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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.

***

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.


 

 

***

Notes

[i] Fnais, N., C. Soobiah, M. H. Chen, E. Lillie, L. Perrier, M. Tashkhandi, S. E. Straus, M. Mamdani, M. Al-Omran and A. C. Tricco (2014). “Harassment and Discrimination in Medical Training: A Systematic Review and Meta-Analysis.” Academic Medicine 89(5): 817-827

[ii] Scott, K., Barrett J, Caldwell PHY (2014). An Australian investigation of ‘teaching by humiliation’. Australian and New Zealand Association for Health Professional Educators Conference. 7 – 10 July, Gold Coast, Australia.

[iii] Evans, R. (2013). Hazing in the ADF: A Culture of Denial?. Australian Army Journal_V10 N3Winter. http://www.army.gov.au/Our-future/LWSC/Our-publications/~/media/Files/Our%20future/LWSC%20Publications/AAJ/2013Winter/AustralianArmyJournal_V10N3Winter_Discipline-HazingintheADF.pdf

***

For help or more information

For people who may be experiencing sadness or trauma, please visit these links to services and support

• If you are depressed or contemplating suicide, help is available at Lifeline on 131 114 or online. Alternatively you can call the Suicide Call Back Service on 1300 659 467.

• For young people 5-25 years, call kids help line 1800 55 1800

• For resources on social and emotional wellbeing and mental health services in Aboriginal Australia, see here.

***

(Update on 9 February)
AMA Victoria suggested these helpline details be added:

AMA Victoria’s Peer Support 1300 853 338

The Victorian Doctors’ Health Program (VDHP) (03) 9495 6011

 Update on 20 February

Readers may also be interested in this article, The Humiliation Heap,  by a concerned parent.

 

Comments 2

  1. The saddest part of this story is that it is deja vu. This has been happening intermittently for decades. A lot of noise is made about it, promises are made, and then after a few “death free” years everyone moves on – until tragedy strikes again.

    It would seem that one of the biggest impediments to seeking help is that the young doctors would be seeking help within their own system and are too ashamed to do so. I understand that in Victoria the Victorian Doctors Health Program was created specifically to mitigate this problem. So then possibly very disturbing for them that these deaths all occurred in Victoria.

    Sadly when this all “blows over” I’m sure the next crop of young doctors will be in the same boat.

  2. PeeBee says:

    I have a relative who is a young female doctor in the public hospital system. She works horrendous hours often on weekends. She is assigned holiday times, usually 2 weeks each six months allotted at random. She finds it impossible to develop relationships as she doesn’t have the time or energy. Furthermore she has to contend with insidious sexism that is sutle but effective.

    It doesn’t surprise me that young Doctors suicide and I am always worry about her. It is most disturbing to be talking about the problems at work to have sit in front of you with tears rolling down her cheeks as she describes the injustice of the whole system.

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Federal Budget 2021-22
Global health and climate change
2019-20 climate bushfire emergency
asylum seeker and refugee health
Climate emergency
disasters
Ebola
extreme weather events
flooding 2011
global health
NHS
NZ Election 2017
WHO
health
Health workers
Healthcare and health reform
abortion
adverse events
aged care
allied health care
Australian Medical Association
cancer
cardiovascular disease
child health
Choosing Wisely
chronic diseases
co-payments
Cochrane Collaboration
complementary medicines
conflicts of interest
death and dying
diabetes
digital technology
disabilities
e-health
emergency departments and care
Equally Well
euthanasia
evidence-based issues
general practice
genetics
health & medical marketing
health and medical education
health and medical research
Health Care Homes
health ethics
health financing and costs
health reform
health regulation
health workforce
HIV/AIDS
hospitals
HRT
infectious diseases
influenza
international medical graduates
journal articles
LGBTIQ
medical marijuana
Medicare Locals
men's health
mental health
MyHospitals website
National Commission of Audit 2014
National Health Performance Authority
naturopathy
NDIS
NHMRC
non communicable diseases
nurses and nursing
oral health
organ transplants
out of pocket costs
pain
palliative care
paramedics
pathology
Pharmaceutical Benefits Scheme
pharmaceutical industry
pharmacy
Pregnancy and childbirth
primary health care
Primary Health Networks
private health insurance
quality and safety of health care
rural and remote health
screening
sexual health
social media and healthcare
suicide
surgery
swine flu
telehealth
tests
TGA
trauma
women's health
youth health
Indigenous health
#CTG10
#NTRC
Acknowledgement
cultural safety
Indigenous education
Lowitja Institute
NT Intervention
social and emotional wellbeing
Uluru Statement
WA community closures
News about Croakey
PIJ Commissions 2021
Public health and population health
#PreventiveHealthStrategy
#UnmetNeedsinPublicHealth
air pollution
alcohol
consumer health matters
COVIDwrap
environmental health
Fetal Alcohol Spectrum Disorders (FASD)
food and nutrition
gambling
Government 2.0
gun control
health communications
health impact assessment
Health in All Policies
health inequalities
health literacy
human rights
illicit drugs
injuries
legal issues
marriage equality
Media Doctor Australia
media-related issues
nanny state
National Preventive Health Agency
obesity
occupational health
physical activity
plain packaging
prevention
public health
public interest journalism
road safety
sport
sugar tax
tobacco control
transport
vaccination
violence
Web 2.0
weight loss products
Royal Commission
Social determinants of health
discrimination
education
housing
justice
Justice Reinvestment
NBN
Newstart
poverty
racism
social policy
Summer reading 2020-2021
Tasmanian election 2021
Testing Croakey News category 1
The Croakey Archives
#cripcroakey
#HealthEquity16
#HealthMatters
#IHMayDay (all years)
#IHMayDay 2014
#IHMayDay15
#IHMayday16
#IHMayDay17
#IHMayDay18
#LoveRural 2014
Croakey Conference News Service 2013 – 2019
2013 conferences
Australian Centre for Health Services Innovation Forum 2013
Australian Health Promotion Association Conference 2013
Closing the Credibility Gap 2013
CRANAplus Conference 2013
FASD Conference 2013
Health Workforce Australia 2013
International Health Literacy Network Conference 2013
NACCHO Summit 2013
National Rural Health Conference 2013
Oceania EcoHealth Symposium 2013
PHAA conference 2013
2014 conferences
#IPCHIV14
AIDA Conference 2014
Congress Lowitja 2014
CRANAplus conference 2014
Cultural Solutions - Healing Foundation forum 2014
Lowitja Institute Continuous Quality Improvement conference 2014
National Suicide Prevention Conference 2014
Racism and children/youth health symposium 2014
Rural & Remote Health Scientific Symposium 2014
2015 conferences
#CPHCEforum
#CRANAplus15
#HSR15
#NRHC15
#OTCC15
Population Health Congress 2015
2016 conferences
#AHHAsim16
#AHMRC16
#ANROWS2016