The medical profession is best placed to help colleagues encountering mental health issues, writes Dr Ian McPhee*, a self-confessed ‘black dog’ sufferer.
In recent times there has been a broad, very public focus brought to the matter of doctors' mental health. Not at all unreasonably, it is the plight of hospital-based, junior doctors that has captured the bulk of attention. Something has happened to make JMO life even more stressful. It isn't just the long hours - we all endured those - nor is it exam pressures, likewise experienced by everyone.
Medicine, as much as it might be the same in so many respects, has begun eating its young.
But wait, I hear you say, there was that surgeon I knew, that GP, the gasman.... didn't they succumb, either with their careers or lives?
And sure enough, the stories are legion, along with data stretching back decades that shows a life in medicine carries risks of mental illness at rates higher than most professions, and significantly higher than the general population.
Within our profession, however, it has remained a dirty little secret. Obituaries in the press, and even our respective College magazines and journals have, until very recently, been long on praise for a life at the coalface, and so sadly short on facts relating to suicide when it has been the cause of death.
For some of us, when personal experience grants insight and a sense of knowing, what has not been said has moved us more than the detail might have.
But what of others? Why are we so reticent to tell it like it is, to shroud an end of life story in euphemism? In answer I have nothing other than a plea for this to change.
My own adult years have been spent always with the black dog lurking ominously. Kept in check for the decades until my forties, I struggled through, bouncing back from an occasional mauling with the assistance of loved ones and, when I could manage it, a holiday. This was just the way it was, I told myself repeatedly. After all, as a student, when I had thought things were tougher than they should have been, it is what I was told when I had gingerly approached liaison psych in the teaching hospital I was in.
The fall though was inevitable. There's only so much 'resilience' - a term I use circumspectly - an individual has, and, up to my eyeballs in an incredibly demanding post, it came.
But what to do when this happened? And why had I allowed it?
To answer the first question requires a little scene setting. I was a freshly minted consultant in a provincial centre. I had no GP. I wasn't even that sure what was going on. I was defeated and frightened. I had no close colleagues and there were some who resented my very presence in the town - did someone say 'turf war'?
Ultimately for me, assistance came down to a phone call. If everything else might have failed someone even today, that same option remains available - the Doctors Health Advisory Service continues to fulfil a special role. Importantly, assistance is prompt, focused, and delivered by individuals with a commitment to supporting their colleagues.
Of course, intervention before a 'fall' would be so much more appropriate. But why is it that this is still not the norm? What are the factors that drive mental ill health on the one hand, and discourage timely help seeking on the other? Is it that we 'allow' this to happen as I had earlier suggested?
And so to ‘resilience’. How easy it has been for doctors to have been labeled at fault - not cut out for the job, bereft of necessary coping skills, failing to care for themselves, or, even more desperately, simply regarded as collateral damage by a system denying responsibility.
The mainstream literature is now full of references decrying the ease with which blame has been levelled at the individual.
This from the BMJ of 27 July:
‘…. a focus on individual resilience can shift responsibility for burnout* away from systems and not tackle the root causes…’
*I won’t explore the burnout/depression conundrum. It is however well reviewed here.
Solutions ultimately lie elsewhere. From that same BMJ piece:
‘….. professional bodies and healthcare organisations must consider the improvement of doctors’ wellbeing and working lives as central to patient care. While individually targeted interventions can make a small difference, only a concerted, system level approach will deal with system level causes.’
Jane Barker’s thoughtful contribution to local discussion of support for JMOs, in the last edition of GPSpeak, explored some of the options for system level responses.
My take is that any such responses should acknowledge and embrace equally the needs of senior clinicians. The story, so poignantly and bravely put by his family, of the suicide of Brisbane gastroenterologist, Andrew Bryant, bears this out.
It simply has to be that, in language that is clear and understood by everyone, we can all tell our stories without fear of stigma, or worse, retribution.
It is time Mandatory Reporting was aligned nationally with the Western Australian model. If this is to be a role for the COAG Health Council, as has already been suggested by Health Ministers, Brad Hazzard and Jill Hennessy, it should be high on the agenda for their next meeting.
Federal Minister, Greg Hunt, meanwhile has openly committed to the issue of doctors’ mental health, although it has been pointed out that his meagre offering of $1M to support this amounts to barely a cupcake per registered practitioner! Sweet? Maybe not!
It is also time that our learned Colleges paid more than lip service to the welfare of their members. ANZCA has had something of a pioneering role here with its longstanding Welfare Special Interest Group, and RANZCOG has more recently initiated in Victoria a number of seminars and workshops led by dynamic psychiatrist Helen Schultz (@drHelenSchultz for the twitterati!).
The RACS’ focus on workplace bullying and gender harassment has gone some way to highlighting issues within their ranks. Others, including somewhat surprisingly, RANZCP, have remained silent.
Beyond the Colleges and governments lie opportunities still to be explored. Mentoring, in the sense of an experienced and trusted advisor’s input, has been suggested for juniors and seniors alike. This is in contrast to the role of supervisor during periods of training. After all, who is likely to confide in an individual responsible for assuring progress through the ranks? Not having a mentor of choice, but rather by assignation, has been blamed for the failure of some of these programs in the past. I know that having such a mentor has been of benefit to me at different times in my career.
Finally, to the matter of professional care for the carers.
Helen Schultz has reported that this has been a significant focus of workshopped solutions to managing doctors’ mental ill health. It is the case that not everyone is suited to treating colleagues. Manipulative, taciturn, poorly compliant… they can be wily critters.
My own lived experience (as a patient!) confirms this. The answer would seem to be the establishment of panels of doctors, notably GPs, in the cities and in the regions who are both willing and trained to take on this role. These are not meant to be mentors or mates, but clinically objective partners in assessment and treatment. And until such panels exist? Everyone of us, without exception, must seek out and retain a GP they have confidence in. It could save your life.