Dr Jane Barker looks at rising suicide rates among the young doctor population and urges the medical profession to be more active in addressing this mounting crisis.
The death of a young person through suicide is a tragedy leaving family and friends devastated, and the medical fraternity is again reeling from more reports of the suicides of young trainees. In 2015, we have learned, three trainee psychiatrists took their own lives in Victoria. While investigations were announced, any changes that have been made did not prevent the deaths of a further three trainees this year, this time in NSW, Sadly, these are only the ones we are hearing about.
A colleague of one of these doctors wrote a distressed and powerful piece accusing the profession of failing to support its young doctors. The family of one is reported as saying that the “brutal and completely unsustainable expectations of her job” contributed to her death.
Whatever the truth, we as a profession should not remain complacent, risking the acceptance of physician suicide as a norm, as mere collateral damage in the battle to combat disease. If these were patients dying from a drug reaction or from medical errors there would be an outcry, but this is worse: it could be caused by a fundamental flaw in the medical system we work in and that we have, in part at least, helped to create.
These young people are not statistics, but represent those we have selected for medical school entry, those we have helped to train, those junior doctors who staff our hospitals, those training to be the medical leaders of the future.
Reasons behind suicide
Of course suicide is not simply caused by the medical system, although statistics comparing doctors to the general population show a significant increase in suicide amongst doctors, in particular amongst women doctors.
This suggests that having a career in medicine plays an important part. Not least because having knowledge and access to a means translates into more successful suicide attempts. In a study of physician suicides around two-thirds were related to mental health disorders, in particular to unipolar depression.
This study identifies around one-in-five instances being attributed to work related causes. I suspect this to be an underestimate as we know, for example, that the high levels of stress and disturbed sleep, common in the lives of young doctors, affect their cognitive function, their relationships, and their performance. We know that burnout, depression, anxiety and cynicism increase over the timeframe of medical school and on through young doctors’ lives.
We know the increased incidence of suicide is a reflection of a high level of anxiety and unhappiness amongst medical students and trainees. We know that periods of transition, for instance a medical student moving into the clinical phase, a junior doctor joining the workforce, a doctor being investigated for malpractice, or matters occurring outside the workplace - such as a child being born or a relationship breakdown - will lead to an increase in vulnerability.
High-risk periods are when a young doctor is not only working but studying for critical exams with overwhelming consequences if they are failed. Added to this is the fact that doctors have difficulty accessing care because of shame, guilt, fear of confidentiality or fear of losing their income or their reputation. This appears to have been compounded by mandatory reporting. Whether or not this system really treats doctors fairly, there is a strong perception amongst the profession that it does not and this adds a further dimension: being a doctor is an impediment to the doctor/patient receiving the care they need.
Challenging the ‘System’
There is no doubt that we need to react urgently to this crisis, that we need to identify causes and to find solutions. It is has never been enough to train doctors in resilience, to mentor and support them to survive in medicine, if we are not willing to look closely at the underlying flaws in a system which is causing what could be described as an epidemic of depression and consequent suicidal ideation.
We need to ask whether the demands on young doctors are realistic and sustainable. We appear to be destroying the very workforce that our society so badly needs. Surely there are other ways to build and assess knowledge and experience, to provide the medical care our population requires without this terrible toll on our doctors.
There is no doubt that programs supporting junior doctors in the workplace are of vital importance. However, speaking of your problems in your own workplace environment is considered by some to be hazardous and may compound a sense of being judged for what is, after all, an illness.
As GPs working in the community we are of necessity experts in the mood disorders, primarily depression and anxiety, which appear to be underlying factors in physician suicide. We have all during our careers had experience as junior doctors, even if this was in another era.
We are aware of the stresses and strains of clinical practice, the complexity and emotional impact of stressful patient encounters. Many of us have been witness to, or personally experienced, bullying and sexual harassment in the medical workforce.
Most of us, if we would admit it, have at some point made errors of judgment and had to deal with the consequences. Many of us have experienced being investigated by the HCCC or being sued when we feel we are innocent. We too have been tired, stressed and at times felt burned out. Some of us, at some point in our careers, may have been depressed and have had suicidal thoughts. We, too, are not infallible and understand how a distressed doctor may feel, and have compassion for them.
What to do?
Doctors have in the main not been adequately trained to cope with their personal responses to the clinical situations they encounter. They have not been trained to monitor their own competency under the stressors of long hours and highly charged clinical situations. Doctors have instead been trained to ‘soldier on’ regardless (as we now appreciate, even soldiers are highly vulnerable to the emotional impacts of their work).
Not all doctors can identify an appropriate colleague to assist them, or have necessarily accessed them. Many self-diagnose and even self-treat. We have not been trained adequately in the value of reflection. Clinical supervision, a requisite for other professionals like psychologists, is not mandatory. That leaves us vulnerable.
GPs are in a wonderful position to support young doctors if we were willing to take on this role. I propose that we consider funding GPs ,who have undergone a well-designed and accessible training program, to act as mentors to junior doctors.
This would be a non-clinical role and the GP would also encourage them to identify a clinically treating GP. For this to be able to happen we need to review the mandatory reporting system so that it is transparent, compassionate and allows all doctors to access the care they need.
Such a mentoring system should be an integral part of medicine, with all junior doctors being involved in what would become an accepted part of the system.
No young doctor should feel isolated and unheard in their distress, nor pay such a high price for choosing to join what we claim is a compassionate profession.