Mental health care for medical professionals
When Dr Nikki Stamp was in her 20s she had experienced more stress and seen more suffering and misery than most people do in their lifetime. The cardiothoracic surgeon, now in her 30s, says that given the huge amount of pressure that is part of being a medical practitioner, she is surprised she’s still around. “Whenever I think of the times in my career that I’ve felt I was under the weight of it all, sometimes I’m shocked that I made it through,” she says.
Several of her colleagues didn’t. When Stamp was an intern she attended the funerals of two of her peers who had taken their own lives. Coronial records show that 20 doctors in New South Wales died from suicide between 2007 and 2016.
A 2013 beyondblue survey exploring the national mental health of doctors and medical students found the level of general distress and specific mental health diagnoses reported by medical professionals was high. Ten per cent of doctors reported having thoughts of suicide in the previous 12 months, and about 2 per cent of doctors reported they had made an attempt to end their life.
“Doctors work incredibly long hours, are often sleep deprived and are directly responsible for someone’s health,” Stamp says. “When we add the enormous system pressures, it really becomes an untenable situation.” Those systemic demands, according to Stamp, include short-term contracts, uncertainty about where doctors will be placed for work, long hours, social isolation, the prevalence of workplace bullying, and stigma around mental health issues.
A 2015 report to the Royal Australasian College of Surgeons revealed pervasive discrimination, bullying and sexual harassment in the practise of surgery in Australia and New Zealand. Bullying was found to be “endemic in surgery; common in training and the surgical workplace; and central to the culture of surgery”. The report represents a watershed for the college, but Stamp says there is still a lot to be done. “The college has taken a tremendous step forward in challenging this culture, but what we really need to do is teach healthcare workers how to manage stress,” she says.
Sydney’s Royal Prince Alfred Hospital (RPA) has sought to address this problem with a pilot program designed to improve the wellbeing of basic physician trainees (BPTs). BPTs have a medical degree and have completed at least one year of a postgraduate internship. In NSW, BPTs undergo 36 months of clinical training that leads to a Royal Australasian College of Physicians examination for admission as a physician.
Dr Bethan Richards, the RPA’s former network director of physician training, says the program, called BPTOK, was prompted by an increasing need for trainees to receive psychological support. “We started to notice a core set of skills were lacking and weren’t being taught in medical school,” she says. “This was a significant problem and it culminated at the beginning of the year when we had four suicides in NSW in a short period of time.” The loss of the trainees prompted Richards “to sit down and do something. We came up with an idea to deliver a program for BPTs to debrief, manage traumatic events, self-reflect and recognise signs of burnout.”
BPTOK is funded through The Pitch, part of Sydney Local Health District’s “innovation challenge”. “The program is delivered for two hours every Thursday afternoon – time that is protected from all other intrusions,” Richards says. “It sends a big message that along with life-saving skills, such as CPR, we are also teaching other skills that may potentially save a colleague’s life or your own.”
The beyondblue study found young doctors were particularly vulnerable to poor mental health and high levels of stress. Basic physician trainee Nishanta Tangirala has no doubts about the impact of the BPTOK program at Royal Prince Alfred. “The greatest hurdle [of physician training] has been the constant striving to achieve balance between the daytime hours and the night-time study, and between personal and professional development,” she says. “I found at the end of three years, I had severely neglected myself.”
Tangirala says that being part of BPTOK means she now has a sense of calm and balance she has not experienced in several years. “With the encouragement from the program’s group exercises and the motivation of routine sleep and relaxation strategies, I have renewed capacity, energy and excitement,” she says.
It’s something Richards hears often from the trainees who are going through the program. “The initial feedback about BPTOK has been extremely positive, but it’s going to take time,” she says. “You have to remember that whole generations of doctors have never learnt any of this and so the people required to help our trainees don’t necessarily have the skill sets to recognise burnout or stress.”
Third-year medical student Will Saunders is acutely aware of the risk of burnout, mental health issues and suicide. “It’s something I constantly think about and I have made a conscious decision to balance study and recreation,” he says. The 23-year-old, who attends the University of Queensland, says he has noticed discussions about the mental health of doctors and students have increased in recent years. “There’s definitely an emphasis by the school [of medicine] to promote mental and physical wellbeing,” he says.
Despite this, Saunders says he can see still enormous pressures on doctors within an acute setting. “The hierarchy [at the hospital] is very clear from day one, with the junior doctors and interns at the bottom and the registrars and consultants at the top,” he says. “It’s really the luck of the draw whether you get a supportive team or one where there is very little support.”
According to Saunders, people drawn to practising medicine tend to be “perfectionists who are a bit obsessive and have very high standards”. While this serves them well in medical school, Saunders reflects that the level of control people have when they study is very different from the unpredictability that surrounds them once they enter a busy clinic. “Once you’re thrown into a hospital as a junior doctor, it’s not structured at all,” he says. “Things are happening all the time, it’s chaotic, and ultimately it’s not very compatible with a perfectionist personality. I think that creates a conflict that has an enormous impact on mental health.”
Medical student selection methods need to be considered when looking at the mental health of doctors, says Dr Michael Gannon, president of the Australian Medical Association. “Doctors have a high-stress, high-pressure occupation, and the medical profession needs to look at the pressures on doctors in training, such as examination fees, training requirements, inadequate access to leave, in addition to mentoring and resilience training,” he says.
Another pressure that doctors face is mandatory reporting. Under the national law, registered health practitioners have mandatory reporting responsibilities regarding their fellow professionals. This means that if doctors have concerns about another practitioner exhibiting an impairment or health issue that may place the public at risk of significant harm, the practitioner must be reported to the Australian Health Practitioner Regulation Agency. This can make health professionals wary of seeking help, because of the possible consequences of a problem being reported.
Only Western Australia has amended the law to include an exemption to mandatory reporting for medical professionals treating another health professional.
A study published in the Medical Journal of Australia last year found that between November 2011 and January 2013, 846 mandatory reports about medical practitioners were made. The authors found a typical report was about substance misuse or mental illness.
While the law is intended to provide protection to the public from impaired health practitioners, Gannon argues it represents a barrier to doctors accessing care. “I have been personally lobbying the federal health minister, Greg Hunt, to lead these changes to modify the law in individual states and territories,” he says. A spokesperson for Hunt recently said the federal government will work with state governments to “establish a common national standard to protect the mental health of doctors”.
While Gannon acknowledges removing mandatory reporting requirements will not fix the pervasive issues associated with doctors’ mental health, it is a good first step. “It is one of the things that the government can, must and should do,” he says.
“The concerns around mandatory reporting mean a perception exists that asking for help will result in suspension from one’s career and that this could be made public,” Nikki Stamp says. “Being ‘kicked out’ of your job is a terrible blow to a person who values their job above and beyond a lot of other things in life. The pain these doctors who die by suicide must feel is hard to picture – it’s heartbreaking. We are taught to care for people’s minds and bodies yet our own are severely neglected.”
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This article was first published in the print edition of The Saturday Paper on Jul 21, 2017 as "Medical emergency". Subscribe here.