With permission from the Sydney Morning Herald managing editor, Stuart  Washington and the author Kim Arlington.  5 June 2017

Dragon Claw has chosen to include this published article on our website because doctors need sympathy from their patients as well.  Be kind to your doctor.

Suicide in the medical profession: 'If we're not well, how can we look after our patients?

June 2 2017

The only career advice my father ever gave me was not to follow in his footsteps and become a doctor. I had no plans to – I already knew I wanted to be a journalist – and never asked him more about it.

Within a year he had died by suicide, in the grip of depression. I was 16 when I found him in our yard, his stethoscope nearby. It seems that, a practitioner to the last, he had listened as his own signs of life began to fade.

Photo: FangXiaNuo

Medical practitioners are under increasing stress.   It is unusual to find a doctor who has not lost a colleague – or several – to suicide. The deaths often come out of the blue, and leave families shattered, patients devastated and colleagues and communities shaken.

But suicide within the medical profession still tends to be regarded as an individual tragedy, accepted, as one medical student puts it, with "shrug of the shoulders ... par for the course".

While suicide is usually the result of a complex combination of factors, there is growing acknowledgment that the demands of medicine can take a heavy toll, and a determined push for change both from government and within the profession.

"We are the ones who are supposed to be preventing other people from suiciding – and we can't even seem to achieve that amongst our own colleagues," Professor Brad Frankum, president of the Australian Medical Association (NSW), says. "It's not good enough to dismiss it all as an individual issue. Until we make the system more compassionate, then we've got a problem."

Frankum says while bolstering practitioners' wellbeing is important, it does not address "the work conditions that are leading to the problem in the first place".

The pressures can be unrelenting: the long hours, shift work and postings that isolate doctors from family and friends; the ongoing training and exams that consume any spare time; the responsibility of handling life or death situations; the exposure to human suffering; the tedium of being buried in paperwork instead of caring for patients.

Michael Arlington, graduating from UNSW with his medical degree in 1969. 

Then there is the highly competitive culture, where bullying, harassment and sex discrimination are rife, and anyone who falters is dismissed as not being cut out for medicine.

Amy Coopes, a fourth-year medical student, says even in medical school "the pressures are piled on as a method of weeding out weak people, and we are warned about how hard it is to get into a specialty training program now. You internalise this idea that you will only make it if you are exceptional and work harder than everyone else. This isn't sustainable over the four to six years of med school, let alone the next 10 to 12 years of training to become a specialist. People are burned out before they even graduate."

Photo: Facebook

Dr Andrew Bryant and his wife Susan with their daughter, Charlotte. "His four children and I are not ashamed of how he died," Mrs Bryant wrote. 

A 2013 beyondblue survey found doctors had substantially higher rates of psychological distress and attempted suicide than Australians in general. A quarter of doctors had had suicidal thoughts – almost double the rate of the general population – and 21 per cent had ever been diagnosed with or treated for depression.

Women doctors and younger doctors appeared particularly vulnerable to mental health problems and work stress, the survey found. Burnout was a serious problem for young doctors, with almost half reporting emotional exhaustion.

Cardiologist Geoff Toogood says the medical profession needs to lead the charge on breaking down the stigma surrounding mental illness. 

A study published last year examined 369 suicides among a range of health professionals from 2001 to 2012, finding female health professionals were at twice the risk of suicide than women in other professions. Though men are generally three times more likely than women to die by suicide, female health professionals take their own lives at roughly the same rate as their male peers.

'We should be leading the charge on this'

Doctors' wellbeing was a focus of last week's AMA national conference, where federal Health Minister Greg Hunt flagged a partnership with the AMA to develop mental health support and suicide prevention measures for medical professionals.

Photo: Pierre Ebbinghaus

Psychiatrist Helen Schultz says mandatory reporting needs to be scrapped. 

A pilot program at Sydney's Royal Prince Alfred Hospital, which teaches physician trainees to debrief, manage traumatic and emotionally challenging events and recognise and prevent signs of stress or burnout, is attracting national and international interest.

And on Tuesday more than 200 participants will discuss junior medical officers' mental health and risk factors at a forum in Sydney organised by NSW Health Minister Brad Hazzard and NSW Health.

Dr Mukesh Haikerwal, chair of beyondblue's National Doctors' Mental Health advisory committee, says the "brutal" culture of medicine must change. 

The death in January of 29-year-old Dr Chloe Abbott, eulogised by the AMA as "passionate advocate for the profession and her patients", was one of several recent suicides among NSW doctors in training and a rallying call for the medical community, while a powerful letter written by Susan Bryant after her gastroenterologist husband Andrew took his own life in May has been shared thousands of times worldwide.

"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 quickly depression can take over, then there might be fewer deaths," the Brisbane mother-of-four wrote.

Melbourne cardiologist Geoff Toogood knew Andrew Bryant. He says news of his death brought home how close he himself had come to suicide while battling severe depression in 2013.

"It's like hanging on to a rope on the edge of a cliff," he says. "You don't want to let go. If someone could just lift you up for a second, you can hang on for a bit longer."

Toogood found his patients more supportive than his peers, and received more empathy for a physical illness which was not life threatening, "whereas my depression was life threatening every day for weeks and weeks".

It was only when he suffered an episode of transient global amnesia, a stroke-like syndrome he believes was triggered by the stress of surviving day to day, that he was given time off work and began to recover.

"[Having a mental illness is] seen as a weakness, that you're not as tough as the others, you haven't survived the rigours that everybody else has," he says. "We need to realise that we're human and we need to be able to ask for help – and get given the support. When you tell people you're suicidal and they're not really reaching out to you in the medical profession, you've got a serious problem."

The stigma surrounding mental health issues "is breaking down generally in the community, but it's still significant in medicine," says Toogood, whose #crazysocks4docs awareness initiative trended on Twitter on Thursday. "We have got to sort ourselves out so we can do our job properly. If we're not well, how can we look after our patients? We should be leading the charge on this."

US psychiatrist Dr Michael Myers agrees. A chapter of his new book, Why Physicians Die By Suicide, dissects the different ways in which stigma kills doctors.

A professor of clinical psychiatry at SUNY-Downstate Medical Center in Brooklyn, New York, Myers is a specialist in physician health and says doctors with mental illnesses "often don't seek help due to the toxic stigma of becoming the patient". Doctors in the US die by their own hand at the rate of one a day.

"Because their lives have been so defined by achievement, doctors may feel even more uncomfortable than most with the notion of being perceived as a failure or, even worse, as a burden," Myers writes. As he tells Fairfax Media: "It's easier for us to look after people, to be the helper, than the one being helped."

'The caring profession needs to care for itself'

Concerns about privacy and confidentiality, particularly in small communities, deter many medicos from seeking treatment, as does lack of time and fear that disclosing a mental health issue could threaten their career.

Under Australia's mandatory reporting laws that fear is very real. A doctor might seek treatment from a GP, psychiatrist or other health professional, but can find themselves reported to the Australian Health Practitioner Regulation Agency (AHPRA) if their treating doctor believes they are impaired and could endanger the public. That triggers a series of investigations and interventions that could end in suspension, deregistration, humiliation.

Myers is scathing of mandatory reporting, saying it is "driving people away from going for what is, in some cases, life-saving care".

Melbourne psychiatrist Dr Helen Schultz says mandatory reporting has "generated a whole layer of paranoia and fear" among doctors and should be scrapped. She is also calling for an overhaul of AHPRA's investigation process and the way doctors are notified.

"A letter is sent in the mail with no notice, no warning, no support, to say you're being investigated, you're suspended," she says. "That's just inhumane."

Schultz says the way bad news is broken to doctors – about missing out on a job or a program, for example – is "really heartless". A minor setback for some might be the final straw for others. "We don't realise that one crucial conversation could end up with a suicide," she says.

A mentor of doctors in training, Schultz lost three young psychiatry colleagues to suicide in early 2015. She says the emphasis on building doctors' resilience is a form of victim blaming, putting the onus on individuals to cope rather than tackling institutional or cultural factors that may contribute to their distress.

"We're actually one of the most resilient bunches of people in society, but we're thrown into a system that is inflexible and intolerable," she says. "If you're being bullied or harassed or being subjected to sleep deprivation, or really harsh competition to get a training position in a college, it doesn't matter how resilient you are or how much mindfulness you practise. Every person has a breaking point."

Dr Mukesh Haikweral, chair of beyondblue's Doctors' Mental Health Advisory Committee, says the "brutality" of the medical culture needs to be addressed – "the [lack of] support mechanisms ... and the sniping, the attitude that anybody with a mental illness is too weak, they're not fit to be a doctor. The caring profession needs to care for itself."

Ratcheting up the pressure on young doctors is the fact that graduate numbers have "skyrocketed" in recent years, intensifying the competition for jobs and training positions.

"You're learning in a very combative environment from your peers and your teachers," Haikerwal says. "You come through this rigorous – vicious, in many ways – training program to become a doctor and there aren't enough training positions ... so you put them on a hiding to nothing."

Brad Frankum says junior doctors "are under incredible pressure" in today's health system. Many toil around the clock, studying for exams on top of their busy working days.

"The whole public hospital system is busier and has a higher turnover and less thinking time than it ever has before," he says. "Junior doctors think if they show any sign of weakness, if they make a mistake, if they say they're not coping, if they want to take some leave or take time out, it will jeopardise their chances of progressing in their careers.

"My feeling is there's a lot of stressed and anxious and depressed and overwhelmed young doctors in the system and a lot of burnt-out older doctors in the system, and that's a really lethal combination."

Frankum believes one factor behind doctors' high suicide rates is that they see death up close as part of their work, making it "perhaps not as distant or frightening" for them. They also have the medical knowledge to end their lives.

"We need better mechanisms to support and identify those in trouble and a system that is less inclined to drive people into the ground," Frankum says. "We need to have this ongoing reinforcement that mental illness is no more or less a medical problem than physical illness, and it's nobody's fault. It's not a weakness; it's biology and circumstance just like any illness."

The aftermath

It's been 25 years since our family was blindsided by my father's suicide.

Always the taciturn type, he had told my mother of his depression without revealing its depths. She assured him of our love, that we would all get through it together.

He took his life less than a week later, at 48. It still pains me that he died alone. Had he been able to speak openly about his darkest thoughts, and given all of us who loved him every chance to help, he might be here now – a part of our lives, and still living his.

But I know myself how suffocating stigma can be. It was years before I discussed Dad's suicide outside our family, for fear that he – that we – would be judged. My grief was complicated by feelings of guilt, shame, anger and abandonment, and I grappled with them largely on my own.

Eventually I came to understand that Dad had not made a choice to leave us. It wasn't death he wanted, but relief. With more time and treatment, he could have found it. There were far better paths than the one he took; lost in his despair, he just couldn't see them.

There are so many things I wish I had said to him. If I had my time again, I'd keep it simple:

You will get better.

Don't give up hope.

We love you.

We need you.

Please stay.

Lifeline 13 11 14; beyondblue 1300 224 636; Doctors' Health Advisory Service NSW/ACT (02) 9437 6552; Victorian Doctors' Health Program (03) 9495 6011

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