Am I OK with #RUOK day? If rhetoric matched reality then maybe.

As a psychiatrist I am not so sure about public disclosures of mental illness.

Today is #RUOK day. It’s also a week where two of the top headlines in media have some sort of personal and professional significance to me. A famous AFL player asks for leave because of ‘mental health concerns’. And the Royal Australasian College of Surgeons (RACS) admits to widespread bullying and harassment of its members by members.

Why do both these topics hit a sweet spot? Well, both highlight the point that society functions better when we adopt the approach ‘do as I say not as I do’. In both instances, the message is the same. Don’t tolerate what is bad behaviour, don’t tolerate stigma, and practice open disclosure if you are struggling.

If only,

As a psychiatrist who works with patients with psychiatric illness every day, I know more than many the personal impact of mental illness on the lives of those experiencing it. That’s why I strive so hard to manage my patients and advocate for their rights and wellbeing. Why I focus on recovery. Why I care. Because I know that mental illness is common and treatable.

So what has got me feeling like I live in a parallel universe? It’s the imbalance of the strong public health messages such as asking ‘R U Ok?’, and the real life situation for many victims and patients who feel they have no voice or no audience. Because they have practical, tangible reasons to keep silent.

So, this week Lance Franklin has been given leave from his professional career as an AFL footballer as he is struggling with something. As he should. What I disagree with is the notion that one is brave only because they speak up and ask for help in a very public way.

I have seen many patients who have disclosed to their employers that they have a mental illness. Patients who need to see me and need a medical certificate to substantiate their whereabouts away from the office. Patients who are actively managing their mental illness and getting better. I have seen the same patients become victims to harassment in the workplace, and I have been placed in the untenable position of providing reports to validate that my patients are ‘safe’ to be at work. When I am not the employer but the treating doctor and confidante. Some of these patients actually work for organisations that donate large sums of money to organisations that work to reduce the stigma of mental illness. Hence the parallel universe.

In one tragic example, an organisation knew an employee was seeing me because my name and contact details were on a medical certificate I provided. They contacted me ‘as a courtesy’ prior to sacking the employee to ensure that they made attempts to keep the employee safe after breaking bad news. Without the employee, my patient, knowing anything about it. I knew the patient was to be sacked before they did. I was placed in an impossible situation, and was furious at the way the matter was handled. On numerous occasions I have been asked to be involved in workplace assessments if a patient of mine is recovering from an episode of mental illness and returning to work in a graduated manner. Very quickly, reports turn into assessments of competency and performance. My role shifts between keeping my patient from relapsing or suffering untoward as a result of these behaviours and explaining to employers why I will not compromise patient confidentiality. In some difficult cases, my notes are subpoenaed and confidentiality is broken anyway.

So, see why the public health message does not add up to the real life experience?  Although everybody knows what is the correct way to act. That is, ask for help if you need it.  Of course I agree because I know help is available and is lifesaving. I just really implore people to be careful who they are telling.

This year has also shone light on the impact of mandatory reporting of impaired doctors and doctors asking for help. New AHPRA guidelines outline that doctors must be reported to our regulatory body if one suspects they are practicing whilst impaired, thus placing the public at risk. Doctors are under intense scrutiny to prove they are competent to work, as they should be as health professionals. Yet they endure monitoring from both their employers and the regulatory body, AHPRA. There is data emerging that this will only serve to drive doctors who are suffering underground, away from care that will help them. As a doctor that treats doctors I know this is a defining factor in whether or not to tell anybody you are struggling.

And now RACS have been shown up to harbour bullies within their ranks, at a rate that would close down any other organisation overnight. We doctors are not surprised. We all have scars from the misuse of power whilst training whether it be from surgeons or senior members of other disciplines. Hopefully RACS will choose to ‘do what it does not what it says’ and out the bullies, rather than asking trainees to speak up. They have enough knowledge and information now after all, and can no longer pretend to be ignorant of these cases.

I know if had done the ‘right thing’ during my psychiatry training and spoken up about bullying, I would not be a psychiatrist today. The bullies do determine your fate.

So, how do I feel about campaigns such as #RUOK in the light of recent events? It would be lovely to believe that we exist in a world where stigma about mental illness can be overcome. That we can move from choosing celebrities as  role models to accepting that 1 in 5 people go through an episode of mental illness. That it is just as much of society as is the common cold. That bullies can be exposed and dealt with by organisations with more power than an individual. That people can speak up about having a mental illness or being bullied without retribution but instead complete compassion. I will continue to try and traverse both universes, yes I will continue to ask my patients, colleagues and friends if they’re OK beyond today.

But I will offer the sage advice based on experience and my own journey;

Ask for help because you deserve it and it is waiting for you. Ask because you only have one crack at a rich fulfilling life. Just seek out the right people to tell. They are waiting. And ask in a way so you feel empowered, safe and above all, cared for.

Dr Helen Schultz is a psychiatrist in Richmond, Melbourne, Australia, and author of “How Shrinks Think”.

 

 

 

How to spot a bully in medicine and what to do about it

Greetings all,

Over the past weeks it has been reassuring to see so much lively debate about the concept of bullying in medicine. Despite the sensationalism, there has been a groundswell of those within and without medicine who simply cannot understand why professions such as medicine can’t adopt the attitudes of most child care centres and kindergartens. The way we encourage 3 year old children to name the behaviour, hold up their hand and say:

‘ Stop it, I don’t like it’.

After completing this first step, 3 year old children are really good at performing the next task. That is,

tell a grown up.

The grown up responds at the time, not days later, sits both down and helps them find a resolution. If discipline is needed that is explained too. Everybody learns and keeps going. Children feel heard, children learn what is unacceptable, and also that grown ups are around when they feel out of  their depth, often for a cuddle and reassurance they are OK.

This consistent measured response that infants can understand and take on as they grow up is crucial as a preventative measure for bullying behaviour. Simplistic, kind, immediate actions that leads to long term resilience.

The behavior we see in our profession is the antithesis of this.

So what happens somewhere between leaving the sand pit and entering the operating room? (I say operating room as apparently that’s where the media feel real doctors hang out so it’s always the background scene)

What happens is complex, multi factorial and beyond exposure in a 1 hour documentary. In this blog I am going to explore a bit more about how bullies get to be where they are, the absolute devastation they can cause at the expense of keeping their ivory tower polished and pristine, and why I can’t think of a single organisation that can be the ‘grown up’ in this issue.

Often the ‘grown up’ is the bully.

My definition of bullying is a culmination of my clinical knowledge, my own lived experiences, and where I see the state of play in medicine. It is written entirely as a mark of respect for those of my colleagues and peers who may not have believed they could get through bullying experiences and chose to die instead. Just as in the world of cyber-bullying, suicide is a tragic and common outcome. I am a victim of bullying, and I have had times where I found myself believing their criticism of me, their comments that I should ‘shut up’ and not answer questions for fear of making others look stupid rather than embrace and foster that I was keen and willing to learn.

For no other reason, bullying is dangerous because it takes our minds off our patients, derails us from contributing to medicine and causes us no end of distress and hardship.

A bully is anybody who does something either verbally, physically, or emotionally, with no other reason but to make themselves feel awesome and you to feel dreadful.

I am going to use this blog to profile one of the biggest bullies I had the displeasure to meet through my medical training and beyond. This person still works as a doctor and holds a number of high profile office bearer positions. I am doing this to showcase what is bullying behaviour, how it takes years to develop and to question why it simply continues when everybody knows. Those relevant to my profession will know who I am writing about. Everything I write can be substantiated by others. If I don’t lead by example, I see myself as someone who is colluding with bullying behaviour, allowing the next generation to experience what we did. Those people just like me that couldn’t find a grown up, or instead of getting that reassurance, were treated with disdain, told to shut up and cop it just like everybody else. After all, we are told

being a victim to a bully makes us stronger.

In my scenario, the perpetrator is a male. I preface by stating this is not a gender specific issue, and I have met women who were quite good at bullying as well.

Let’s paint the scene,

A bunch of keen medical students sitting in a large tutorial room of a major teaching hospital waiting for the “Prof”. Waiting as we did at the same time every week for a spray and perhaps a glimpse of something worthwhile learning.

Prof enters the room when he feels like it. He is after all, extremely busy, and often began tutorials by naming which prestigious media person he had just been speaking to on the phone.

We sit in silence. After all, he is the Prof, and we have all heard really scary things about him….

Prof begins the session by reaching into his wallet and pulling out a fistful of business cards, which he then proceeds to flick across the table like some random card game at a casino.

His first question for the audience;

Do you know who I am?

Well, yes, we do, but nobody has the guts to say. Then the following answer to his own question;

I am everything my business card says I am. I am the recipient of all these awards and merits. When I get on the phone to the media, my call goes straight through. I am one of the most influential people in my field.

This was the beginning, middle and end of the tutorial. We all left with a business card after watching a DVD made by a pharmaceutical company, featuring the Prof who had left the room by now.

Now, hopefully, most of the audience saw this  ‘tosser’ behaviour for what it was. But maybe some didn’t. Maybe some really started to believe from that moment on, this person was the one to impress if you wanted to get anywhere. Sadly, this was the case. You did have to be a golden child of the Prof to enter his kingdom.

Also, crucially, Prof was being very strategic and targeted with his ‘tom cat’ marking of his territory. He was making very sure that he was and would always be the smartest person in the room. Intolerant of criticism, and insightless to his behavior, not least of which was discouraging some fine future doctors from his area of specialty, the Prof legend continued to grow and the power imbalance became greater.

In later years, if you did decide to chose to enter the Prof’s turf, that is, choose the same specialty as him, and then become his registrar, you would be subjected to public humiliation on a weekly basis. The weekly ward round was your chance to present a case, in front of the patient you were speaking about, as well as the rest of the multidisciplinary team. All would watch in horror as the Prof took you down, bit by bit, in order to once again demonstrate he was still the most important and intelligent person in the room, and that humiliation was the best way to get you to think on your feet faster and suffer the rigors of being a real doctor.

This public humiliation went on for years, consistently, and without any attempts at intervention.

The complexity continues, as the needs of the Prof grow to maintain relevance over the years, to be seen to be furthering his career at every opportunity, getting onto boards, into professional organisations, marking his territory, and ensuring he remains

Untouchable

So faced with this, what do we do? How can we simply say with any hat that we have a zero tolerance to bullying, as if that will solve the problems without understanding where it all began? Shouldn’t we instead say to our peers, do not be defined by the criticism of bullies, but by those you trust and respect as they are everywhere too. Above all else, be defined by your own self worth which should be more than obtaining a fellowship to a college.

I don’t believe any organisation has the capability of removing bullies from medicine. The Australian Medical Association is a membership organisation that takes subs from bullies and victims. It also has a role in defending members who are wrongly accused of bullying. Colleges also cannot rid their hierarchy of bullies, and because of this, cannot offer assistance to members who receive threats from bullies.

In this whole argument, nobody is declaring they have a clear conflict of interest in dealing with bullies

As a doctor, a mother of a son who has been told how to manage bullies in the playground, and as a psychiatrist who sees patients that are suicidal as a result of bullying, I say the best way to manage this is;

1. Keep safe, get help and remember, you are so much more than what your supervisors write on your assessments. Bullies do in fact have much more to lose than you.

2. When you are ready, and if you so choose, name your bully’s behavior to protect others. If you can’t find a grown up to tell, be that grown up yourself and name it to your peers.

3. Take up the charge to rid bullies from the profession we are passionate about, understanding how much they will hang on, and appreciate how entrenched they are within the organisations that state they are trying to ‘out’ their bullies.

I have ‘named’ a bully. Now it’s your turn.