How to avoid flinching when hurt (and other bad advice)

The slap didn’t register for the first few seconds, but the spit landing across my face brought out tears. For a brief moment, I felt intensely ashamed and confused. Then, thankfully, my clinical brain kicked back in. This patient needed sedation and restraint, transport out, hospital executive needed to be notified, etc etc etc. 

I was a junior resident in a rural urgent care, staffed by other residents that like me were seconded from the large hospital hours away, and supported remotely by GPs in the busy clinic in town. Everyone was doing their best, but it was difficult. And the assault itself, in a funny sort of way, didn’t really bother me. The deeper injury occurred later. 

I decided not to call my family or friends; they’d worry and wouldn’t understand why I was going back to work. Instead, I went back to my assigned apartment alone. One of the other doctors (whom I barely knew) came over, cooked me dinner, gave me a bottle of sav blanc and then left to go to his own shift. 

At the time, it didn’t feel like a watershed moment in my descent into alcoholism, but in retrospect it’s telling. Doctors learn to compartmentalise their own distress and emotions in order to get on with the job; we lose the capacity to discuss how we’re feeling and coping, and deflect into intellectualisation to cope. In Gabor Mate’s theory on addiction, emotional mis-attunement and attachment injury result in a reliance on external foci to soothe internal distress, and thus vulnerability to developing behavioural and substance abuse disorders. As a physician himself, he describes his own obsessive workaholism as “the self-oblivion …of constant need for consuming activity”, and the always escalating “anxiety, ennui and fear of the void” driving him onward. As much as we find the label distasteful, he courageously calls it addiction. 

Substance abuse among doctors is probably much more common than we realise, with prevalence estimated at 8-15%, and risk factors including overwork, specialty and psychiatric comorbidity (especially anxiety and depression). The barriers to doctors recognising their issues are significant, and can be summarised into: denial, misunderstanding and stigma around addiction, tendency to over-emphasize their own capacity to force themselves well, over-emphasis on professional identity. 

Perhaps most telling is the following statement in F Vayr et.al: Physicians have a “natural tendency … [to] ignore their own impairment. … Admitting to having a problem and to a greater extent seeking assistance are almost impossible ... because healthcare providers are expected not to complain and never to acknowledge their needs”. 

Barriers to seeking help are similarly significant, not least of which is the fear of reporting to the regulator. Bradfield’s research into the impact of AHPRA on unwell doctors is sobering, with doctors reporting that regulatory processes triggered psychological distress, symptom relapse, and adverse financial and vocational implications. AHPRA’s processes have now changed, and they have implemented many of the strategies from the expert advisory group on minimizing practitioner distress. 

With all of this in mind, how does one reach out to doctors with substance use issues, before it becomes so disastrous it is impacting their professional lives? The simplest answer is perhaps the most obvious; education, story-telling, and safe spaces to seek help. My own recovery would not have been possible without the wonderful work done by my state Doctor’s Health Program, and I’m endlessly grateful for their efforts; tireless, patient, compassionate and quiet, and so often unacknowledged. 

Gen is an Australian emergency doctor.