A call for medicine to stop devouring its young

The recent deaths of four junior doctors are an urgent reminder that medicine needs to confront “the dark side” of its institutional culture, says Dr Kimberley Ivory, Senior Lecturer, Population Medicine and Sub-Dean of Student Support in the Sydney Medical School at the University of Sydney.

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Kimberley Ivory writes:

Media reports have highlighted the recent sudden deaths of four junior doctors. Notably, their deaths coincide with the commencement of the medical training year: a hectic time of transition in roles and responsibilities for doctors in training at hospitals across the country.

No doctor ever forgets the excruciating fear of that first day, first week, on the job. Tragically, for some, the fear doesn’t go away.

In the nearly forty years since I started medical school, I have known of a number of suicides of colleagues and friends. And it has not just been suicides. There’s the exhausted resident who drove off the road to her death after 56 hours on-call. Then there’s the one who did the same, but survived.

The actual suicides are simply the tip of an iceberg buoyed by the many that tried and failed, thought about it and changed their minds, numbed their pain with drugs and alcohol, or walked away from the profession completely in order to keep body and soul together.

The discussion so far around the tragic deaths of these four young professionals has centred on the lack of mental health support provided to doctors. With all its best intentions, this should be seen as a form of ‘victim-shaming’ and deserves dissection.

While our mental health services in Australia are unarguably underfunded and under-resourced, there are avenues for medical students and doctors to seek help and support for mental health issues throughout their careers.

Simply asking the questions, “So why didn’t they get help?” or “why wasn’t help provided?” ignores the very significant determinants of psychological distress in the medical community and the barriers to accessing care.

The BeyondBlue National Mental Health Survey of Doctors and Medical Students released in 2013 is a sobering account of the massive amount of psychological distress experienced by doctors, especially young doctors and female doctors. The report suggests the “intense work environment may contribute to the high levels of general and specific mental health distress … in comparison to the general population.”

Examining the medical culture
Faced with the evidence, it’s time to seriously discuss the role and responsibility of the medical culture in the death and destruction of its own.

For a profession that constantly talks the talk of ethics, professionalism, compassion and empathy, the medical profession often fails to walk the walk within the halls of its institutions.  BeyondBlue euphemistically calls the working environment of doctors and medical students, “challenging”. In fact, for many, the working environment is downright treacherous.

Both here and overseas, healthcare students and advanced trainees report frequent experiences of mistreatment in their clinical teaching spaces. “Mistreatment” includes sexual harassment, bullying, humiliation, physical and verbal aggression and discrimination.

A recent meta-analysis of 51 studies on harassment and discrimination in medical training showed that 59.4% of medical trainees had experienced at least one form of harassment or discrimination during their training (i). “Teaching by humiliation” was experienced by 74% of students and witnessed by 84% (ii).

These experiences have profound implications for student wellbeing and learning, and are known to have long-term implications for subsequent career progression, performance and creativity, mental health and workforce retention. Indeed, experiences of mistreatment during training continue to haunt many clinicians decades later.

How the student or trainee responds to these experiences also has profound implications for their future career advancement. Often, the perpetrator is also their supervisor or superior. When that is the case, a culture of fear of negative consequences and under-reporting develops. Discrimination in advancement selection processes can be subtle and hard to prove but the fear of it is strong in a competitive profession.

Many students believe that tolerating such behaviours is a necessary part of professional development rather like the process of hazing or bastardisation favoured in highly masculinised environments like private schools, frat houses and the military. As a result of a series of recent scandals, some of them criminal offences, the ADF has been forced to acknowledge this ‘dark side’ of their institutional culture (iii). It is time for medicine to do the same.

Overcoming stigma
Stigma also plays an enormous role in the ability of doctors to name their distress and seek help. Starting in medical school, fellow students will shame each other for inevitable human lapses such as failing a test or being unable to snap out the answers to a consultant’s rapid-fire questions.

The BeyondBlue report highlighted the significant number of doctors who think their colleagues with mental health issues are less competent (40%) and that being a patient is embarrassing for doctors (59%). The source of that stigma is internal: doctors against doctors.

If a doctor overcomes that and finds a supportive psychiatrist, they still face the difficulty of getting their anti-depressant script filled discreetly at the local pharmacy or running the gauntlet of the waiting room of the local counselor or psychologist. Yes, there is stigma towards doctors with mental health issues in the wider community too.

Despite evidence from BeyondBlue that most doctors experiencing psychological distress do seek care and the impact on their work and life is relatively modest, the stigma faced by these doctors is further compounded by the requirements of the medical registration board for mandatory notification of a doctor who has “mental impairment” that “detrimentally affects or is likely to detrimentally affect their capacity to practice” and places the public at risk of substantial harm.

The definitions of detrimental and substantial are vague, and even if neither of these conditions is met, voluntary notification remains an option. Mandatory reporting makes many doctors nervous of seeking help for fear of possible consequences on their employability. Similarly, insurance companies refuse to offer comprehensive professional income protection to doctors being treated for depression. Ironically, if you don’t seek help, you can be insured.

Much of the work in medical education currently attempting to address this problem focuses on the formal teaching of professionalism and ethics and the development of resilience in students. Students in their earliest years of medical training can instantly spot the disconnect between what they are taught and what they observe and experience in their clinical attachments. Rather like suggesting that the doctors who committed suicide should have sought help, this approach targets the victims and ignores the deeply entrenched cultural factors perpetrating the distress.

There is an ethical obligation for medical education to support students and trainees to develop their professional identity with integrity. A “challenging” workplace culture is detrimental to that process and undermines students’ personal and professional development.

Until the profession at large, the medical educators, the trainee selection committees, the professional colleges, fellow trainees and workplace managers are prepared to own the ‘dark side’, there will be no solution and talented young people will continue to die.

• Dr Kimberley Ivory (pictured left) is Senior Lecturer, Population Medicine and Sub-Dean of Student Support in the Sydney Medical School.