The Road… Not Taken

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Every now and then there is a presentation or talk that you have to give, that you have been waiting a long time to do. This is one of mine that has been floating around in my head for sometime looking for the right occasion. DFTB17 was the right occasion.

*Just a warning before I start. Some of this stuff might bring up some emotions or feelings that you have kept hidden for some time. If you need help then I’ve put a list of contact addresses at the bottom of this post*

I want to take you back… Back to the year 1999. It was a year of partying purple pop pixies, the year trench-coated hacktivists first graced our screens and the year we did not colonize the moon. It was also the year that I first tried to kill myself.

Does this make me unusual in the world of medicine? Data from the 2013 Beyond Blue survey would suggest otherwise. They looked at data collected from over 12,000 doctors and 1000 medical students. 21% of doctors reported having been been diagnosed with, or treated for depression. 24.8% had had suicidal thoughts in the previous 12 months and 2% had actually attempted suicide. Self-identified paediatricians reported slightly lower levels of depression (18.8%)

The rate of suicide amongst male doctors in Australia is around 14.8 per 100,000 person years, not much difference from the national average for non-medics (14.9 per 100,000). It is higher for male nurses and midwives (22.9 per 100,000 person years). The suicide rate for female doctors is almost 3 times the national average however. It is 6.4 per 100,000 person years compared with 2.8 per 100,000 for other women.

There have been some recent high profile cases that have made the press over the last year and brought this conversation into the public domain.

 

So what is depression?

On a purely neuropharmacological level it is thought to be brought about by an imbalance in the neurotransmitters serotonin and noradrenaline. But to those of us who have suffered from depression it is something much more than that.

It’s an illness, like a cancer, with its own set of genetic predeterminants that, if coupled with toxic exposures, may lead to disease in later life. If not detected or treated early it can grow outwards from its dark heart consuming the light until the suffering it causes leads to the death of its victim.

For me it was apathy, ennui, anhedonia. I couldn’t be bothered to do anything. My day was a perverse Groundhog rendition of wake, go to work, come home, go to bed, wake, go to work, come home, go to bed. If you looked in my fridge you would have found it bare but for the shrivelled remains of a capsicum. I couldn’t be bothered to go shopping for food. So in two months I lost around 10kg in weight.

 

A genetic predisposition

Twin studies, beloved by psychologists, have shown a heritability of around 50% with first degree relatives showing a two or threefold increase in incidence of major depressive disorder.

 

Toxic exposures

Some of the things we are exposed to are a part of our humanity – love, life, death – but there are particularly toxic elements that medicos, especially those in training, are exposed to on a regular basis.

Like most who get into medical school I was in the academic top 5% at school, All of this changed when I got to university and was surrounded by a collection of academically above average individuals. Part of our ego-driven image is that we do not fail. This can lead to a crisis of ego when it inevitably does happen. The law of averages would suggest that at least half of us are going to fail an exam at some point. The problem is that which we give up when we are studying, often for long hours, when we are not at work. We miss out on family gatherings, exercise and the dying embers of a failing relationship.

The training program is long. It took me six years to get out of medical school and I have taken a very roundabout route to consultant-hood.  During that time I have had to contend with moving posts every six months, studying for exams whilst working long, uncompensated hours, and moving to a different hemisphere to get the career I wanted. Prolonged exposure to this sort of workplace stress coupled with a lack of basic human needs such as sleep and access to decent meals may lead to anyone feeling overwhelmed and unsupported.

As a member of the ACEM working party on Discrimination, Bullying and Sexual Harassment (DBSH) I have been working hard to help figure out the prevalence of these negative contributors to physician mental health. No matter what the outcome of the recent ACEM survey I am sure the college will advocate for cultural change with the view that any reduction in DBSH behaviours will reduce the risk of mental health disorders amongst FACEMs and trainees alike.

 

Truth and consequences

There is an undeniable stigma attached to mental illness. It is something that stops people asking for help. Doctors, especially those still in training, feel that admitting to mental health issues might imply a general lack of coping skills. This can lead to the phenomenon of ‘presenteeism’ – turning up to work when you shouldn’t. But this means colleagues have to work just that little bit harder to cover and this doesn’t go down well with the team.

The perceived need for mandatory reporting to health care regulating authorities, both at a state and national level, is a disincentive for doctors to seek help. Currently, in Australia, WA is the only state that does not require mandatory reporting. Whilst the language is wooly, if a doctor is perceived to be impaired, then they should be reported to the regulatory authorities – the Medical Board of Australia and the Australian Health Practitioners Regulatory Authority. This could lead to restrictions of practice or occasionally suspension – something that no doctor wants on their permanent record.

 

The myth of resilience

Despite being profoundly unwell I continued to go into work, do my ward rounds, dictate my clinic letters. My job was a mask, hiding the real me. And it was easy to answer, “How was your weekend?” with a trite, “Fine, thank you” and “How are you feeling?” with the same.

Doctors are expected to cope with anything thrown at them – a failed neonatal resus, a knife wielding ice addict, an extra hour of paperwork – without it barely ruffling their (non-existent) white coats. Amongst certain senior clinicians the thought is that the increase in mental health issues amongst junior staff is because they are just not tough enough, that they are not resilient enough to make it through the work day. It’s the “I worked 120 hour weeks on a one in two on-call roster. There was barely enough time to take a leak, let alone eat a meal. And I made it through unscathed and you can too!” approach to mentoring. This is usually coupled with the medical staffing trying to fix the problem by creating resilience and mindfulness training programs for the juniors who are then burdened with yet more to do. You don’t tell the doctor working in an abusive environment to be more toughen up, to be more resilient, you try to fix the system.

 

Does speaking or writing about suicide make it more likely that others will follow suit?

When I started researching this topic for my talk I wondered if it might provoke anxiety in my audience. The simulation literature is full of how to create a psychologically safe learning environment but how does one do this if one is giving a twenty minute talk? The reporting of suicides in traditional and social media have been associated with an increase in suicide rates. People who are at risk may be drawn to stories of celebrity deaths especially when the behaviour is glamorized. You can find a great guide on responsible reporting on the MindFrame website.

 

All right now?

So that’s it? A failed suicide attempt, a brief inpatient stay, some strong medication with odd side effects and I’m cured? Depression is not the sort of illness that just disappears. Like a cancer, it may go into remission with the right treatment, but that does not mean it has gone for good.

 

It’s not all about me

Whilst my talk and this accompanying blogpost are a form of catharsis, there is a point, two points, in fact, that I wanted the audience to take away with them.

  • There is nothing wrong with admitting you have a problem and need help.
  • WE need to change the system, the way we treat each other, if we want to really make a difference with regard to physician mental health.

 

 

If you need help or any of this really resonates with you then you may want to make an appointment with your GP – you do have one, right? Alternatively, here are a few services available in Australia.

Lifeline – 13 11 14

Suicide Call Back Service – 1300 659 467

Beyond Blue 1300 22 4636 

 

Victoria – Victorian Doctors Health Program – website – (03) 9495 6011

Queensland – Doctors Health Advisory Service – 07 3833 4352 

ACT – Doctors Health Advisory Service – 9437 6552

New South Wales – Doctors Health Advisory Service – 02 9437 6552

South Australia -Doctors Health Advisory Service  – 08 8273 4111

Northern Territory -Doctors Health SA – 08 8366 0250 xxxx

Western Australia – Doctors Health Advisory Service – 08 9321 3098

Tasmania – Victorian Doctors Health Program – 03 9495 6011

New Zealand – Doctors Health Advisory Service – 0800 471 2654

References

Some Practical Thoughts on Suicide by Tim Ferriss

Beyond Blue Doctors Mental Health Program

Life in the Fast Lane – Physician Suicide by Andrew Tabner

Self Compassion by Dr Kristin Neff

Conversations Matter

The Mental Health of Doctors – A systematic literature review – August 2010 from Beyond Blue

The National Mental Health Survey of Doctors and Medical Students – October 2013 from Beyond Blue

Lohoff FW. Overview of the genetics of major depressive disorder. Current psychiatry reports. 2010 Dec 1;12(6):539-46.

Hill AB. Breaking the Stigma—A Physician’s Perspective on Self-Care and Recovery. New England Journal of Medicine. 2017 Mar 23;376(12):1103-5.

Milner AJ, Maheen H, Bismark MM, Spittal MJ. Suicide by health professionals: a retrospective mortality study in Australia, 2001-2012. The Medical Journal of Australia. 2016 Sep 19;205(6):260-5.

Kõlves K, De Leo D. Suicide in medical doctors and nurses: An analysis of the Queensland Suicide Register. The Journal of nervous and mental disease. 2013 Nov 1;201(11):987-90.

Bright PR. Depression and suicide among physicians. Curr Psychiatr. 2011;10(4):16-30.

Pirkis J, Blood W. Suicide and the news and information media. Commonwealth of Australia. 2010 Feb.

Hassan, R. (1995). Effects of newspaper stories on the incidence of suicide in Australia: A research note. Australian and New Zealand Journal of Psychiatry29(3), 480-483.

Hawton K, Clements A, Simkin S, Malmberg A. Doctors who kill themselves: a study of the methods used for suicide. Qjm. 2000 Jun 1;93(6):351-7.

Lindeman S, Laara E, Hakko H, Lonnqvist J. A systematic review on gender-specific suicide mortality in medical doctors. The British Journal of Psychiatry. 1996 Mar 1;168(3):274-9.

Lake FR, Ryan G. Teaching on the run tips 11: the junior doctor in difficulty. Medical Journal of Australia. 2005 Nov 7;183(9):475.

With grateful thanks to...

Ash Witt, Cian McDermott, Helen Schultz, Henry Goldstein, Ian Summers, Ross Fisher and Simon Carley for their advice.

And PC, JE and EW for getting me here.

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About 

An Emergency Physician with a special interest in education and lifelong learning. When not drinking coffee and reading Batman comics he is playing with his children.

@andrewjtagg | + Andrew Tagg | Andrew's DFTB posts

17 Responses to "The Road… Not Taken"

  1. Dee Bren-Clarke
    Dee Bren-Clarke 4 weeks ago .Reply

    Beautifully written. Eloquent in its storytelling and heartbreaking honesty. The final 2 points should be mantras for us all – supported by our employers and colleagues.

  2. Tim Leeuwenburg
    Tim Leeuwenburg 4 weeks ago .Reply

    Well done Andy – a powerful talk, expertly delivered and whilst cathartic will hopefully spur others on to both put their own hand up, to help others and to campaign for better system NOT ‘resilience training’

    Echoes my smacctalk from Chicago – and you managed to keep clothes on!

    Kudos

    http://kidocs.org/2015/07/you-are-not-alone/

  3. CC
    CC 4 weeks ago .Reply

    We need to talk about this more. I worry for our overworked Registrars, SRMOs and nurses. Absurd hours, no food, then blamed and shamed for (very minor) mistakes or that missed cannula.

  4. Carly Debinski
    Carly Debinski 4 weeks ago .Reply

    Andy, To see you write so openly and honestly about something so deeply personal and as you say, often stigmatized is just another reason you are a truly fantastic teacher and mentor for us juniors. Seriously inspirational and I hope that the system listens, that we are respected as people and not just cogs in the wheel and that changes continue to be made. Thank you for sharing.

  5. Simon Carley
    Simon Carley 4 weeks ago .Reply

    Thanks for writing this.
    S

  6. Suzanne Mason
    Suzanne Mason 4 weeks ago .Reply

    Can you talk about solutions sometime please. Acknowledging problem exists is important but more to it?

  7. Kym Jenkins
    Kym Jenkins 4 weeks ago .Reply

    Thanks for writing this and sharing your story

  8. Bishan Rajapakse
    Bishan Rajapakse 4 weeks ago .Reply

    Hi Andrew – what a brilliant post mate.

    The article was pristine, but I must say I really related to these reflections; –

    —-“Like most who get into medical school I was in the academic top 5% at school, All of this changed when I got to university and was surrounded by a collection of academically above average individuals. Part of our ego-driven image is that we do not fail. This can lead to a crisis of ego when it inevitably does happen. The law of averages would suggest that at least half of us are going to fail an exam at some point. The problem is that which we give up when we are studying, often for long hours, when we are not at work. We miss out on family gatherings, exercise and the dying embers of a failing relationship.

    The training program is long. It took me six years to get out of medical school and I have taken a very roundabout route to consultant-hood. During that time I have had to contend with moving posts every six months, studying for exams whilst working long, uncompensated hours, and moving to a different hemisphere to get the career I wanted. Prolonged exposure to this sort of workplace stress coupled with a lack of basic human needs such as sleep and access to decent meals may lead to anyone feeling overwhelmed and unsupported.” —-

    These are great words. Thaks for sharing

    It’s my hypothesis that we work best when we are “human” as after all we are “human beings” not “human doings”.

    In medicine, and in medical training we barely have time to “be”, because we are so focused on “Doing” in order to survive.

    Even in writing this comment I am strapped for time as I had a long shift yesterday, one tomorrow, and am shifting house. In amongst this i have to write lots of emails to try and get to a number of course for the ACEM OSCE. The professional exams are tough even if we did study full time, add on busy jobs and “life” – the odds of a guaranteed pass seem to disappear in the practicable distance.

    For people who have never learned to cope with failure – like most medical people (because they have had lots of experience with success, and not failure) this sets up an arena for depression and anxiety.

    It always perplexes me that so few like to to talk about it. Having progressed in my career, i’ve realised why this was the case. It’s not very safe to talk about any vulnerability.

    The work the college is doing with the Discrimination, bullying and harassment is profound and a paradigm shift. I think it is great that you are part of this . To me this message from the college president and people like yourself on this front means that the tide has finally changed, for it to be “okay” and more importantly to talk about this issues .

    At the end of the day – it is about feeling safe and loved both in our success and failures.

    You’re talk and post are adding significantly to the foundations of a safe space, where I believe the most human of doctors can feel safe to be themselves.

    thanks 🙂

  9. Bishan Rajapakse
    Bishan Rajapakse 4 weeks ago .Reply

    Also – I must share this podcast that goes along with the theme of this article . I listened to it recently and it was brilliant — https://lifeinthefastlane.com/mastering-intensive-care-013-with-sara-gray/

    thanks again 🙂

  10. Linda-Jayne Mottram
    Linda-Jayne Mottram 4 weeks ago .Reply

    Thank you for shining a spotlight on this. I often wonder if the cynicism displayed by seniors /mentors towards juniors who may be struggling is in fact a feature of their own burnout or psychological distress. They too may be struggling.
    The Intensive Care Society is maintaining a focus on workplace wellness this year. Good opportunities for collaboration with other colleges/faculties to really put weight behind it.
    Thanks again

  11. Shiela
    Shiela 4 weeks ago .Reply

    I’ve been a nurse for 30 years and over this time have seen very little change in the recognition of this condition – as those there to help others we seem the worst at recognising a need in Ira he other. I to was brought up in the world of do more, not less, you shouldn’t need time to sleep, eat, be ill or grieve. I have watched friends and colleagues not take the time they need to heal, come back too soon only to crash and burn later.
    Thank you for sharing your experience it’s brave and needed!

  12. Kay
    Kay 4 weeks ago .Reply

    Thank you for sharing.

  13. andrew coggins
    andrew coggins 4 weeks ago .Reply

    Thanks for sharing, agree with my friend Bishan’s observations about the human (medic) experience

  14. Diane Campbell
    Diane Campbell 4 weeks ago .Reply

    Excellent. Can I put in a plea to remember those who have dropped out of consultant training and are working as CMOs or night shift cover….. don’t even have the peer support of trainees and even the best ED directors sometimes just say – well, I don’t have the resources to care for everyone.
    Anyone remember the ACEM ASM at the Adelaide Convention centre a few years back? Lots of people jumping around yelling “We have the best job in the world!” Which is often true but I kept thinking of the two recent ED suicides in that state, and wondering if the hype was making the depressed feel even worse and more out of it.
    And…. make sure that ED registrars rotating out of the department aren’t lost. Some of ’em are just used as workhorses in medicine etc while the physician trainees get all the support.

  15. Andrew Tagg
    Andrew Tagg 3 weeks ago .Reply

    Thank you everyone for your kind comments.

    This is a work in progress.. Changing the culture is a work in progress. I’ve been approached by so many people over the week that have been in the same place as I was. It is time to normalize asking for help.

    If I figure out how to change the culture, I’ll let you know

  16. SK
    SK 3 weeks ago .Reply

    Hi Andy
    Thanks for Sharing your story.
    I have been or is in the same boat.
    Things get worst when you continue to sit OSCEs exams for 3 years.
    Hope someone someday will listen and understand the plight.
    Hope it’s not too late.

  17. Shivi
    Shivi 2 weeks ago .Reply

    Hi Andy,
    Thank you for your honesty! I have seen first hand as both a daughter and a friend the so call ‘Resilience training’ my medical colleagues are expected to endure. It is shocking to me as the caring profession nurses and doctors that we so easily disregard the struggles of our colleagues and put it down to it being ‘all part of the job’. This article was beautifully written and so brave and hopefully it will help more clinicians to take that first step. Thanks again
    Stay Well

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