is a past Chairman of the Royal Australian College of General Practitioners, board member of beyondblue and Deputy Chancellor of Monash University.
If this article has raised issues for you, help is available at:
Doctors’ Health Advisory Service (http://dhas.org.au):
NSW and ACT … 02 9437 6552
NT and SA … 08 8366 0250
Queensland … 07 3833 4352
Tasmania and Victoria … 03 9495 6011
WA … 08 9321 3098
New Zealand … 0800 471 2654
Medical Benevolent Society (https://www.mbansw.org.au/)
AMA lists of GPs willing to see junior doctors (https://www.doctorportal.com.au/doctorshealth/)
Lifeline on 13 11 14
beyondblue on 1300 224 636
beyondblue Doctors’ health website: https://www.beyondblue.org.au/about-us/our-work-in-improving-workplace-mental-health/health-services-program
The statements or opinions expressed in this article reflect the views of the authors and do not represent the official policy of the AMA, the MJA or MJA InSight unless that is so stated.