Why are doctors pushed to breaking point?

Junior and senior doctors are demanding an investigation into the "professional tragedy" of suicide

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A recent spate of doctor suicides has left grieving family, friends and colleagues fighting to end the culture of denial about stress and depression in medicine.

In an act of extraordinary compassion, the usual veil of silence was pulled aside in the case of Dr Andrew Bryant by his wife, Susan, after the Brisbane gastroenterologist died in his office early last month.

“If more people talked about what leads to suicide, if people didn’t talk about as if it was shameful, if people understood how easily and how quickly depression can take over, then there might be fewer deaths,” Ms Bryant wrote in an email to friends and colleagues. “His four children and I are not ashamed of how he died.”

Ms Bryant said that her husband had “never before suffered from depression”.  She had been worried about Dr Bryant not getting enough sleep, “but he had never been a great sleeper”.

“He was very busy; but he had always been busy.  Just before Easter he became he became anxious – about his private practice, about being behind in his office administration, about his practice finances, about some of his patients, about his competence.”

After a run of nights on call at a hospital, Dr Bryant had also become teary and unusually distressed over the death of a patient.

“In retrospect the signs were all there,” Ms Bryant wrote.  “But I didn’t see it coming.  He was a doctor, he was surrounded by health professionals every day; both his parents were psychiatrists; two of his brothers are doctors, his sister is a psychiatric nurse – and none of them saw it coming.”

In NSW, the death in January of Dr Chloe Abbott, a fourth-year trainee doctor in Sydney and former World Championship swimmer, has  sparked calls for a special inquiry into the pressures and demands on young doctors. Dr Abbott was also deputy chair of the AMA council of doctors in training.

Dr Ben Veness, a psychiatry registrar who went to medical school with Dr Abbott, said he wanted to see “something positive, if possible, come out of such a tragedy”.

With a handful of colleagues, Dr Veness wrote a letter in April to NSW Health Minister Brad Hazzard asking for a parliamentary inquiry into the deaths of Dr Abbott and two other medical trainees in the space of four months.

“Sadly, the suicide of a young doctor is not altogether uncommon,” they said. “These deaths follow the apparent suicides of four other doctors-in training in Victoria in 2015.”

The deaths of these young people went beyond personal tragedy, to become a “professional one, too,” the letter said.  More than 150 doctors, trainees and students co-signed the appeal.

Subsequently, the NSW coroner’s office has advised the minister that “at least” 20 doctors and medical trainees had committed suicide in the state in the 10 years prior to 2016.

Dr Veness would like to see an independent investigation into junior doctors’ workplace conditions by someone with fresh eyes from outside the healthcare system.

“When you talk about conditions in medical training, usually people from outside of medicine think it’s bizarre, over the top. When these things are done internally, most people have a form of Stockholm syndrome which stops them, I think, from seeing how aberrant things are.”

He points to the model of the Garling inquiry into the NSW hospital system, conducted after a series of failings led to the death of a young woman who had been hit by a golf ball.

“The Garling report enabled people at all levels in the system to have a voice in expressing their opinion on what needed to change.  But also it meant the government had officially commissioned and was therefore some extent obliged to follow up with these independent findings.”

As TMR went to press, the state government had not agreed to an inquiry but announced plans to hold a forum on the health and well-being of junior doctors on June 6.  More than 200 junior and senior doctors and representatives of medical schools, colleges and health services would gather to examine options and prepare a plan to further improve support for JMOs, a NSW Health spokesperson said.

The occasion is certain to be lively.

In the wake of publicity over Dr Abbott’s death, the internet has been alive with complaints from junior doctors about 75-hour weeks, inadequate overtime pay, the stress of studying for exams, pressure to work while sick and the burden of accumulating a mountain of debt.

Some trainees also reacted with displeasure with media coverage of a new wellness program for trainees at Sydney’s Royal Prince Alfred Hospital, calling it a “PR campaign”.

The BPT OK program, which encourages stress-busting habits such as exercise and mindfulness, has been operating only for a month, overseen by Dr Bethan Richards. In five years as RPA’s director of physician training, Dr Richards said she had noticed the pressure and stress on trainees rising to the degree that about 10 per cent needed expert psychological help.

The spate of suicides earlier this year was the catalyst to roll out the program, with the goal of giving young doctors skills to help them maintain well-being not only during their training but also for the rest of their careers.

“This is not just a junior doctor problem, it’s at all levels,” Dr Richards said.

“We have an elite group of people who are highly competitive, they have never failed an exam in their life.  You throw them into a system where …they might just fail for the first time.  That’s one of the amplifying factors.

“They’d stop their exercise, anything outside medicine that would give them a break from it.  Everything was about the exams.”

The program includes advice on how to handle traumatic and emotionally challenging events at work, such as breaking bad news.

“They are not trained to do the hard stuff they need to do on a day-to-day basis. There is also no culture of debriefing in medicine.”

Trainees still felt that talking about their anxiety would indicate they were not coping. “That means I’m a bad doctor, I’m not cut out to do medicine, maybe I won’t get a job next year,” Dr Richards said.

The idea is to normalise debriefing as part of daily clinical practice, as well as training them to recognise symptoms of stress before they reach breaking point.

A body of literature shows that high levels of stress and anxiety affect doctors across the board, with particular impact on women doctors.

In Australia, a beyondblue survey report published in 2013 found one in 10 doctors had had suicidal thoughts in the preceding year; for medical students the ratio was one in five.

Further, a landmark retrospective study, published in the MJA in 2016, found that the rate of suicide for women across the health professions in 2001-2012 was “markedly higher” than that for women in non-healthcare professions.

The suicide rate for health professionals with access to prescription medications was 1.62 times the rate for health professionals without such access.  Poisoning was used in 51 per cent of doctor suicides and 40 per cent of suicides by nurses and midwives, but only 10 per cent among other occupations.

Dr Mukesh Haikerwal, a Melbourne GP and beyondblue board director, says the issue is not whether suicides among doctors and medical students are on the rise – they may be higher than in the general population but an increase cannot be substantiated – or whether they may occur more frequently than in other high-stress professional groups.

“The issue is that the situation has not got better – and it should have,” Dr Haikerwal said.

Like most doctors, Dr Haikerwal has been affected personally by the suicide of a colleague. He supports calls for a coronial-style inquiry into the problems bearing on doctors and trainees.

“I think you need that level of interrogation – a psychological autopsy – because these people end up in a very bad position and doing terrible things to themselves. People should never get to that stage.

“What were the dominoes that fell for this to happen?”

The intervention of families and concerned friends in the debate over unsafe working conditions and stresses should be a “game changer” for the profession, he said.

“The families are very important in this. Previously they have not been willing to come into this space.  Now that they are, I think it’s important to accept that huge gesture and use it to try to determine what are the changeable aspects in the set of dominoes, so that it doesn’t happen so much in the future.”

The largest US study of suicide rates by occupation, reported last year by the Centres for Disease Control and Prevention, found farming, fisheries and forestry had the highest suicide rate of 85 per 100,000 deaths.

The CDC report identified risk factors including job-related isolation and demands, stressful work environments and work-home imbalance, as well as socioeconomic factors.

Doctors were on par with lawyers with just 19 suicides per 100,000 – behind police, architects, carpenters and a range of other occupations.

But concern over American doctors dying by their own hand has reached the level of national debate, according to Dr Michael F Myers, a psychiatrist who specialised in treating fellow doctors for most of his 35-year clinical career.

“The stress and burn-out among physicians has increased over the past 10 to 15 years,” he told TMR in a telephone interview.  “Around the world, you find that 50 per cent of doctors report at least one sign of burn-out.”

Dr Myers, author of Why Physicians Die By Suicide, a new book drawing on the insights of the families of doctor suicides, said there were many different reasons why physicians might reach that point of desperation.

The worry was that a doctor might slip into a severe depression without recognising it; and colleagues and families may be equally unaware. The illness could progress to a kind of  “tunnel vision” where they saw no option other than suicide.

“We generally believe that 85 to 90 per cent of people who die by suicide have been living with some form of psychiatric illness, and it has often been unrecognised and undiagnosed or poorly treated.  So that’s what drives that desperate decision in people who were once well,” he said.

“Common reasons for depression in physicians are PTSD – they may have experienced some sort of trauma earlier in life, having to do with being sexually assaulted, witnessing a crime, being physically assaulted or serving in the military, or a trauma in the medical workplace.

“Say, they’re working in an emergency room. There’s a severe motor vehicle accident and in comes a severely injured child the same age as their child, but they don’t have the time to deal with it because you’re looking after other people. Or they are in a psych unit and assaulted by a patient.

“The third big thing comes with alcohol and other drug use; it could be street drugs or it could be self-prescribing tranquilisers or taking drugs from a hospital.”

Dr Myers says doctors suffering from burn-out – which, anecdotally, has been blamed in part on the extra work demands created by the use of electronic health records – feel demoralised and unhappy.

“It troubles them, because they don’t feel they have the same compassion they once did. One of the symptoms is feeling estranged or numb. And because of the workload, or the system they are in, they don’t feel valued, or they don’t have a voice.  That gets them down.”

As for a solution, he counsels lifting the lid on what he calls “medicine’s dirty little secret”, that students, trainees, residents and fellows can fall victim to suicidal despair.  “The title of my book is jarring to some people, but we know it exists and it needs to be talked about.”

In a profession where stress and anxiety apparently go with the territory, doctors are largely critical of Australia’s mandatory reporting rules that discourage help-seeking by doctors with mental health or substance-abuse issues.

Despite the advice of the AMA, the mandatory reporting rules for doctors treating an allegedly impaired colleague apply in every state except Western Australia.

AMA NSW President Brad Frankum, another doctor whose life has been touched by the suicide of a colleague, says health bureaucrats do not appear to understand the relentless pressures junior doctors – and senior colleagues – work under.

“Even though perhaps junior doctors don’t work the same sort of hours that people did in the past, there’s no thinking time any more,” he said.

“It’s constant pressure about four-hour rules in emergency, early discharge, getting all the paperwork done and ordering myriads of tests on patients, and communicating beautifully with all the staff, and the families, and the patients … I think it is draining on people.”

Dr Frankum says doctors need to lose their “unforgiving attitudes” and training pathways should made more flexible, so that trainees could be their training around other demands in their lives.

“Doctors are human, there needs to be a little bit more leeway for people to make mistakes and to take some time off when they need it.

“We can be a bit inclined to view difference or poor performance in a very bad light and maybe we have not been as supportive as we should be.”

Another public hospital doctor remarked: “Bullying culture is rife, working hours are excessive, expectations of junior doctors remain high. I, too, am exasperated by the lack of change.”

Teaching doctors to cope with adversity is one approach; reducing the adversity would be a better goal for authorities, Dr Veness said.

He considers a barrier to the medical profession effecting change from within is that many senior doctors have never worked outside medicine.

“The mining industry, for example, has had a lot of problems with suicides,” he said. “Their fly-in fly-out system has a lot in common with the way we ship medical trainees off sometimes at short notice to places where they are not supported by family and friends.  Social and personal isolation might play a role in the stress, and (miners) are having to address that.

“But you don’t commonly see medicine looking to other industries for advice.  Because I think there’s somewhat of an arrogance that medicine is so much its own world that it wouldn’t be able to learn from other industries.”

Of course, general practice is not immune to the stresses of increasingly complex demands.

“I’ve seen a lot of talk about building more resilience in health professionals and empowering us with well-being skills – which is great – but it can become an element of victim-blaming,” commented Dr Melanie Smith, president of the General Practice Registrars Association.

She called for acknowledgment of the increased pressures of the job and, for trainees, the stress of losing control over their lives.

“You need to work hard to learn.  But I think the job has changed a lot in the last several decades in medicine and in general practice in particular. The knowledge base is far broader and deeper than it was 40 years ago.  There’s the whole drug formulary and branches of medicine that didn’t exist 50 years ago.”