Wannabe surgeon Frankie Bell persuades a patient to have life-saving heart transplant surgery. When the patient dies of cardiac arrest after a post-surgical bleed, Bell is shattered. “Shit happens,” counsels her surgical mentor.

Much later, the surgeon who performed the transplant apologizes to a young resident who had assisted during the operation for attacking her when she pointed out that a stitch had been missed in a vital part of the procedure. “I have been up for 14 hours …  I shouldn’t have spoken to you like that. That wasn’t cool,” he says. But he can’t, or won’t,  admit he blundered.

This is a scene from the ABC hospital drama Pulse, a series which does a better job than many in this perennially popular TV genre in portraying the gruelling realities of the medical profession. The egos, the turf wars, the politics, the punishing training pathways. Medicine is not for the faint hearted.

While doctors have long since been displaced from the pedestals that were once their preserve, there is still a professional mystique – due in no small part to the reruns of ER, Greys Anatomy, and their ilk. In reality, doctors are mere humans  functioning under the weight of perfectionism and the expectation of resilience. The self-belief required to do the job makes it difficult, if not impossible, to falter, admit mistakes or request time out when they cannot function. Such conditions take a toll.

COUNTING THE COST:

–       A 2013 national survey by the mental health foundation Beyond Blue found that Australian doctors have substantially higher rates of psychological distress and attempted suicide than the general population, and that one quarter of them had had suicidal thoughts.

–       The suicides of four junior doctors in NSW in 2017 prompted a State Government investigation. News reports cited coronial records showing at least 20 doctors had taken their own lives 2007-16.

–       A 2016 study published by the Medical Journal of Australia analysing 369 suicides among health professionals nationally, 2001-12, found that suicide rates for female medical practitioners, and for male and female nurses, were higher than for women in other occupations.

–       International data has long recognized that physicians have an increased propensity to die by suicide. A 2011 US study found that one in 16 surgeons experienced suicidal thoughts the previous year.

–       In the UK, a 2016 survey of doctors found 60% had experienced mental illness (82% in England).

–       A 2016 meta-analysis of studies from over 43 countries concluded that overall prevalence of depressive symptoms among medical students was higher than that reported in the general population.

The figures provide stark evidence that medicine as a profession is a personally costly and often shatteringly risky business.

In recent years, pressures on young doctors and medical students have come under scrutiny and inspired some efforts to reform systems. A key focus of campaigning by doctors’ groups has been the reform of stringent mandatory reporting laws, which as they exist often require medical practitioners to report other medical practitioners who seek help.

At a meeting of the Council of Australian Governments (COAG) health council in Sydney on Friday 13 April, health ministers agreed that there had been significant unintended barriers to doctors and nurses seeking the appropriate mental health treatment because of mandatory reporting requirements. Federal Health Minister Greg Hunt announced that they had agreed on a new system that would both protect patients and remove barriers to health professionals receiving and accessing the mental health treatment they want. The announcement was received with “cautious welcome” by the Australian Medical Association, pending signing on the final wording.

The breakthrough addresses a key concern raised by doctors in a special investigation by The Citizen into the mental health burdens of medical practice, including interviews with more than a dozen active health professionals (many of whom could not be named). But the investigation also identified a range of other issues they say contribute to the crisis afflicting too many of their ranks, including those in senior positions. They include:

·      Extraordinarily demanding working conditions and lack of resources for health professionals in public system;

·      Apathy of hospital management, and a lack of insight on what is actually needed;

·      An enduring professional culture of racism, sexism, bullying and harassment rife;

·      Persistent stigma around seeking help, often perceived as a sign of professional or character weakness;

·      Long hours, lack of work life balance, routine health checks, peer support and safety net;

·      Lack of mentors and role models among senior doctors, people who have normalised seeking help and continued to do their jobs successfully.

While there are pockets of movement occurring in this space, such as the Royal College of Surgeons’ initiative on racism and bullying, doctors say much more needs to be done. The challenges to creating a healthier medical workforce straddle legal, cultural and professional realms.

(Warning: this article discusses suicide. If you or someone you know is struggling, please seek help. Call Lifeline on 13 11 14 or chat online here between 7pm and 4am.)

A view from the edge

Dr Geoff Toogood, a cardiologist at a Victorian hospital, is one of those who has lead the push for improving doctors’ health, initiating the “CrazySocks4Docs” awareness campaign and going public with his own painful experiences in a bid to shake the profession into action.

Four years ago, Toogood was in a bad place. He felt suicidal and requested help from the management at his hospital. Instead, he says he found himself alienated.

Toogood says he was asked if he was seeing a psychologist, and told his request for time off would be denied unless he resigned from his senior position as a department head. “I said I don’t need to [resign]. I just need time off. I have suicidal thoughts.”

He was shocked at the offhand way his mental health issue was handled.

“Not because I am a doctor, but as a human being … if I told you that I was suicidal, would you just let me go?

“People I reached out to tried to assassinate my career. I was in a mess. I was going through a separation. I needed help…”

It wasn’t until Toogood was diagnosed with transient global amnesia, a form of mild stroke, that he was given time off, because now he had an “organic” disease.

Toogood credits his recovery to a general physician who chose to help him instead of reporting him under existing mandatory reporting laws, which many argue in their current form undermine efforts to encourage doctors to recognise and seek treatment for mental health issues. He also says that the management culture and responsiveness is much more supportive.

The existing rules of mandatory reporting – which now appear set to be thrown out – have required general practitioners to report to the Australian Health Practitioners Regulatory Agency, AHPRA, any doctor they perceive to be “placing the public at risk of substantial harm because of an impairment (health issue)”. The rationale was to protect patients and public confidence, but the law has often been misinterpreted and proven counterproductive, especially to the doctor reported, critics say.

The implementation of the existing rules has been so faulty that “no one really knows what it is, how it is done, and what constituted it”, says Dr Helen Schultz, a psychiatrist who has long campaigned for an overhaul of the law.

If the treating doctors do not have a clear understanding of the law, they end up reporting any doctor who comes to them to seek help. The result has been that few doctors would own up to a mental health issue, let alone see a psychiatrist, because they fear it will jeopardise their career.

 

Pride, prejudice, and the public system

Dr Hanlie Engelbrecht, a maxillofacial surgeon, migrated from South Africa to Australia in search of a better lifestyle and working environment. Back in her homeland, she’d been distressed at her treatment as a trainee. Breaking point was being ordered back to work despite her own premature baby being hospitalised with croup.

After fighting her way through the formidable licensing process to practice in Australia, Engelbrecht was shocked to find the expectations and demands within the Australian system weren’t so different to the ones she left.

“How do you cope when you hear a remark such as ‘for a female, you are not a bad surgeon’?” It is not just the sexism that is wearing her down. Working in a public hospital for the past four years, she says she is mentally exhausted

“The public system is vastly understaffed. There is no back up.”

Getting to the ranks of senior clinician is a brutal business. Then, she says, “having survived that with some semblance of sanity, you now look at junior doctors and see the same thing happening to them and no matter how hard you try and support them, in the end it just puts more pressure on you because you are supporting them but no one is supporting you”.

The 2013 Beyond Blue survey of 12,000 doctors found those in training were almost twice as likely to cite very high levels of psychological distress compared to their senior colleagues.

The findings helped fuel a major push to address the growing rate of mental health issues and suicide among junior doctors, achieving some significant changes in the regimes for training junior doctors. Prolonged shifts and continuous on-call rosters have been discontinued in most, if not all, health service rosters. More emphasis is being directed to better orientation, supervision and mentoring of junior doctors in hospitals. Reports of the suicides of junior doctors in NSW in 2016 prompted Sydney’s Royal Prince Alfred to initiate a pilot program to improve its basic physician trainees’ mental wellbeing. A first of its kind forum was also conducted in NSW to support and discuss the mental health and well-being of junior doctors.

But the cultural issues are not confined to the junior ranks, and a substantial cohort of senior medicos are still outside the reach of these programs.

Dr Ranjana Srivastava, a senior oncologist and a Fulbright scholar, says that there is no protocol for counselling or supporting senior clinicians, even in circumstances of obvious potential crisis, like an adverse event with a patient. “Who do we debrief with? No one. No one asks the director, or a department head or a senior consultant if they were ok?”

The relentless push within hospitals for increased productivity, together with ever-tightening purse strings, increase the pressure on doctors – especially those working in public health – and the potential for them to make some error in judgement or practice or to collapse under the accumulated toll of their work.

Providing employee assistance and peer support and counselling programs is only lip service unless the support is there to take the time to use them, says Srivastava. Many specialists say that taking time off for self-care only results in more work piling up.

Long waiting lists and crowded waiting rooms take their toll, Srivastava says. “It’s not under our control, but I think those tensions build up all the time and they are the things that cause burnout … a feeling that no matter how hard you work you are always struggling for resources and are under recognised.”

The AMA past president Mukesh Haikerwal, who was also a previous chair of the advisory committee for Beyond Blue’s National Doctors’ Mental Health Program, describes the situation as “fiscal bullying”. He blames inadequate funding for poor service provision and sub-standard care. (The AMA recently issued a damning report card as part of its campaign for a new public hospital funding model.)

Inadequate funding leads leading to poor service provision and sub-standard care pathways ultimately also delivers bad health outcomes not just to patients, he says, but underwrites aggression and stress among the people who care for them.

 

“Physician, heal thyself?”

Medicine’s culture of exceptionalism, paired with its mandate to “keep calm and carry on”, underwrites a double whammy for any health professional struggling under the weight of the work.

Srivastava says that part of the problem is medicine’s own making, where admitting mental health concerns is still perceived as a sign of weakness.  Senior doctors lack self compassion, she says.

“Debriefing is for other people, and we don’t accept that we are not coping,” she says. While leading consultants are open to debriefing junior staff or nurses, they are less likely to recognise and respond to their own danger signals.

Susan Bryant is the widow of a Queensland doctor, Andrew Bryant, who last year, at 54, took his own life. Her decision to speak out publicly about his death and the circumstances around it sent shockwaves through the professional community.

Bryant says what happened to her husband was a result of many factors, part of it being his personality. “He never complained – about his health, his workload, things not going well. He was very much a ‘put your head down and get on with it’ sort of person. Not a whinger.”

But she also lays much of the blame on the inherent culture of medicine. “We took it for granted that he always left early, often was not home for dinner, usually worked weekends, always tired,” she told The Citizen. She imagines he would have laughed if off if given the option of debriefing or talking about his problems. “He was too busy.”

“Being surrounded by colleagues who are all very accomplished, intelligent, high achievers – to admit that you are not coping to those sort of people, when you are one of them, is difficult,” she says.

Helen Schultz, psychiatrist, says that even when a doctor does make the leap to seek treatment, he or she soon strikes another hurdle. Treating a doctor is almost a speciality in itself. Schultz is urging the College of Physicians to establish special training and support for GP’s to be able to treat and refer other doctors for their mental health issues effectively.

Engelbrecht says that she would find it hard to share her problems with a GP or a psychologist who is not specialised in treating doctor’s mental health. “Most senior doctors have already done a whole lot of introspection. We have all tried to diagnose our own mental health, trying to debrief with colleagues and now the hospital sends us to counsellor with an inadequate experience to deal with that. The system is woeful.”

Closed medical culture also keeps important stories of redemption, of doctors facing and conquering their demons, out of the public gaze.

“We never see role models of people who went and sought help and got alright. It is never normalised. It is always on the quiet,” says oncologist Srivastava.

Associate Professor Andrew Davies is a rare exception to that rule. But it took a potentially career-destroying crisis and a forced hiatus of two years for Davies, an ICU physician, to realise that the only way to save himself from spiralling down the path of increasing stress and performance anxiety was to pull back to part-time work and change his life style.

Until five years ago, he was a consultant and a high achieving researcher at one of Melbourne’s busiest intensive care units. He got drawn to research when his then mentor said that the way to make a real difference to millions of lives was by moving into the laboratory.

“Research is very ambition focused. I found without even recognising this that it was all about achievement and to be on next pedestal, in the end I got involved in so many studies that I started slipping away.”

The consequence was a spiral into some “stupid, silly behaviour”, what he admits as a lapse in judgement. He was forced to take time off work for two years. The wake-up call made him seek help and therapy.

Had he recognised the danger signs of his symptoms – anxiety, tiredness and burnout – early on, it would have saved him and his family a lot of grief.

“I got only six hours of sleep for 15 years, and that’s ok because you can function – but it’s not ok, as my body was showing signs that it’s not coping.”

Davies shows a photo taken few years ago. “I was chubby. I was picking at sores all the time.” Today he runs marathons, spends time with his daughters and hosts a podcast discussing doctors’ work life balance.

He says that he paid a huge personal cost before he sought help. “I thought ‘my life is over’, and I would be running a café.”

But he found the right GP and a psychologist who helped him understand that there was a difference between being a bad doctor, and being a doctor who had done a bad thing, and who could again be a valuable part of the health system. Her attitude, he says, was instrumental in his recovery.

 

A changing workplace – for good and ill

Modern medicine has delivered many wonders. It has also delivered many older, sicker patients, with high expectations of the treatment and therapies that will be offered to them. Their doctors need to keep pace with all these changes, and the ever-increasing operational treatment.

Although the options and interventions for patients have increased, the infrastructure and staff providing them have not, says the AMA’s Haikerwal.

The pay awards for doctors have safeguards such as paid overtime, safe hours, rostered time-off, time for holiday, sickness or for study, but there are stumbling blocks to accessing them. “How do you make that happen? Who is going to sign your leave form?”

Geoff Toogood says doctors rarely feel comfortable calling in sick, and when they do the repercussions can be toxic. In his case, he says, he was not only asked to step down from his senior post before he took some time off, he was repeatedly harassed about when was he going to resume work.

The career trajectory of a medical specialist allows no leeway for such hiccups. They have on average trained 10 to 15 years before they become a consultant. That position, within the public system, also comes with a substantial burden of administrative tasks, together with teaching junior doctors, publishing research, and continuing professional education on top of the normal core of duties of seeing patients and, in many instances, maintaining a private practice.

Hanlie Engelbrecht explains that this constant juggling act between various roles leaves little scope for the critical component of professional development.

“All this with shrinking resources…How do we stay current with knowledge?”

Although the Beyond Blue survey sounded an unequivocal alarm on the scope of the crisis in the medical professions, there’s still an inertia around finding solutions. There’s little effort even to keep track of statistics, to determine whether any of the initiatives to date have brought any relief.

So what will it take to improve the health of our doctors?

All the medicos interviewed for this story argue that changing mandatory reporting laws – as now approved by Australian governments – would have a transformative effect.

Beyond that, Haikerwal says that in the interests of both doctors and their patients, medical organisations of all stripes must come together to find effective strategies – the AMA, colleges, the Medical Defence Organisation, health policy makers, hospital administrators.

A Health Department spokesman said the department was working with the Post Graduate Medical Council of Victoria (PMCV), which with Beyond Blue has developed a workplace mental health strategy for hospitals. The PMCV is also scoping the development of an ‘app’ for junior medical officer welfare.

But the most profound change must come from within, and from the behaviours and attitudes of the top tier of the profession, says Geoff Toogood. “You need senior clinicians like me to stand up and call out and change the culture.”

Krati Garg is a graduate of the University of Melbourne’s Master of Journalism program, and a consultant oral surgeon. 

If this article raises issues for you, or if someone you know is struggling, please seek help. Call Lifeline on 13 11 14 or chat online here between 7pm and 4am.

Other resources: Kids Helpline on 1800 551 800; MensLine Australia on 1300 789 978; Suicide Call Back Service on 1300 659 467; Beyond Blue on 1300 22 46 36; Headspace on 1800 650 890