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.
|Psychosocial contributors to doctor suicide|
|High prevalence of Axis I disorders
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”.
|Lifestyle related reversible and treatable physical contributors to fatigue and depression|
|Substance misuse and dependence, including nicotine, caffeine and energy drinks|
|Physical, neurological and movement disorders
|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).
|Specific physical issues for women|
|Menstrual and gynaecological disorders, including abnormal uterine bleeding, endometriosis and adenomyosis|
|Fertility concerns, investigation and treatment|
|Pregnancy and breastfeeding|
|Postpartum sleep deprivation|
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.
Dr Kathryn Mainstone
Dr Mellissa Naidoo
Mrs Kirsty Whitmore
Mrs Susan Bryant
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