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”

Supervision versus mentorship What we don’t learn in medical school, but find out from the school of life.

I was a pretty outspoken registrar during my psychiatry training. That’s a comment that has been levelled at me many times. Along with the one about caring ‘too much’. Self-reflection revealed that this was a combination of being passionate, as well as trying to transition from a life where I worked as a pharmacist to one of a medical student. I was older than many of my peers and also some of my ‘seniors’ which proved very difficult for me. In addition, I had worked in very senior roles and did not quite fit the paternalistic mould of master and student. And I knew that although I knew a lot about pharmacy, I had a load to learn about medicine.

Because of these reasons, I recognised early that if I was going to succeed at being a doctor I would have to go out and find some like-minded individuals to get the support I needed.  I needed mentors to guide me to and beyond training years. I needed this as importantly as my professional training

And then I was accepted into psychiatry training. A large part of my training occurred on the job and in lecture theatres but also as part of what I would come to know as supervision. Peers training in other specialities regard psychiatrists to have a layer of support they might not have because of this formal component to psychiatry training known as supervision. This article reveals my impression regarding why this is often not the case, what can go well and not so well in supervision, and above all else, why one mustn’t confuse supervision with mentorship.

Supervision in psychiatry is as old as psychiatry itself. But it was never designed for support. Classical supervision would occur behind closed doors and be a vehicle for further exploration of what Freud described as the ‘transference’, that is, the dynamics of the interaction between patient and therapist. In these early times, supervision allowed another psychiatrist, aka the ‘supervisor’ to interpret and analyse the treating psychiatrists’ feelings about the case, and the dynamics at play between the treating psychiatrist and their patient. The supervisor was kind of like a fly on the wall in the therapy session yet a on a wall down the corridor and about 2 days later. Maybe a Venn diagram would help explain this dynamic as well. It’s tricky.

Yes, so much of early psychiatric diagnosis and even today is about interpretation of what is said and the way it is said by the patient. Having a supervisor in modern times is still based on these foundations. When you are primarily involved in the care of a patient, ie a consultant psychiatrist, you seek out a supervisor to discuss complex cases. Such as patients that don’t seem to be responding, challenge what else you can try, and explore why you feel a certain way about a patient and how they respond to you. (I am hoping Freud is looking down on me and ensuring I have this correct).

The reason I labour this is because supervision in the strictest sense is not about your stuff. It is not about how you are, what is annoying you this week, and how your own personal life interplays with professional duties. These more personal conversations occur between a person who just happens to be a psychiatrist and a mentor.

And then there is the role of a supervisor during psychiatry training, as set out by the training college for all registrars, the RANZCP. As part of training, registrars move sites and roles ever 3-6 months and are lucky (or unlucky as I will explain) to have the same role for a year. Each time they are rotated through, they get to meet their new supervisor who is invariably their consultant, ie, boss. Their direct report, the one who hopefully engages in meaningful bedside teaching, dispels some myths about psychiatry and shares anecdotes over coffee in the hospital cafeteria. These supervisors may be swamped by all the forms they need to fill out about your progress, which is given to the college of psychiatrists, and they may be good or not so good at giving feedback. They are often busy consultant psychiatrists who juggle public and private practice work, their own lives, hospital administration and whatever else. They may have all the time in the world for you, or they may encroach on your dedicated supervision session times (which should be protected) because they are consumed by the tasks of service provision. No matter what, however, by the time you work out what they are like, it will be time to move to the next rotation.

This is important to note because it is a trap for young players to presume the role of supervisor before getting feedback about how they see and perform their role. They may be somebody you see only once a week, they might be very hands on, or they might not have a lot of time to teach you. They may not be the best people to tell if you are struggling as they are also the ones that fill in your progress reports.

Don’t get me wrong. I have some outstanding colleagues and friends in my life whom I aspire to be like and would never have met if it wasn’t for the fact that fate sent me to a rotation where they would be waiting for me. But the key is, you need time to work out which ones these are. This takes time and experience. Just as Freud would sit back and observe, we also need to do the same with our supervisors. And then make considered decisions about what we disclose and what we leave for others.

In some cases, clashes can occur between supervisor and registrar and during these times it is very hard to identify a mediator. Often it’s about waiting out the rotation, hoping that the feedback isn’t too harsh and trying to move on. I have been on occasion quite vulnerable in some supervision sessions that have occurred behind closed doors. What made it worse was that I discovered I wasn’t the only registrar to feel that way with that particular supervisor. But sadly, nothing often changes and registrars do rely on the ‘get out’ clause of the weeks ticking by till the next move.

Supervisors also have a role to play in protecting the public and reporting up if they feel a registrar is impaired. This is an extremely difficult situation for everybody not least the supervisor who is concerned. Often systems are bad at handling these situations. Often the people most in need of support find it lacking. At the pointy end, some supervisors without adequate support themselves may fall into a role of trying to treat the registrar as if they were a patient, or somebody to rescue. These blurring of boundaries can lead to harm, they can happen insidiously and cause devastating outcomes.

So hence, my advice is to find mentors. Mentors can be absolutely anybody within and without medicine. In this era of social media I now have mentors I have never met in real life, who send me private messages and make me feel connected at times of vulnerability. Some mentors come and go, often to plant knowledge and wisdom within you that you will share with others over time.

My wonderful example of this was a lovely medical registrar who was working on night shift alongside me when I was a frightened resident, sleep deprived and about to throw my never ending buzzing pager at the wall. It was about 5.30am on the fifth night of night shift in a row and it felt like time had stood still. As often happens in the early hours of the morning, multiple patients experience cardiac and respiratory symptoms requiring urgent attention all at the same time. Unless you have experienced it, it is hard to comprehend how surreal the combination of sleep deprivation and terror really feels.

So as we were sorting out the latest complex case (well he was sorting out and I was doing what I was told), he looked over at me, must have recognised I was in that crazy sleep deprived/terrified/surreal state and said

“You know, they can hurt us but they can’t stop the clock”

In that moment I knew he got me. He got the sheer frustration of a system that makes you work in such difficult circumstances and he was reassuring me that it would end. Because I had forgotten that at some point I would go home to reality.

That person became my hero and my mentor for the rest of the nights I was on duty.

So in summary, when thinking about supervision and mentorship, perhaps have a think about the following:

  • Just because psychiatry registrars have supervision does not mean they have support, or are more resilient than other folks in medicine. In psychiatry, the concept of supervision is much more complex than this.
  • Nobody teaches you how to work out which supervisor you will tell what to, that’s up to you to discern. In the meantime, form your own opinion.
  • Sit back a lot and work out why you have chosen certain people in your career that you want to aspire to be like in medicine.
  • Tap those same people on the shoulder and ask if you can meet with them for a coffee sometime
  • Have the utmost respect for anybody who comes along after you that you may mentor, and needs help working out who they trust and respect as well. Work out which camp you are in. Declare your conflicts of interest up front so they can work out how to relate to you. If you are supervising and having a direct impact on their progress through training, perhaps you just aren’t the best person to be a mentor. But maybe, when that conflict has disappeared and the registrar has moved on, you can be.

Dr Helen Schultz is a consultant psychiatrist and mentor of doctors in training. She wrote about her experiences as a psychiatry registrar in her new book, How Shrinks Think. She was recently a part of Radio Nationals Background Briefing documentary regarding doctors in distress. Helen loves being a mentor but it has to involve good coffee.