Doctors as Patients

Petra Jones

• Publisher: CRC Press
• Year: 2022
• ISBN:
  9781315344553
• Edition: 1
• Topic: Medicine
• Subtopic: Public Health, Administration & Care

Doctors, as strong, clever, resourceful professionals, are heir to human frailty and illness, like anyone else. This book is about diagnosable, label-able mental illness such as eating disorders, affective disorders and, sometimes, psychosis. More than that, it is a book about doctors, many fully-functioning, practising doctors, who suffer from these illnesses, and the unique insights and problems that arise when the doctor is the patient, especially when questions of insight and judgement are blurred.

Part One

The Stories

Chapter 1

Setting the scene

Petre Jones

Mental illness is difficult to understand unless you have close experience of it, and to understand it in the familiar context of members of the medical profession is even harder unless you have been involved in such a situation. Doctors are traditionally strong and almost by definition have achieved a high degree of ‘success’ by most standards. How is it that doctors can fall prey to mental illness? How are we to comprehend the nature of this intrusion into our comfortable world? The personal stories contained in this book give a clear insight into the coming of illness into the world of ordinary individuals. This chapter will try to give a broader perspective, into which those individuals fit.

A study by Caplan in 1994¹ looked at stress levels in GPs, consultants and health service managers. They found that 47% of the study population reported high levels of stress on the general household questionnaire, with 29% suffering ‘clinically significant’ levels of stress. Of the consultants and GPs, 27% scored >8 on a hospital anxiety and depression scale (1–7 normal, 8–10mild, 11–14 moderate, 15–21severe anxiety/depression) and, worryingly, 14% of GPs and 5% of consultants displayed suicidal thinking. Women report more mental illness than men, but overall an estimated 25% of doctors are vulnerable to mental health problems.

The numbers trip off the tongue, but consider a fairly typical teaching hospital with, say, 175 consultants, in a typical district with 125 GPs. That works out as 75 ‘vulnerable’ professionals on the edge of formal mental illness, or 27 professionals having suicidal ideation, in one health district at any one time. That is quite a problem.

But how does this compare with the rest of the population? We are all heir to the frailties of human flesh after all. Murray² looked at admission rates for mental illness for doctors, and compared them to a control group of non-medical professionals. The study found admission rates were twice as high for the doctors, and, revealingly, that the doctors were more likely to be admitted via self-referral or by non-GP referral.

A similar story is told by relative risks of suicide, as shown in Table 1.1,³ derived from a meta-analysis of suicide studies.

Table 1.1 Relative risks of suicide in doctors

Rates compared with the	Male doctors	1.1–3.4
general population	Female doctors	2.7–5.7
Rates compared to other	Male doctors	1.5–3.8
professionals	Female doctors	3.7–4.5

Why should this vulnerability be so great when, after all, doctors are intelligent resourceful people who have jumped over many hurdles just to get to be doctors? Bellini and colleagues⁴ in the US looked at psychological indicators in people starting internship posts. He found that initial enthusiasm gave way to feelings of depression, anger and fatigue after only five months in post, despite the cohort starting the jobs with better than average scores. This not unsurprising finding is influenced by professional culture factors, job factors and personal factors.

The job we do is inherently stressful. The work is intense and people’s lives and wellbeing depend on our actions and the choices we make. The importance of the work tends to lead to a sense of being responsible, adding to stress and a tendency to work longer than contracted hours. Our work also brings us up against critical life events for others such as deaths, disability and emotional distress on a daily basis whatever our specialty, and traditionally we have only rudimentary ways of dealing with the inner effects of this on us.

Organisational issues within medicine compound this. Frequent job changes in trainees compound lack of support and increase their stress⁵ and substantial and persistent organisational and technological change across the service is bad for everyone. ‘The management of change is an art that the NHS has yet to perfect.’⁶

The culture of medicine compounds rather than alleviates the damaging effects of these stressors. After a major incident it is rare for a medical team to debrief and support its members. The work keeps coming, time is at a premium and we just don’t see the need. In my role as course organiser of a GP training scheme I help run case discussion groups looking at the emotional baggage left behind for junior doctors in both hospital and GP settings after such events. Suicides and deaths and unsupportive attitudes of colleagues are the most frequent causes of problems, which are often only reported weeks or even months after the index event. Difficult emotions are stored up and ruminated upon. Almost never is a major incident within a department discussed in a supportive team setting, exploring emotions raised and looking for actions to take. Usually the doctor, and other staff, just dust themselves off, over a coffee if they’re lucky, and throw themselves into the next challenge. This may be okay for some personality types, but for the vulnerable 25% at least, it is storing up trouble. This silent stoicism happens in all specialties as well as in general practice, where even apparently close partnerships can be remarkably closed to emotional discussion. A medical culture of needing to be ‘manly and tough’ and minimising one’s own symptoms, whilst feeling that patients overestimate their symptoms, seems to be learned in medical school.⁶ One general exception to this ‘don’t talk about it’ rule seems to be the one-to-one relationship between GP registrar and trainer, where talking and even an informal psychotherapeutic relationship can happen.

Competition and rivalry between colleagues makes mutual support harder. In the training grades we compete with each other to pass exams, which are themselves often peer-referenced, where you are competing against each other for a set proportion of passes. We compete with each other for the ‘best’ jobs. This is not conducive to mutual support. In senior grades and in GP partnerships we compete in departmental politics and encounter those interpersonal difficulties that can make working life so difficult.

And then there’s stigma, and prejudice. Of course no one would admit to being prejudiced against mental illness, but stigma in the medical profession was considered so grave that in a report on the tragic suicide of one doctor with mental health problems it was considered a major contributory cause.⁷ Other chapters in this book look at this issue in more detail, but suffice to say that if a doctor feels they would be stigmatised by disclosure of personal distress they are not likely to seek support, which is exactly what happens.

Not all doctors succumb to mental illness, so what is it about those who do that makes them vulnerable? Choice of career at an early age is associated with vulnerability, and many authors have postulated psychological scenarios, arising in childhood experience, which can not only underlie career choice but also make someone more susceptible to the effects of the stresses of the work.

A medical career may serve as a defence against feelings of anxiety or impotence resulting from the experience of illness or death in family members.^9,10

Bowlby¹¹ described ‘compulsive care giving’, in which the doctor, having experienced unsatisfactory parental attachments, gives care to others that they themselves never received as a child, and Malan¹² talks of the ‘helping profession syndrome’ in which other people’s needs are seen as demands which they have to satisfy. If they are unable to satisfy those needs of others they experience a sense of failure and become liable to depression. The idea that we as professionals have to make it all better for everyone else is quite familiar, and works if we can confidently improve the lives of our patients. If we cannot, we have failed.

One can go on speculating about personal traits which lead people to become health professionals, but the point is simple enough: that medicine for many of us is a type of compensation for, or occupational therapy for, psychological scars. Of course, we all have our neurotic traits, that is part of what it means to be human, it is just that for some of us those traits interact with our working lives to the extent that as a profession we suffer from a heavy excess of psychological morbidity, including suicides.

A different perspective can be seen in an Old Testament story. Seven centuries BC, one of history’s great empire builders, Nebuchadnezzar, King of Babylon, built an empire from the Indus valley to the Nile. Biblical and archaeological evidence stands testimony to his conquests and building triumphs. However, later in his reign it seems he became ill. He left his palace and lived rough, neglecting his self-care, letting his nails and hair grow. He was clearly unable to govern, and remained in this state for a period of ‘seven times’, however long that may be. Eventually he returned to a state of mental health, and his officials went to find him. He was restored to the throne and, as one would expect from a story in an ancient document, he became even more successful as a ruler after his illness. The point of retelling this story is simple. Whatever the causes of the excessive psychiatric morbidity in medical professionals, the majority of illnesses from which we suffer – affective disorders, addictions, eating disorders – if treated, leave the patient with a reasonably preserved level of social functioning. The King of Babylon did well with his illness. He was allowed to recover and was eventually restored to his former role. So too with doctors suffering from mental illness; with proper treatment, we stand a good chance of being restored to work. It is helpful if those around us can allow us to get on with it and await our recovery without adding stigma to our burden.

References

• 1 Caplan RP (1994) Stress, anxiety, and depression in hospital consultants, general practitioners, and senior health service managers. BMJ. 309: 1261–1263.
• 2 Murray RM (1977) Psychiatric illness in male doctors and controls. Admission rates for mental illness in doctors. British Journal of Psychiatry. 131: 1–10.
• 3 Lindeman S et al. (1996) A systematic review on gender-specific suicide mortality in medical doctors. British Journal of Psychiatry. 168: 274–279.
• 4 Bellini LM et al. (2002) Variation in mood and empathy during internship. JAMA. 287: 3143–3146.
• 5 Firth-Cozens J et al. The effect of 1-year rotations on stress in preregistration house officers. Hosp Medicine. 62(5): 305.
• 6 Donaldson LJ (1994) Sick doctors (editorial). BMJ. 309: 557–558.
• 7 North East London Strategic Health Authority (2003) Report of an independent inquiry into the care and treatment of Daksha Emson and her daughter Freya. www.nelondon.nhs.uk/documents/de_inquiry_report.pdf
• 8 Court C (1994) British study highlights stigma of sick doctors. BMJ. 309: 561–562.
• 9 Pfeffer CR (1983) Early adult development in the medical student. Mayo Clinic Proceedings. 58: 127–134.
• 10 Gabbard GO (1985) The role of compulsiveness in the normal physician. JAMA. 254: 2926–2929.
• 11 Bowlby J (1977) The making and breaking of affectionate bonds. British Journal of Psychiatry. 130: 201–210.
• 12 Malan DH (1995) Individual Psychotherapy and the Science of Psychodynamics. Butterworth, London.

Summary

• • Mental illness is common amongst doctors, with about 25% vulnerable to it.
• • Suicide rates are between 2 and 4 times those of other professionals.
• • The work of medicine is inherently stressful.
• • The culture of medicine is not generally supportive.
• • Stigma and prejudice exacerbate mental ill-health.
• • Personality traits in some doctors make them more vulnerable.
• • Most ill doctors either make a reasonable recovery or reach a functioning chronic or recurrent state.

Chapter 2

Personal view

Sally Mason

Why do idealistic, intelligent, resourceful young adults choose a career which cares for their physical and emotional wellbeing so badly? Youth never fears for death, but doctors have a high risk of occupational misery with long hours, outmoded practices, stiff upper lip and vast numbers of sick people at their medical mercy every day!

When you start out in medicine, you work according to the book, but gradually the gifts of intuition and expertise develop. The demands of family, government and patients take more and more from us all. Often there is not even the time or energy to continue those hobbies and activities which previously ‘defined’ you as an individual. Some burn out – switch off and withdraw from partners and patients except for the absolutely necessary or find solace in information technology. Others care too much and turn the emotion back on themselves, leading inevitably to depression. The innate sensitivity and desire to care, followed by exposure to so much suffering – in the world, your domain and your family – adds up to a haemorrhage of ‘brain juice’. It is silly to think that one has to have been ill to better empathise with a patient, but having had ‘depression’ one can sense it in others’ eyes, and care and comfort – if not cure. The wounded healer can be a better healer, but s/he needs to be respected. In the same way other gifts are admired – ability to understand an ECG, the renal tubule, chemotherapy – why are the emotional and spiritual not? You could say that such should be the remit of the priest or counsellor – but so can the ECG and the renal tubule be the domain of the technician or scientist. Having both a medical training and other gifts is valid and powerful.

Some of us will find the intuitive side of medicine second nature after a while, and empathy is a useful tool. What comes first? The ability to recognise suffering in one’s fellows, or a tendency to melancholia, being overwhelmed by the misery of the human condition? Does one necessarily beget the other and vice versa? When car...

Table of contents

• Cover
• Title Page
• Copyright Page
• Table of Contents
• Foreword
• About the editor
• List of contributors
• Acknowledgements
• Frontispiece: It could never happen to me
• Introduction
• Part One: The Stories
• Part Two: What’s It Like?
• Part Three: Dealing With It
• Index