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”

DiT Forum at AMA house on Thursday 5th March 2015.

Greetings all,

In light of recent deaths amongst our Victorian DiTs, a small working party has formed, and a decision has been made to hold a forum on Thursday 5th March 2015 at 7pm at AMA House, Parkville.

This is short notice but it was decided that it would be prudent to hold the meeting sooner rather than later as we are aware of impending examination timetables.

I am involved because I was a DiT not long ago, used to be a president of the AMA(Vic) DiT subdivison and around when there were some suicides amongst our friends about 10 years ago. What came of similar forums was the establishment of the AMA peer support service.

I have never shied away from being outspoken and an advocate for all DiTs including medical students. DiTs are a large, invaluable, resourceful and caring group of the medical profession.

DiT’s also get very bogged down in making to the ‘ticket’. They work hard and endure a lot to get good reports and pass exams.

Despite being a large group of the medical workforce DiTs can feel alone.

I have been vocal recently about what I do know. 4 DiT’s including 3 psychiatry registrars are no longer with us. There is and probably will always be conjecture and a lack of understanding about why they are no longer with us. These deaths may be unrelated or there may be a factor that ties more than one.

We don’t know unless we start talking. 

And even if we do not know, we may be able to use this tragedy, and it is a tragedy, to regroup so trainees can tell those that want to listen exactly how it is to be a DiT nowadays.

We may uncover that other DiTs working in the 4 sites where they lost colleagues are not coping with the news. They may be struggling too. There may be systemic or their may be local issues.This is not about blame, it’s about guiding future discussions that hopefully will implement real change.

AMA (Victoria) and its senior officebearers, including the current AMA(Victoria) president, Dr Tony Bartone, and past presidents have stepped up to hear about this from the time we all heard about the deaths of 4 DiT’s since January 2015.

AMA(Victoria) have kindly offered to host the meeting and provide facilitators to assist the discussion.

I will be there because I want to know as well.

It’s Ok to say if you are not coping, or if you can see others not coping.

Please attend, regardless of your involvement in the passing of 4 DiT’s and especially if you are affected by the news. You do not have to be an AMA member to attend.

RSVP here

Please see your GP, or contact the Victorian Doctors Health Program via AMA(Victoria) if you need more formal support.

See you Thursday,

Helen