THE catchy lyrics of M*A*S*H* tell us that “Suicide is painless, and brings on many changes, and I can take or leave it as I please”. In reality, suicide inflicts deep wounds, and has a ripple effect far and wide across loved ones, family, friends, colleagues and the community.

In the medical profession, it seems that doctor suicide has been shrouded in secrecy for some time – we know it happens, but nobody talks about it. The recent, highly publicised suicide of Dr Andrew Bryant, a prominent Brisbane gastroenterologist, has changed this. In a brave and widely circulated email, Andrew’s wife, Susan, pleaded to our profession, to openly discuss factors and events that led to him taking his own life, in the hope of preventing similar tragic deaths.

“I don’t want it to be a secret that Andrew committed suicide. If more people talked about what leads to suicide, if people didn’t talk about as if it was shameful, if people understood how easily and how quickly depression can take over, then there might be less deaths. His four children and I are not ashamed of how he died.”

In our profession, suicide is more common in female doctors, particularly young women, than in the general population. There are many reasons for this (Boxes 1-3) — biological, psychological and environmental — which are the focus of discussion at present within medical women’s societies in Australia and the Australian Federation of Medical Women.

Box 1

Psychosocial contributors to doctor suicide
High prevalence of Axis I disorders

  • Mood disorder, alcohol or substance misuse
Cognitive style

  • Suicide as a rational choice (especially for women)
Psychosocial factors
Role strain

  • Lack of personal support and excessive occupational demands, competing life responsibilities (especially women)
Role conflict

  • Career dissatisfaction (educational debts, unrealistic expectations from patients, pressure on performance and continuing education, insurer rankings, worries about medical malpractice, loss of social status and competition from other health providers
Personality style

  • Obsessive compulsive, dysthymic, oriented on achievement, conscientious, introvert, anxious, self-blaming, sensitive
  • Excessive reliance on self, high expectations of self, non-disclosure of personal distress

* Adapted from Sansone RA, Sansone LA. Physician suicide: a fleeting moment of despair. Psychiatry (Edgmont) 2009; 6: 18-22.

We are reminded by Andrew’s death that suicide in doctors occurs across the genders and all age groups of our profession. And we know that suicide is only a fraction of the problem when considering depression and anxiety among doctors. The 2013 beyondblue National mental health survey of doctors and medical students documented the higher rate of psychological distress, including attempted suicide rates among doctors and medical students when compared with the Australian population and with other professions. Stigma associated with mental illness was identified as an ongoing concern for medical professionals, potentially worsening their symptoms and reducing the opportunity for doctors to seek help for their mental health problems.

So what can we do to honour Dr Bryant’s death and Susan’s heartfelt and utterly justified call to action?

First and foremost, we must start discussing openly, frankly and without shame the risk factors for doctor suicide, and the stressors that lead to mental health problems in physicians. And importantly, we need to remove the stigma from a doctor seeking help.

We need to encourage all doctors to ensure they have a trusted GP or physician to turn to at times of distress and fatigue, someone who can tease out the emotional factors from the physical and medical issues (Boxes 2), so that help can be provided swiftly, professionally and compassionately. Someone who can respect confidentiality and tactfully arrange investigations in a way that ensures the dignity of the person being laid bare on “home territory”.

Box 2

Lifestyle related reversible and treatable physical contributors to fatigue and depression
Sleep disorders

  • Sleep deprivation
  • Obstructive sleep apnoea
  • Circadian rhythm disturbance
Substance misuse and dependence, including nicotine, caffeine and energy drinks
Nutritional disorders

  • Obesity and metabolic syndrome
  • Eating disorders
  • Nutritional insufficiency (including iron deficiency, and deficiencies of vitamins B12, D and C
Physical, neurological and movement disorders

  • Lack of exercise and fitness
  • Chronic pain
  • Excessive physical exertion
Endocrine disorders

  • Cortisol and prolactin excess due to stress
  • Thyroid failure and thyroiditis
  • Diabetes
  • Other hormonal problems
Chronic allergy
Cardiac disease, including undiagnosed chronic hypertension
Chronic low grade infection, autoimmune disease, bleeding and early malignancy
Gastrointestinal disease, including low grade enteritis such as irritable bowel syndrome, coeliac disease, helicobacter and parasitic infection, Crohn’s disease and inflammatory bowel disease

Source: Personal communication from Dr Lydia Pitcher

This also means managing the barriers imposed by mandatory reporting. And within the many hours of required continuing education for our professional bodies, more time could be allocated or acknowledged for health and wellbeing training and support for doctors.

There have been a number of high quality position statements published in recent times, including the Australian Medical Association’s 2011 Health and wellbeing of doctors and medical students, and the Royal Australasian College of Physicians’ Position statement on the health of doctors. These, together with the beyondblue report, provide a good framework for ongoing action. Several factors emerge as key driving points for change: dealing with doctor empathy, doctor fatigue and doctor resilience.

Empathy is not only crucial for doctors to show their patients, but it’s also vital that they receive it as well, especially from their workplace, colleagues and patients if we want to prevent burnout. The trend in our society in general, it seems, is to harden and show less empathy, but empathy can be learned and taught. It starts by speaking out so others can become aware of what you are going through. It does not help to deny our vulnerabilities, but among doctors, there are particular concerns that this may be embarrassing, seem shameful or expose weaknesses.

Doctor fatigue is explicitly described in Susan’s account of the factors that contributed to Andrew’s death. Physical factors (Box 2) leading to doctor fatigue are easily overlooked or trivialised, and it is important to manage these in conjunction with mental factors, including compassion fatigue or burnout, as they are inextricably related. Specific to the health profession, we should be aware of the consequences of sleep deprivation and circadian disturbance.

As described by Sarris, there is emerging and compelling evidence that nutrition is a key factor in the high prevalence of mental health disorders, and it is as important to psychiatry as other specialties such as cardiology, endocrinology and gastroenterology. Among the causes of fatigue, both mental and physical (including iron and vitamin B12 deficiency), young women are especially vulnerable due to the added demands placed on their bodies and minds by fertility concerns, pregnancy, breastfeeding and menstruation (Box 3).

Box 3

Specific physical issues for women
Menstrual and gynaecological disorders, including abnormal uterine bleeding, endometriosis and adenomyosis
Fertility concerns, investigation and treatment
Pregnancy and breastfeeding
Post-natal depression
Postpartum sleep deprivation
Menopause

Source: Personal communication by Dr Lydia Pitcher

If doctors are encouraged to invest time in building a trusting relationship with their own medical practitioner, clinically concerning fatigue may be more likely to be recognised early. Time constraints, a lack of familiarity, shame or denial are all barriers to seeing a GP in busy doctors’ lives. It is paradoxical and ironic that doctors oversee the personal health and wellbeing of their patients, often at the expense of their own. Think not only of nutritional insufficiency but also obesity, alcohol excess, lack of exercise and sunlight, poor dental hygiene and low prioritisation of preserving secure relationships and intimacy.

The Harvard study on ageing shows us again the importance of feeling securely attached to our partners to prevent depression. And Daniel Buettner (The blue zones), when analysing human longevity, identified among his nine key factors spirituality, family connectedness and social networks as critically important. We need to ensure that doctors are not only intellectually capable, but are also consciously taking sufficient time both within and outside work to relax, enabling the recharging of physical and mental reservoirs.

Compassion fatigue is a form of burnout, caused by secondary traumatisation, and is highly prevalent in health care professionals. It is associated with reduced job performance, increased psychological distress, poor career satisfaction and decreased ability to express empathy (here and here). If identified early, it is treatable with potential positive outcomes for patient care, medical professionalism, the safety and wellbeing of the doctor and the sustainability of the health care system.

This leads us to resilience, a dynamic, evolving process of positive attitudes and effective strategies. It is critical to reducing doctor stress, so we can bend psychologically rather than break when faced with challenges of our day to day lives. The Council of Doctors in Training of the Australian Medical Association Queensland recently developed the Resilience on the Run (ROR) Program to deal with specific problems that young doctors face, to provide future life skills for when they face workplace and interpersonal issues. We can learn important lessons from the robust evaluation of the ROR Program, which to date has been provided to more than 350 interns in Queensland.

The development of this program was informed by an extensive search in international literature. Central to its objective is the intensification of personal awareness aided by the skill of mindfulness, which has a proven positive association with resilience, increasing doctors’ wellbeing, professionalism and attitudes to patient care (here, here, and here), and a negative relationship with burnout.

Designed to be implemented in a group environment, the ROR Program encourages the sharing of personal experiences, leading to engagement and bonding. Awareness of personal stressors for burnout and compassion fatigue are discussed. The stigma of identifying and discussing psychological struggles is decreased by creating a greater understanding that others may be in the same circumstances. It also creates much needed empathy among colleagues and may counteract isolation. Evaluation of the ROR Program showed that it was particularly important that the trainer is an experienced, senior psychiatrist and, therefore, knowledgeable about mental health and work place problems for doctors in particular.

Resilience training could deal with some of the concerns that were expressed in relation to workplace stress in the medical environment. the frustrations of doctors because of increased bureaucracy and demands, expressed recently in a post by Dr Eric Levi.

Doctors need to become aware and speak out about what they are willing to accept and what elements they cannot accept in their work. This has to lead to a broader discussion about how we want to regulate our workplace, and how we can prevent workplace bullying within our own profession and training system. The previously mentioned beyondblue report also showed that the transition from medical school to the workplace appears to be a particularly stressful period in the medical career. The ROR Program is managing this. But what are the targeted interventions that should be put in place for other groups? Senior doctors and doctors working in the isolation of solo or private practice also require special consideration.

There is so much more to be said and done, and an opinion piece can only shed light on a fraction of this problem. But in conclusion, we feel the need to ask the question: are current systems of support, training and surveillance of doctors’ physical and mental wellbeing enough? The recent reports of doctor suicides in young women and our senior male colleague, Andrew, would suggest otherwise.

How can we better ensure that every doctor has their own trusted physician or general practitioner to oversee their health, rather than Medici, cura te ipsum (physician, heal thyself)?

There has been a strong commitment to the Doctors’ Health Advisory Service nationally. We need to ensure that available programs like these, as well as employee support programs and training such as the ROR Program, are adequately advertised, encouraged and destigmatised, and made widely available so that doctors will access help when and where needed. They must feel that they can seek assistance, without the fear of loss of privacy or unfair repercussions.

Peer support groups, such as the state-based medical women’s societies, and the nationally representative body, the Australian Federation of Medical Women, can help to deal with the problems facing in particular young females in the medical profession. The Queensland MWS plans to host a dinner discussion on this topic in October 2017. Should there be a national think-tank with leaders from this area, to drive further change?

Another option, suggested in response to the death of a colleague in similar circumstances to Andrew’s, has been to raise funds for a faculty and chair of doctors’ mental health, which can enable good quality research in prevalence numbers, risk factors, calls for actions and evidence-based prevention programs.

Doctors need to regain their sense of control in their work–life balance and in their profession, and to be able to access their own trusted doctor at times of need. We have to discuss mental health, and be able to speak honestly and be heard in times of challenge in our medical work. We must care for one another with the empathy we too often reserve for patients. And as in Susan’s courageous plea, we must not and will not be ashamed to discuss this more.

Dr Lydia Pitcher is a haematologist and oncologist, an executive member of the Timor Children’s Foundation and President of the Queensland Medical Women’s Society.

Dr Ira van der Steenstraten is a Netherlands-trained psychiatrist. She currently works as a life coach and has created Resilience on the Run and Rapid Resilience for the Australian Medical Association Queensland. She is the vice president of the Queensland Medical Women’s Society.

Co-authors:

Dr Kathryn Mainstone
Dr Mellissa Naidoo
Mrs Kirsty Whitmore
Mrs Susan Bryant

 

If this article has raised concerns for you please contact:

Lifeline 131 114
beyondblue 1300 224 636
Doctors Health Advisory Service (helpline and office, 24-hour phone assistance):

NSW and ACT
02 9437 6552
www.dhas.org.au

NT and South Australia
08 8366 0250
www.doctorshealthsa.com.au

Queensland
07 3833 4352
dhasq.org.au

Tasmania and Victoria
03 9495 6011
www.vdhp.org.au

Western Australia
08 9321 3098

New Zealand
0800 471 2654

 

To find a doctor, or a job, to use GP Desktop and Doctors Health, book and track your CPD, and buy textbooks and guidelines, visit doctorportal.

 

 


Poll

Mandatory reporting laws dissuade doctors from seeking help for mental health issues
  • Strongly agree (68%, 368 Votes)
  • Agree (26%, 141 Votes)
  • Neutral (3%, 16 Votes)
  • Disagree (2%, 11 Votes)
  • Strongly disagree (1%, 8 Votes)

Total Voters: 544

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6 thoughts on “Dear Dr, find someone you trust and start talking

  1. Anonymous says:

    Mandatory reporting per se is not the problem. We need instead to ask why mandatory reporting might dissuade doctors from seeking help. Mandatory reporting is only a problem if it results in unfair and drawn out processes which add to the stress and distress of the doctor concerned. If mandatory reporting resulted in a process that supported the doctor, that facilitated access to good medical and psychological care and that fundamentally expedited the return to wellness and to safe work, then it wold be a good thing. The problem is that this is not presently the case. Doctors can be precluded from the workforce for lengthy periods with no support or even clarity around what the process is to enable their return to work. I have seen this many times in my patients who are also doctors and who have mental illnesses (typically depression or Bipolar affective disorder). This loss of control and agency contributes to suicide risk. Instead of throwing out mandatory reporting we need to insist on better processes (from AHPRA and the MBA) to make the system safe and effective.

  2. Anonymous says:

    ……………and I don’t even want to see a GP for fear of mandatory reporting now or in the future when consultations could be held against me. My health is so intricately related to my affective state that to delete it from a discoverable consultation would negate the value of a GP consultation. Cheers

  3. Dr Greg Mewett says:

    An important aspect of doctor well-being that is hardly ever mentioned is that of clinical supervision. This of course has been for years embedded in other helping professions such as psychology, social work, counselling and is a crucial part of most psychiatrist’s working life.
    By supervision I don’t mean overseeing a doctor’s competence (there are other mechanisms for that after post-grad training) but as a means for doctors to share and discuss practice concerns, to reflect on their approach to the demands of patient care, to gain insights into their own modus operandi and be supported generally in what is often a stressful occupation.
    This supervision can be one-on-one, usually, but not always, with someone outside the doctor’s immediate clinical environment (such as an experienced psychologist or a senior medical colleague perhaps from a different discipline) or it can be in a group-setting (e.g. Balint-type groups, often more suitable to groups of GP’s). These ongoing, supportive relationships often have a psychodynamic flavour but are not therapy. However, mental health difficulties can often become apparent during such supervisory sessions and appropriate action including referral for further assessment and intensified support can ensue.
    I am not suggesting this is a panacea but it has been shown, in other professions, to improve practitioners’ performance, reduce risk of burnout and improve overall job satisfaction – none of which are to sneezed at in terms of prevention of mental health problems.
    As a profession we don’t take this type of supervision seriously and it is often dismissed as “airy fairy” or “fluffy stuff”. Also, someone has to pay for it, especially one-on-one sessions, and health employers do not seem to have an appetite for allocating resources to what should be an Occ Health & Safety measure, at the very least.
    Doctors groups (AMA, Colleges etc) should investigate such supervision as a means of improving doctors’ wellbeing.

  4. Anonymous says:

    I am a medical student on my mental health rotation. I struggle with depression. Any sign of it that slips out, and people, doctors and students, start asking about other diagnostic criteria as a joke. I have never felt more afraid of the stigma. Statistically, so many of us have these issues. Everyone must be so afraid to speak up. No one in med school talks about their feelings, their grades, or anything important to us personally. Everyone is afraid to show weakness. We have no role models who show us how to be brave, how to live with our mental illnesses, how to seek help and still be successful and respected as doctors. Even our role models are too afraid to admit to it. What hope have we?

  5. Ira van der Steenstraten says:

    Dear medical student, we feel for you and your problem is exactly why we have written this article. We want to give you a voice and hope that role models will no longer fear to speak out. Reach out and find help, it is out there, for you as well. Do you have a trusted GP? You could also contact your state doctor’s health services (anonymously if needed) https://www.doctorportal.com.au/doctorshealth/.
    You cannot learn to take care of others if you cannot help yourself as well.

  6. Anonymous says:

    As an anaesthetist am considered at risk recognised by both my college and the society of Anaesthetists. Have low moods and periods of introspection, but not medicated, no therapy, missed no work, currently two friend dying outside of work. Open with my GP so far no issues. Applied for insurance with BT. Oh dear, GP states low moods – insurance declined unless I accept their exclusions regarding mental health.

    So am now uninsurable.

    Forget your strategies, welcome to the reality.

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