Is it possible to be a ‘good enough’ mother in a profession that demands perfectionism? My keynote from #IWD18

Today I presented as a keynote speaker at The Melbourne Clinic’s International Women’s Day breakfast. I spent a lot of time deciding what to talk about, given the audience was built from members of various disciplines. But I knew I wanted to incorporate my struggles to get through medical training as a doctor and mother, on behalf of all female trainees who fear speaking up.

I was asked by some if I could video the keynote but I decided not to, for it contained a lot of personal information that I did not want to reach the public domain. Nevertheless, I do wish to share some of the points I made about the rigidity and inflexibility of medical training and how that impacts on all trainees. But given it was International Women’s Day, I focused on motherhood and medicine. And being in a psychiatry setting, I drew on the work of Donald Winnicott, a paediatrician and psychoanalyst who defined the phrase ‘the good enough mother’.

This article describes eloquently Donald Winnicott’s actual definition when using the term, ‘the good enough mother’.

a mother is neither good nor bad nor the product of illusion, but is a separate and independent entity: The good-enough mother … starts off with an almost complete adaptation to her infant’s needs, and as time proceeds she adapts less and less completely, gradually, according to the infant’s growing ability to deal with her failure. Her failure to adapt to every need of the child helps them adapt to external realities.

The article states that being a ‘good enough mother’ is actually better than being a perfect mother when it comes to a child’s well being.

So, to examine the life of a mother who is also training to be a doctor, is this attainable?

When exploring this idea, I focused on my own journey through training. Motherhood waited until all of my formal training requirements were out of the way. I was lucky and fortunate that life turned out that way. Women are often blamed for delaying parenthood for the sake of the careers, but when I was brutally honest about my own predicament, I knew that the way training programs and workplaces run, with the degree of inflexibility and dismal variety of part time positions, I had to be a realist and wait.

After speaking to many trainees I know that the facts are that women are often asked (illegally) when they plan to start families when applying for roles, and women are looked down upon and viewed as ‘not dedicated enough’ if choose to train part time. Training colleges such as the Royal Australasian College of Physicians hold the most critical of exams on only one day per year. With he surplus of medical graduates and the bottleneck to attaining valuable physician training places, men and women, parents or want to be parents put their lives on hold to study for 1-2 years. It is difficult to comprehend in such an inflexible system, how one can adapt to a child’s needs to achieve being ‘good enough’. In many cases ‘good enough’ has to be re-classified as absent or at the very least inconsistent. A mother in this position would require enormous practical and emotional support to be able to meet all the training requirements imposed upon them to pursue their careers. Not all mothers have that. And why should mothers be expected to meet these needs at all costs, when they are such a vital component of our workforce?

Two years ago, The Royal Australasian College of Obstetricians and Gynaecologists added the following topic for debate at an annual scientific meeting – “Membership before maternity leave: Should every registrar have a Mirena?” (an form of contraception for women). It was designed to encourage debate about the very issues I spoke about today. But it was brutal, and deeply hurtful for many trainees around the world. Because to many it described what is actually spoken about in the workplace, and flies in the face of colleges who purport to offer flexible training conditions. There was no parallel discussion about the need for male registrars to use contraception.

In addition to this, our work, our training, our ability to enter medicine requires a degree of perfectionism. Our patients expect we don’t make mistakes. We are asked the most intricate and minute details of medical conditions in our exams. Things we may never see in real life, but we have to be on top of to pass. How does a mum switch out of the behaviour of a perfectionist when approaching or juggling motherhood?

In my case, and I know for most doctors employed in the public system, we are employed on one year contracts. This is so we can’t accrue leave entitlements afforded to most other women. So when I went on maternity leave, I was given around 8 weeks. My contract was not renewed, and I was told to contact my training hospital when I ‘felt like returning to work’. I was therefore unemployed, despite paying ongoing fees to my training college. This had financial and emotional repercussions on my family, and I did not return to that hospital to complete my training. In 2018, working mothers are rostered to be on call but there are still no child care options after hours available to them.

I make these points because as a consultant psychiatrist I am safe to do so. Trainees can’t speak up. So we must combine our efforts to fight for their conditions, as our successors.

The rest of my presentation focused on two issues I hold very dear to my heart when it comes to my approach to being a mother.

  1. Normalising mental illness so my son accepts it is common and treatable. Just like colleagues in other specialties in medicine, he came to the hospital and sat in the nurses station while I did my rounds. He knows what a psychiatrist does which is better than many in the population. He knows his mum is a doctor and helps people.
  2. The vital role mothers play in their son’s life about teaching them how to treat and respect women. Leading by example, standing up for myself if feeling mistreated and talking about good and bad experiences in the playground or society.

I’ll elaborate on the second point, one of the most amazing ‘a-ha’ moments of my life, and the one I reflect upon when unsure if I am being ‘good enough’ when fulfilling these goals. My son had to choose a famous Australian who had made a difference in society to research when he was 10 years old. He chose the Former Australian Prime Minister, the Hon Julia Gillard, without my knowledge or influence, and some of the key features he elaborated upon were that she proved women could change stereotypes, and her advocacy for gender equality. I was thrilled to be able to provide her with a copy of my son’s work at a recent event.

So, is it possible to be ‘good enough’ in medicine as a woman and mother? I argue yes, but it is all in the timing. And until we afford women the same rights as in other professions it will remain that way. At the expense of losing a significant amount of doctors from the workforce when we need them, because they have chosen to be mothers.

Dr Helen Schultz is a consultant psychiatrist, author, public speaker and doctor’s mental health advocate. 

The ins and outs of doctor mental health

On Friday 16 February 2018, I took part in a Grand Round at Peninsula Health in Melbourne, Australia that talked candidly about the current state of play with regards doctor’s mental health. Alongside me was Dr Geoff Toogood (convener and instigator), Dr Mukesh Haikerwal, AC, and Australia’s current federal health minister, the Hon Greg Hunt.

 I have been involved in the doctor mental health space for several years, as have my colleagues on the panel. I shared my experiences about doctor’s help seeking behaviour from the point of view of a psychiatrist with a special interest in treating doctors and students with mental illness.

Over time, I have seen more medical students and doctors at all stages of their career, from all different crafts come through my door. I am aware that by the time they have made it to see a psychiatrist they have navigated quite a lot of practical and emotional hurdles to get there. Unfortunately, in some cases, they have presented very unwell, as they have tried to move past the point where others would put up their hand for help, for fear of discrimination or retribution. As a doctor working in this space I do not minimise this at all, but am dismayed that in 2018, with all the talk about reducing stigma in the medical profession, it is still alive and well. And I become particularly moved when I hear about doctor suicide – probably doctors who never made it to the consulting rooms of somebody who could help them turn their life around.

The ‘ins’

At the heart of the matter is the fact that doctors are hard wired and built exactly the same as all human beings. Our neurotransmitters are the same, our organs are the same, our vulnerability to disease is the same. As a consequence of this, we are also able to recover and move on just like any other human being. I am somewhat overstating the obvious because in countless discussions about this topic it is often argued that somehow we are not. The flip side of this and the irony about doctor help seeking is that we also respond to evidence based treatments and recover just like other human beings.

Doctors and medical students are invariably perfectionists. We have to be to jump hurdles and treat patients, focusing on the detail while looking at the big picture at the same time. It is like body building. We focus on one particular muscle group, but may not know inherently that other muscles that work in tandem need to be trained as well to avoid injury. Just like an athlete who runs for kilometres but forgets to stretch. Inevitably their results will improve but they are susceptible to injury. Our most overworked ‘muscles’ are tied into perfectionism and success, our most atrophied,  are the ones that are linked to humility, compassion towards ourselves, and forgiveness. So when we become injured, when we set our standards very high, and often unrelenting, when we miss out on sleep, or friendships, or significant life events, we fall over.

The ‘outs’

There has been much discussion about external factors that impair help seeking behaviour in our medical profession. I plan to focus on two of these factors.

  1. Mandatory reporting

I understand the requirements to report doctors who pose a risk to the public under current AHPRA mandatory reporting laws. I know some of my colleagues don’t. I know doctor’s help seeking behaviour is directly impacted because doctors and medical students don’t know which camp the doctor they attend falls into. I also know of cases where reports are made behind the doctor’s back, coming as a complete surprise to the notified doctor.

Nobody would argue that a doctor or medical student who is posing a risk to the public for whatever reason, including practicing with untreated mental illness or substance misuse should be reported from an ethical perspective. But this does not have to be mandated and is not in Western Australia.

Reporting of doctors and medical students to protect patients should not occur at the expense of risk to the notified doctor

The reporting process in itself is gruelling enough. But the investigation that ensues has been shown to cause further deterioration in mental health of the doctor being investigated.

Suicide whilst under GMC’s fitness to practise

Last week, a widow in the United Kingdom spoke about her husband’s suicide. He was reported to the GMC and the claims were found later to be of no substance. But it delayed the family’s move to New Zealand, and, according to his widow, triggered a severe case of depression. It may have been a contributing factor to his decision to suicide. That remains unclear as in many cases of suicide. What was the final tipping point? What we do know is that there is a growing movement for families of victims of suicide are coming forward to talk to the media about their experiences to help us understand.

The only answer to this issue around mandatory reporting is to get rid of it. It makes doctors very mistrustful of asking for help, despite all reassurances that they wont be reported, when there are already way too many other barriers. It was pleasing to hear the Hon Minster for Health, Greg Hunt state he would do whatever it took to see this law removed.

   2. Stigma around mental illness is alive and well in the medical profession

As a psychiatrist I encounter stigma from my non-psychiatric colleagues on a regular basis. There remains an inherent misunderstanding around what psychiatrists actually do, which is why I wrote my book, “How Shrinks Think” in 2014, in an attempt to address this. Medical students complete about 6 weeks of psychiatry training and during that time see very acutely unwell patients. They have little or no exposure to most other aspects of psychiatric care, and are unable to follow a patient through their illness to recovery due to the length it often takes to recover from  a mental illness. This astounds me as there are many other areas of medicine where patients remain chronically unwell, such as patients with renal failure waiting for a kidney transplant. Yet many physician trainees still aspire to become nephrologists. I have spoken to many medical students who are turned away from psychiatry as ‘nobody ever gets better’. Nothing is further from the truth, but their exposure to psychiatry in their formative years skews their perception.

In addition, the way I have been spoken to by non-psychiatric colleagues is also borne of ignorance of what we actually do. We are life savers just like cardiac surgeons, or emergency department physicians, and many others. It’s why we all do medicine. If medical students and doctors in training are exposed to the dialogue around psychiatrists being ‘real doctors’ why would they ask us for help if mentally unwell?

Where to from here?

There is so much active discourse and tangible movement in this area. I remain hopeful that we have enough of a growing movement to end mandatory reporting laws in Australia, and doctors hopefully will be more accepting of care, and at an earlier stage of their illness so they recover more quickly. I continue to be hopeful that we address the inherent stigma within the medical profession about mental illness, the factor I see as the greatest barrier of all to seeking help. I also implore any medical student or doctor who is struggling to start by seeing a general practitioner, and if it is recommended that they need to see a psychologist or psychiatrists that they do so. For the sake of themselves, their families, and for the profession that needs them and cares about them.

 

If you find this content distressing, please reach out to emergency and crisis services including the “Suicide Call Back Service”

Breaking news – medicine is not depressogenic

Abandoned scratched vintage metal ex USSR whirligig. Isolated.

From where I sit the doctor’s mental health debate has gone around in circles like a spinning top, only to fall over sideways. Almost discarded and relinquished to the toy box for another time. Stalwart warriors in this space are beginning to become very frustrated, and rightly so. As a stalwart warrior for many years, I have spoken to politicians, lobbied and campaigned extensively and despair as I hear about more suicides. Imagine the near misses or attempts nobody hears about.

But this article is not written as another to add to the growing content forming the doctor’s mental health debate. It is based on my concerns that we are losing focus and our campaigning may be off the mark. So may be our attempts at finding solutions.

I fear for medical students who read about the high suicide rate in the medical profession. I fear they will believe their future profession will cause them to become depressed. That they  believe they are going to exchange valuable resources such as money, time, energy, enthusiasm, passion and drive for a lonely miserable existence. That they will follow Twitter feeds that debate this, and keep their head down even more.

These issues are not unique to medical students, and there are similar concerns for students of veterinary medicine, nursing, dentistry and pharmacy. Rather than seeing these professions as ‘callings’ to help others, they are directly blamed for causing mental illnesses such as depression in the very people chosen to commit to the calling.

As a psychiatrist, I have treated numerous medical students and doctors, as well as other members of the health professions. I have also spent time with family members who have lost a loved one to suicide. I use evidence based strategies to deliver best practice. Part of my work is thorough history taking, including a detailed past and family history. Just as with many other medical conditions, thorough exploration leads to revealing information. And these patients are no different to most of my other patients. Doctors in their 30’s will talk about a time in medical school that would have fulfilled the criteria for a major depressive episode, if they had told anybody about it . It may not be the first time that the patient has experienced suicidal thinking, but may be the first time they have told anybody about it. They may have a parent or sibling with a diagnosed mental illness, or a relative who was talked about as being unwell. They may have witnessed or experienced devastating childhood adversity, leading to problems with personality, but nevertheless gifted and skilled in so many other ways.

Medical training does not cause depression. But impairments in help seeking, both within the person and within the system, leaves that person untreated and vulnerable.

Mental illness is common in the community, so why do we believe that medical students, who live in the same community are somehow immune? That if we make them ‘resilient’ by offering a few lectures in medical school about managing stress we will ensure that they never go on to experience an episode of mental illness? Medical students, like everybody else who may have depression deserve early, evidenced based treatment delivered in a sensitive, caring and compassionate manner. And despite all the rhetoric, the lip service, the campaigns to educate to ask for help, there still lies an impediment to asking for help.

The very reason for this is the entrenched stigma the medical profession has about seeing mental illness as a weakness or impairment. It is an extreme case of ‘do as I say not as I do’. And medical students are exposed to that from the get-go. As consultants and leaders we may reinforce these ideas. Medical students may believe it to be true in themselves, holding their own stigma. The system is gruelling and unyielding at times, but this could be endured and even enjoyed if those who are struggling receive the help they need, rather than blamed or discouraged from speaking up.

I must be very clear that I am writing about depression, and not other issues such as vicarious traumatisation, compassion fatigue or even post traumatic stress disorder. These serious conditions occur as a result of external factors and should be seen as such. We are all vulnerable to these conditions by the very nature of our work.  Yet even these conditions are stigmatised when we know that they can be treated as well.

The era of mandatory reporting, and variation in states such as New South Wales, have directly damaged doctor’s help seeking behaviour. Regardless of all the talk that doctors and medical students who are actively seeking help and not putting patients at risk do not need to be reported to AHPRA, the message is drowned out by anecdotal evidence and fear mongering. Competition for scarce training places, the introduction of more medical schools purely for money not clinical demand, and the high rates of bullying and harassment well documented in the profession can destroy one’s capacity to be brave enough to speak up.

So, as doctors we know that depression is an illness that is treatable and that early, evidence based interventions lead to recovery. We know that an episode is invariably brought on by a combination of internal (often genetic) vulnerability and external stressors, whether they be in personal or professional life. So is the solution that difficult?

Why don’t we apply a more logical and reasonable approach to this most awful situation? Make it as easy as possible for medical students and doctors to recognise they are experiencing symptoms of depression, and deliver that care just as we would for any of our patients? Eliminate external stressors that we can do something about, by actively campaigning to adopt Western Australia’s stance with regards mandatory reporting, and fight back about building more medical schools.  Check in with our own feelings about stigma, and be honest. Would we regard a colleague as inferior if they were taking antidepressants? Would we feel the same if they took insulin for Type 1 diabetes?

There are many things we can do, and we must if we care about the next generation of doctors, as well as the current ones. And guess what, ad hoc mindfulness training, or throwing an afternoon barefoot bowls session for staff simply doesn’t cut it. Finding caring professionals, believing you are worth receiving help, and getting better is much more enduring and successful, and there are people out there who will do that. All you need to do is ask.

New Doctor’s mental health workshop – tackling crucial conversations

It is fantastic to be running a workshop for RANZCOG addressing doctor’s mental health in one week’s time. I have been advocating in this space since 2003, when armed with the important role of AMA(Vic) President, Doctor-in-Training Subdivision. At the time we were rocked by the news of suicides among our registrar population. In 2003, some of the responses made by consultants included;

Maybe they weren’t cut out for medicine

Maybe they just weren’t ready to face the pressure

Maybe they shouldn’t have sat the exams

Maybe they chose the wrong career

What are the current factors impacting on doctor’s health and wellness?

In 2017, 14 years later, I hear the same thing. I hear that somehow when a tragedy such as suicide occurs, it must be something to do with the doctor’s weakness or vulnerability. Few real conversations have focused on the external factors that push doctors to the edge. Seldom do discussions focus on how doctors reach out for help, are spoken to in the workplace, or suffer when they speak out against intolerable conditions or heartbreaking situations.

Some shifts doctors endure contain enough graphic content that if a movie would attract a R 18+ rating. Doctors are inherently resilient because they turn up again the next day for more. So the conversation we need to have isn’t about resilience or self care. It’s about true advocates standing up for others so we can have safe, compassionate workplaces and rewarding careers.

So, after spending so much time in this space, participating in many committees and panels, speaking at conferences and treating so many doctors and medical students, I am using this opportunity to go straight to the heart of the matter. How to have a crucial conversation. What can happen when conversations go well and what can happen when they don’t. How breaking bad news can lead to suicide or a positive outcome. How third party regulators such as AHPRA and our colleges have conversations with us, whether we are prepared to hear them or not. Knowing when to put our hands up and ask for help and when to keep our opinions to ourselves and go elsewhere for what we need.

Communication is the key.

So, most  of the agenda for the RANZCOG doctor’s health workshop will play out via role plays using the brilliant acting skills of Mr Glen Hancox, professional actor and director of ACTReal. Glen has worked with me for 7 years, and together we have run through hundreds of scenarios to display rather than preach valuable learning. We have coached and trained many doctors in key specialty areas, worked in the corporate world and now developing conversations around doctor’s mental health.

So what sort of conversations will we be examining in depth?

The clinical scenarios I have written to be included in the workshop are based on conversations and interactions I have either witnessed or have been involved with. They will encapsulate the following;

  • doctor’s help seeking behaviour
  • the need for every doctor to have their own GP
  • managing performance rather than being labelled a bully 
  • how to relate to junior colleagues to be the mentor you truly want to be.

 

All are raw and controversial, designed to be so that we can have real conversations to evoke change. They are also completely fictional (including names).

Keen to read more? Here are the teasers:

  1. That corridor conversation. After a multidisciplinary team meeting,  Dr Anne Salter, a psychiatry registrar working in consultation-liaison psychiatry (wanting to be a perinatal psychiatrist) is approached by Dr Alex Scott, an O&G registrar. Alex is being paged but wants to have a ‘few minutes’ with Anne to ask her opinion about something….
  2. Doctors treating doctors. Dr Alex Scott consults with Dr Simone Davige, a GP in a busy family medical centre. Alex is nervous but after talking to his wife, and trusting in Anne, he decides to open up and be honest about how he is struggling…..
  3. The supervisor asking “So,  how’s it going?”. Dr Ian Anderson is a senior consultant in the gynaecology department. He is well meaning, but quite detached from the issues facing junior doctors. His idea of mentoring a junior doctor is to share his own experiences that he thinks are valuable to hear about rather than listening….
  4. The consultant delivering negative feedback. Dr Peter Richard is a consultant and supervisor. He has had feedback from the college and other peers that his registrar Dr Sophie Donald is ‘not up to scratch’ He hates conflict but knows he has to tell her some hard truths….

By working through these scenarios, and with the guided expertise of Dr Mukesh Haikerwal, and Ms Mayada Dib, we hope to uncover what is at the heart of the matter for doctors who have mental ill-health and need our help. They are, after all, valuable, meaningful people who have devoted their lives to helping others. We owe it to work out how to help them, or not put them in a situation where they are distressed.

And all kudos to RANZCOG who are holding their regional scientific meeting in Albury NSW after they lost a fellow to suicide in Albury in 2016. They have opened the event up to all health professionals regardless of specialty.

If you would like to contribute to the discussion to help our colleagues please register here

See you in Albury,

Best wishes,

Helen