Addressing doctors’ suicide and mental health in the world of medicine.
The path of becoming and being a doctor is challenging. We may graduate from medical schools, enter training, and find success together, but it is strange how alone we can find ourselves when things go wrong. As a junior doctor this is something I am intent on changing.
Some doctors reach out and find help, others may quietly self-medicate in different ways. Sadly, a few come to the conclusion that there is only one option left.
Suicide comprises so many factors that to focus solely on one will eventually limit our understanding of what has happened. But if that factor is a workplace that is marred by stigma and fear, then it is definitely something we need to address.
Clare Gerada, on preventing suicide in doctors, says:
Suicide prevention means tackling the pain in the whole system, not just in individuals. Systemic change won’t come about just through compulsory mindfulness, yoga, or suicide prevention training (although these might help in bringing people together), nor indeed through creating metrics for “kindness” or “compassion.” What we need is to tackle the policies that go to the heart of the cause of distress — bullying, complaints, a culture of shaming, workload, targets, and inspection.
In part 1 of When the Healer Cries, I covered the problems facing the doctor as an individual. In this part, I will discuss institutional issues that contribute to mental illness in doctors, and what prevents them from being honest.
At the level of the institution(s):
In one U.S study of State Medical Board (SMB) license applications, 13 of the 35 SMBs responding showed that a psychiatric condition by itself sufficed for sanctioning physicians, meaning they did it only on that basis. It was with no evidence of impairment or any specifics, onset, treatment or duration.
The same states disclosed that they treat physicians receiving psychiatric care differently than they do physicians receiving care for physical illnesses. Whether in a local hospital setting or in the licensing bodies, such standards may need revision with immediacy as they hinder help-seeking by doctors.
Doctors are ‘’chosen for personality traits that predict good doctoring — perfectionism, obsessiveness, and even elements of martyrdom — traits that can act against them.’’ Are our selection criteria too narrow and punitive?
For entrance to medical schools and training, do we place too much emphasis on scores and intellectual achievements on paper? What about applicants’ lives beyond their CVs and certificates — early traumatic life experiences, illnesses, and genetic vulnerabilities? Should we consider those in applications — if so, how much of pre-existing conditions should we have insight to?
We may not have acceptable answers to these questions. These may not even be the right questions to ask in our attempt to understand suicide in doctors. But they are important to bring forward, nonetheless.
The healthcare environment is packed with pace, time pressures, birth, death, and a plethora of life-changing events in between. It is often a cauldron of intense emotion. Palliating a cancer patient, watching a trauma victim have their leg amputated or delivering a dead baby is hard. Witnessing these events can lead to burnout, something which is very common amongst doctors.
Without proper funding and resources, doctors end up lacking support, overworked. The demand and complexity of health services increase as the population does, begging for more resources. This also includes Mental Health Services — despite a renewed focus on mental health in the past decade, financial help for it remains inadequate globally.
Burnout in doctors is a universal dilemma. Many doctors have amazing resilience, myriad ways of coping, and a good support system, but every human has a breaking point.
So what must be done to shield these doctors from experiencing chronic burnout and falling ill? The results of many burnout studies lie waiting for policymakers to put together and facilitate fruitful change.
How do they walk a path of balance and well-being without straying too far? There may be support programs in universities and hospitals that invite students and doctors in a non-judgmental way. But if such programs exist, how effective have they really been? Or have we reduced them to monotonous box-ticking exercises?
Many medical students and trainees, myself included, have faced at least one professor or senior doctor who has used shame, bullying, and abuse as a way of teaching. Humiliation, belittlement, and verbal abuse were the most common types of adverse treatment reported. Students would come to learn the importance of hierarchy in medicine through teaching by humiliation (‘the hidden curriculum’).
Emotion can be a medium of power. Emotions like humiliation, anger, fear and shame can be used as a form of social control and rehearsal of power dynamics. As Stephen Fineman says in Emotions in Organisations:
Different positions within hierarchies of power give access to different emotion scripts; and our place in this structure will influence how emotions, such as fear, anxiety or disdain can be exploited.
Many doctors and students hide their feelings of discomfort and exhaustion behind a mask of competence. They are afraid of being branded as incompetent by their seniors if they do. They come to understand that their capacity to tolerate and accept humiliation and intimidation without questioning power dynamics is vital for their career progression. Then, they learn to respect and reproduce a similar work environment where opinions cannot be asserted and authority cannot be challenged.
Participants (trainees) in a study described the typical work culture and hierarchy in medicine as one that led them to feel unheard, angry, oppressed, scared and humiliated. It also made them feel alienated and disillusioned. This is important to discuss and understand in mental health.
Discussion must not be misunderstood as an attempt to paint the seniors as ‘bad guys’ of the field, or to negate their experience. They too are affected and may struggle like the rest. This is simply to highlight the toxicity in medical culture, and how this can all snowball into isolation and illness. And if abuse may beget abuse, how do we break that cycle?
This is a call for more kindness and mutual respect in the work-place.
An unfriendly working environment in medicine is a problem. While some may only feel a discouragement of sorts, the psychological damage to others may stir up substance misuse, symptoms of PTSD, depression, and ultimately suicide.
Can we — or should we — change the culture of medicine?
asks Dr Michael Myers in his paper on physician suicide.
I am referring to the ‘‘macho’’ mystique, the normalcy and rewarding of overwork or workaholism, the ascendancy of intellectualisation and rationalism over feeling, compassion and humanism, the competition, the materialism in some sectors, and male and female sexism in our medical centres and institutions.
Did Medicine fail those doctors who died by suicide? Or did we construct this culture in medicine that seems in denial that a doctor can suffer from mental illness and take their own life?
The future and what we can do
When a doctor dies by suicide, the reaction is absolute shock and confusion. Disbelief claws at the chests of their loved ones, leaving a heavy ‘why’ in its wake. Here are some reactions from the loved ones left behind, as presented by Michael Myers in his paper:
The words of a doctor’s widow: “We have this belief that physicians have chosen that profession to continue and sustain and protect life……….and when a physician kills himself or kills herself, it is very, very confusing…….because it’s almost as if….if they’re giving up…what’s that mean for the rest of us?”
The words of a doctor’s physician colleague: “Today I learned that you died and nothing will ever be the same again. I refused to believe the words I heard, that you committed suicide. Only terribly depressed people kill themselves. You weren’t terribly depressed….but then I learned that, yes, secretly you had been. How could I not know, not realize?”
The individual and the institute must make a collaborative effort on challenging the issues plaguing medicine.
There may be some universal models for all suicidal people that can be helpful for assessing ill doctors, but we still need one’s specifically for suicidal doctors. More evidence-based research on mood disorders, personality disorders, substance abuse and others in the medical student and doctor populations are necessary. Also, existing research on suicide risk factors may require updating with diversity into account.
Prevention and postvention studies are important. As is research on medical students and doctors who have attempted suicide and did not die — so we may get an understanding of thought processes and feelings at every step leading to suicide. It would not only be helpful for the individual taking part, but also for early intervention in those like them.
We should put forth results and reliable findings to health and medical directors, department chairs, college deans and professors, program coordinators, supervisors, and others so it can establish a more understanding and supportive workplace. We need to meet doctors and medical students at their level of emotional expression and work hard to create a safe space for them to share their feelings without being ridiculed or facing discrimination.
In order to tackle the problems with treatment — diagnostic and therapeutic services must become available and accessible. Care must be comprehensive, advertised, and accepting. It also needs to be kind, confidential and respectful.
The complexity of the illness that suicide is may encourage us to use a team that is diverse and specialised to help the doctor heal. Sometimes, their loved ones may play very important roles in their healing and should be considered.
Stigma must be confronted and discussed on all fronts — overtly and covertly, in speech and in action. We could encourage those with lived experience into leadership roles so they can carve a more open, supportive and accepting workplace. The stigma-related work is a steep hill to climb in many places. But climb we shall.
Critiquing this beautiful service to humanity does not equate to the condemnation of the job of being a doctor, or medicine. I have not found more fulfilment and meaning in a work I did than this. But history is full of powerful lessons for those of us who complacently row along with the current of wrongs that we are very much a part of.
No matter how horrendous a state, there is always some collateral beauty and good in it, even if we may not initially perceive. There is always a better way to go about things, and always things that we can better.
Perhaps what we need then is to embrace healthier notions of what it means to be a proactive, successful doctor. And to push for better, humanising institutional changes. Perhaps that is our real challenge.
If the work we do today would mean tomorrow has lesser pain and disruption to society and loved ones, lesser loss of productivity and promise, then today’s work is of utmost importance.
If you are struggling and in need of support, below are a few incredibly helpful organisations which provide both resources and direct help:
Shout Crisis Text Line — you can text Shout to 85258 if you are experiencing a personal crisis, are unable to cope and need support.
Talk to the Samaritans — they offer 24-hour emotional support in full confidence. You can call them for free on 116 123
CALM (Campaign Against Living Miserably) offers a chat and hotlines service from 5pm to midnight
Papyrus (Suicide Prevention Charity) offers similar service for adolescents and young adults under the age of 35
Mind — you can call the Mind Infoline on 0300 123 3393 / info@mind.org.uk, the Mind Legal Advice service on 0300 466 6463 / legal@mind.org.uk
