I haven’t written on here for a long time for a myriad of reasons but I hope that this post that I wrote for NASGP and which has had a lot of comments and interest will be the start of many more…
You may have seen Victoria Derbyshire’s BBC show “Doctors’ mental health at tipping point”, a powerful piece on the scale of mental ill-health and high suicide rate in doctors and some of the barriers that doctors face in accessing care. It is well worth watching if you haven’t.
Doctors experience more mental ill health and addiction than other professional groups, and there are higher rates of suicide in doctors than other professionals, especially in young women, who are two to four times more likely to kill themselves than other women.
So what is it that makes us so vulnerable?
I believe that there are four main factors:
- Biology and nurture: personality, genetics, upbringing and traumatic life events and experiences.
- The challenges and conditioning of our training such as moving every few months, those who do least well getting the least favoured jobs, “never show weakness”, “the patient comes first”, and difficulty saying no as it may affect future job prospects.
- Work: the clinical and emotional demands, the potential high stakes of making a mistake, the work structure and work culture, and the potential devastating effects of public complaints.
- Factors outside work – caring responsibilities, ongoing chronic medical conditions, previous mental ill-health, financial stresses, relationships (or lack of), hobbies (or lack of), and habits or unhealthy coping mechanisms such as alcohol and drugs.
We can look at these developing across a timeline.
Many of us enter medical school having been top of our year group, or at least in the top few. Some of us may never have failed an exam. We start medical school, discover that we are no longer so unique, and find ourselves amongst student peers equally intelligent and high-achieving. I remember being totally bowled over by this when I first started. It was exciting and stimulating, but also at times a little overwhelming.
This realisation, coupled with other factors, can make us vulnerable. The stress of living somewhere new, the possible loss of significant relationships, personality traits that make us so good at performing, such as perfectionism and industriousness, and for some a possible genetic predisposition to anxiety and mood disorders. All load stress onto an already high intensity degree, and later, professional working life.
A working life that demands us to learn to live with stress, rather than learning to reduce it to healthy manageable levels. For example, we adapt to live without sleep, without food, without exercise and without a break (even for the bathroom). We learn to assimilate vast amounts of information required in order to practice, often to find ourselves overturning that knowledge according to a shifting evidence base.
We learn to walk the tightrope of stress. Finely balanced, most of us stay standing in the early years, but many do fall, in increasing numbers, as external stressors increase. Some decide quite sensibly that enough is enough and choose alternative paths.
The rest of us are comforted that this is all worth it. Things will get better – we just need to persevere, work harder, get to the next stage, the next rung in the ladder. Once we are a consultant, or a GP, we will have arrived. We can start to relax a bit.
Learning to just walk the tightrope however is not enough. In 21st century doctoring you must learn to dance on it, walk upside down on it, hop on it and still stay upright. You need to be able to dodge or deflect the curve balls thrown at you (mounting workload, fragmented team working, increased public expectation and greater patient complexity) in order to stay steady. As we know, burnout and mental ill-health in doctors is now a global phenomenon, a public health crisis. Dr Pamela Wibble calls it “physician abuse”.
As these stressors mount and significant life events transpire in our personal lives – becoming a parent, or a carer for elderly relatives, undergoing the death or loss of someone close, relocating due to the job change of a spouse – we may start to feel out of our depth or out of control.
To mitigate this, we might work harder. Our stress increases as habits that worked before, when we were less stressed, become maladaptive. We may feel frustrated and angry, continually falling short of the unrealistic expectations that we have set ourselves and others.
We may lose confidence, particularly after a complaint, and question our decision making more, seeking reassurance from others or spending longer with patients so not to miss anything, checking or doing things only in a certain way. These behaviours may temporarily reduce stress, but absorb lots of our time, and can affect our ability to perform effectively. This is worsened by lack of sleep, poor diet, and self-medication with caffeine, alcohol or drugs. Our mood plummets.
We may be aware that we are struggling but feel a failure if we admit it. We have coped before; surely we can cope now? Working harder has always worked.
Exhausted, we start thinking of ways that we can escape. It starts to become clear that working harder is not working.
We hit a wall and if we don’t stop and seek help, we risk becoming unwell, if not already, physically, mentally or both. And we may, when we are completely devoid of all hope, take our own lives – the only way to escape the pain and distress. And tragically, according to the National Office of Statistics, 430 health professionals did take their own lives between 2011-15. And this year alone there have been over 40 cases.
The Last taboo?
A recent survey of 1066 GPs by the charity MIND, found that despite the high prevalence of mental health problems among GPs (2 out of 5), many didn’t feel able to turn to colleagues for support, an issue all too often echoed by many other organisations for fear of negative judgement and discrimination by colleagues.
So, apart from the much needed changes that need to be made at top level around the ever mounting workload, the blame culture and the way that public complaints are handled, to mention just a few, it is important that we remember to be kind and care for each other, as well as ourselves.
We often give so much to our patients that we have nothing left in the tank for our colleagues, or we fear taking on their problems or supporting their time off for what it might do to our own perhaps fragile state. We may not even notice a colleague is struggling as we are so absorbed with our own workload and problems. But as psychiatrist Dr Alys Cole-King says:
“If you know someone struggling or dealing with upsetting life events, don’t wait for them to ask for support. The cost of asking for help is too much for some. Visit, text, message, phone, send a card – don’t worry if you don’t have the exact words – showing you care could be lifesaving.”