DOCTORS’ MENTAL HEALTH

Workplace
scars
PAUL HAYES

Anxiety, depression, burnout, fear, anger – doctors experience the

gamut of mental health issues. A recent cluster of suicides is shining
some much-needed light on the often overwhelming pressures of
a life in healthcare, as well as some of the options for help.
Chris*, a GP of five years who runs a successful group Long-time Brisbane gastroenterologist
practice with three other doctors, recently visited the Dr Andrew Bryant, Sydney fourth-year
coroner’s court following the unexpected death of a doctor-in-training Dr Chloe Abbot, Sydney’s
child who attends his practice. Dr John Moutzouris, who worked in renal medicine
While he has debriefed with his peers about the at Liverpool Hospital, and several more in healthcare
incident and received medico-legal advice assuring all took their own life this year. Each of these
him he was not at fault for the child’s death, suicides was attributed, at least in part, to the
Chris has been unable to shake strong feelings stresses and pressures of the life of a doctor and
of guilt about how he handled the case. He the fact they felt unable to discuss their issues.
has since become uncertain about clinical ‘Chloe said … that she was too scared to
decision-making, leading to problems with speak up to anybody about [a colleague’s
time-management and a tendency to recent suicide] in case she was put on suicide
over-investigate patients. He is irritable, watch, too,’ Dr Abbot’s sister, Micaela, told the
sleeping poorly and not enjoying his Australian Doctor Group.
usual hobbies. The fact so many healthcare professionals
Chris recognises he is experiencing are dealing with issues of mental health and find
mental health issues that stem from it so difficult to discuss begs the question: how
his patient’s death and a number of can they get help?
other work-related pressures, but is
unsure of the best way to access help
and is hesitant to discuss the issue
with his colleagues.
Stories such as this have become
increasingly commonplace in
Images iStock; Eric Levi; beyondblue

Australian healthcare. An alarming

rash of suicides within the profession in
recent months has highlighted the fact
that many doctors are not only struggling
to cope with the burdens of their vocation,
but also with how they can even acknowledge
the issue and ask for help.

6 Good Practice Issue 8, August 2017

 There are options – their GP, psychiatrists,
psychologists, professional support programs,
etc. But a deeply-embedded professional
culture in which doctors are often expected to
‘suck it up’ and build resilience, combined with
an inability to do so often being seen as a sign
of weakness, means accessing any mental
health services, let alone acknowledging an
issue, presents a range of problems.
Many in healthcare cite these issues of
stigma, coupled with difficulties in ensuring
privacy, fear of deregistration and the desire
to continue helping patients, as major barriers
in accessing care.
‘There is ample evidence that, as doctors,
we are not good at taking care of ourselves
and seeking appropriate professional help, Left to right: Cardiac surgeon Dr Geoff Toogood found the help of his GP vital when taking the first steps in
whether for routine medical care or when we addressing his own severe depression; ear, nose and throat surgeon Dr Eric Levi described his nomadic training years
as an often stressful time for himself and his family.
have a problem,’ Dr Joanna Flynn, Chair of
the Medical Board of Australia (MBA), told
Good Practice. ‘This is not good for us, for ‘When I carefully dissect my dark seasons, said at an Australian Medical Students’
our patients or for the profession as a whole.’ some common themes often emerge,’ Dr Levi Association conference earlier this year.
wrote. ‘Work is often the critical exacerbating ‘Chloe’s death can’t be a waste.’
Finally talking about it and perpetuating factor in those dark times.’ Cardiac surgeon Dr Geoff Toogood is one
Following Dr Bryant’s suicide, his wife Susan The blog proved to be something of of the most prominent voices in the discussion
penned a powerful open letter in which a turning point in starting a more open and the main driver of the #Socks4Docs
she outlined his anxieties about ‘private dialogue, a genuine discussion, about doctors campaign. He has been very open about
practice, about being behind in his office and mental health issues associated with his own experiences with severe depression
administration, about his practice finances, their profession. and suicidal thoughts in 2013, saying he
about some of his patients, about his found the process of initially discussing his
competence’ in the days and weeks prior problem and accessing appropriate help a
to his death. Susan Bryant didn’t want her
As a profession we problematic one. >>
husband’s suicide to be a mystery, an issue should be pushing ... for
people would be afraid to discuss because every doctor to have their
of fears that surround people in healthcare
own trusted GP
admitting to and seeking help for depression
and other issues of mental health. RACGP self-
‘I don’t want it to be a secret that ‘My blog post had about 260,000 views.
Andrew committed suicide,’ she wrote.
‘His four children and I are not ashamed
Obviously, it is something that a lot of
medical practitioners feel,’ Dr Levi told Good
care support
of how he died. Practice. ‘That sense of loss of control of The RACGP’s GP Support Program
‘If more people talked about what leads to their practice, a sense of loss of support is ‘committed to supporting
suicide, if people didn’t talk about [suicide] as because they’re always moving, always members in their pursuit of clinical
if it was shameful, if people understood how having to go to different places during their excellence’. The program is a free
easily and quickly depression can take over, training, and a loss of meaning in this world of service that can provide RACGP
then there would be fewer deaths.’ modern medicine.’ members help with:
News of so many doctor suicides hit The issue has since taken on a huge profile • handling work pressures
Dr Eric Levi hard, and Susan Bryant’s letter in traditional and social media, sparking not • managing conflict
– in which she also wrote that Dr Bryant took only myriad debates and conversations across • grief and loss
his life despite having access to help and no social media and in multiple publications, • relationship issues
pre-existing mental health conditions – awoke but real-world campaigns like #Socks4Docs • concerns about children
more feelings. Dr Levi, an experienced ear, and #CrazySocks4docs, when healthcare • anxiety and depression
nose and throat surgeon, was moved to write professionals throughout Australia wore odd • alcohol and drug issues
a blog post, ‘The dark side of doctoring’, socks as a sign of solidarity for one another. • traumatic incidents.
discussing his own negative experiences and ‘It’s absolutely devastating that this Visit www.racgp.org.au/yourracgp/
how life as a surgeon has at times led to conversation was only generated after the membership/offers/wellbeing for
feelings of depression, anxiety, burnout, loss of my sister, but we need to get these more information.
hopelessness, lethargy and worry. important changes in place,’ Micaela Abbot

Good Practice Issue 8, August 2017 7

DOCTORS’ MENTAL HEALTH

Doctor Katrina McLean

@drkatmclean
#CrazySocks4docs is working! Dr saw me as a patient

insights yesterday - said it was his colleagues socks that gave him
the courage to.

Comments from healthcare

professionals who appeared on the
20 June episode of SBS’s Insight,
‘Critical care’, during which they >> ‘I faced issues of privacy, stigma – you
discussed mental illness among can tick all the boxes,’ he told Good Practice.
junior doctors and nurses. ‘More people knew about my illness than I’d
Karla (junior doctor) told, so obviously the news spread. I had some
• ‘I think we get really good at discrimination.’
pretending like we’re okay, This discrimination was compounded when
and I think we start believing his many responsibilities were challenged by
it ourselves. When we realise, trying to take time away from work in order to
“Oh, dear, something’s wrong”, address his illness.
it’s really difficult to admit that ‘There’s the roster, you’re on call, people
to ourselves and then to get are emailing you and asking, “When are you
help from anyone that knows coming back?” You don’t need that, it doesn’t
us because we’re ashamed that help,’ Dr Toogood said. ‘Applying guilt to
we’re the one that’s struggling’ someone who already feels guilty for taking RACGP President Dr Bastian Seidel showed solidarity
leave for an illness – which most people with his fellow doctors by wearing odd socks as part of
Lizzy (general practice registrar) the #Socks4Docs and #CrazySocks4docs campaigns
think is in your head and you’ll be able to on 1 June.
• ‘It wears you down quite a bit, get up the next day and feel better – is not
not getting enough food into helpful for recovery.
you, not enough water, not ‘That is a barrier, but it’s more of a ‘I went into medicine to be a doctor
enough sleep at night and back long-standing cultural issue.’ but, here we are, only spending a third of
there again. And you just have Dr Toogood was ultimately swayed about our time actually physically with patients,
to keep going. There is no, “Oh,
not returning to work when discussing his talking to patients.’
not feeling too good today, I
issues with his own GP. According to Dr Mukesh Haikerwal, a
might not go”, because you just
‘I remember my GP saying, “You can’t go long-time GP and mental health advocate,
think, “God, the work is going
back to work today or this week”, and I said, many of the pressures doctors face are
to be double when I get back
“I’ve got all these patients and procedures. present throughout their healthcare journey.
there the next day”’
What’s the hospital going to do?”’ he ‘The levels of stress start from the very
Femy (fifth-year medical student) explained. ‘She told me, “It doesn’t matter. If beginning,’ he said.
• ‘I guess it’s a cultural thing you go back to work, then they won’t have you ‘What underpins it all is a stressful
within medicine that you can’t to look after them”. She was that blunt. upbringing, if you like, to get to a position
let your guard down and if you ‘Then she said, “I’ll ring them to tell them of being fully ready or trained as an
come out and say, “Oh, I don’t that you can’t go”. I needed that.’ independent practitioner.’

Images Bastian Seidel (@DrBastianSeidel); Medical Board of Australia; Caroline Johnson

think I’m coping well”, you’re Dr Levi described his training years as
worried that people will judge From all sides mentally and emotionally challenging.
you for being incompetent. Long hours and a heavy workload, fear of ‘As a resident and junior registrar, [my
Like you can’t deal with what’s making mistakes, stresses of work and study, family and I] were moving from one country
in front of you’ balancing work and personal responsibilities, town to another every three months. With
• ‘I’ve come to realise the most burnout, less contact with patients, and a young family, you can imagine the kind of
important thing of being a doctor many more factors rate as significant areas social impact that has when you move every
is being a healthy person. You that contribute to mental health issues three months or every six months,’ he said.
can’t function to look after other among doctors. ‘Working after hours, working late,
people if you don’t know how to ‘The increasingly bureaucratic, or missing significant social events, birthdays,
take care of yourself’ industrialised, modernisation of health practice anniversaries, reunions. That chips away at
Visit www.sbs.com.au/news/ means you get a lot more clerical duties your social network.
insight/tvepisode/critical-care associated with being a doctor. The system ‘My traditional social network was
to view the full transcript is getting more complex,’ Dr Levi said. essentially non-existent because for up to
of the episode. ‘It eats away at why I went into medicine in four years of my life I was being a nomad
the first place. and moving around.

8 Good Practice Issue 8, August 2017

 ‘It takes away your sense of control
over your own career. It’s all determined
by other people.’
Dr Levi has found this type of personal
stress, on top of the work itself, studying for
exams and the driven nature of people who
take on a life in healthcare, will often have
a significant effect on the mental health
of young doctors as they get a taste of
their new lives.
‘I spoke to medical students recently and
said, if you have an underlying mental health
disorder and you walk into medical training,
it’s a tough training … that will almost
certainly exacerbate your pre-existing mental Left to right: Medical Board of Australia Chair Dr Joanna Flynn wants healthcare professionals to know that
health conditions,’ he said. ‘If you don’t discussing a mental health issue with a doctor does not meet the threshold for mandatory reporting; Dr Caroline
Johnson makes an effort to treat doctors in much the same way she would any other patient.
have a mental health condition, you actually
might be predisposed to experiencing the
symptoms of mental health conditions as Regardless, efforts to at least soften the protect the practitioner and the patient,
you go through training. laws – essentially exempting clinicians from but that’s a different group,’ he said. ‘I’m
‘[Medical students/practitioners] are often having to report impaired colleagues – have talking about practitioners who are competent
made up of high-achieving, goal-driven, gathered momentum in recent months, and safe, but have an underlying mental
intense individuals. Healthcare attracts with Federal Minister for Health Greg Hunt health condition, a group of essentially
that group of people, and the need to supporting measures designed to better well-functioning medical practitioners who
maintain a high level of performance is one protect doctors. A spokesperson for Hunt told do have mental health issues, but who are
of the things we often have as medical Fairfax Media earlier this year that the Federal afraid to report for fear of what restrictions
practitioners. Government was working with all states and will be put upon their practice.
‘Therefore, letting our guard down, by territories to alter the laws and establish ‘a ‘These people are the ones who are
allowing other people to know we have common national standard to protect the not seeking help because of the fear of
mental health conditions, is something that mental health of doctors’. being reported.’
may be considered a negative thing.’ One of the keys to helping healthcare In her experience, Dr Johnson has found
Doctors’ concerns about discussing professionals discuss their issues with that doctors run a much greater risk to
their issues of mental health are often other doctors is a better understanding of themselves and their patients if they avoid
exacerbated by fear of Australian the idea that most people experiencing seeking help out of any underlying fear for
Health Practitioner Regulation Agency’s mental health issues are usually perfectly their career or reputation.
(AHPRA’s) mandatory reporting laws for capable of competently performing their ‘Doctors should be careful not to
healthcare professionals and the potential professional tasks. put themselves above that professional
for deregistration. According to those laws, ‘We know that one in five Australians in responsibility, which is to be well enough to
doctors must inform AHPRA ‘if they have any 12-month period, and 45% of us in our do your job well,’ she said. ‘If a doctor has
formed a reasonable belief that a registered lifetime, experience symptoms consistent a question in their own mind about whether
health practitioner has behaved in a way that with a mental illness. If every doctor didn’t they’re fit to practise, then it’s the responsible
constitutes notifiable conduct’.1 (Refer to work because they had a mental illness, thing to do to have a conversation with
breakout on page 10 for more information.) we would be seriously short of doctors,’ someone else who is an expert in the matter
Many in healthcare believe these rules Dr Caroline Johnson, a mental health as to what they think about your fitness.
to be restrictive and a key reason so many advocate and GP who often treats other ‘In that setting, when someone is seeking
are reluctant to discuss their own issues. healthcare professionals, told Good Practice. help, acknowledging that they have a problem
According to Dr Flynn, however, there Dr Levi agrees that a mental health issue and doing something about it, I would say
is a widespread misunderstanding, or does not equal incompetence. their likelihood of being safe as a practitioner
misinterpretation, within healthcare as to ‘No doubt, if you’re an impaired medical is much higher than if they ignore it, put their
what doctors have to report when treating practitioner something needs to be done to head in the sand and don’t get help at all.’ >>
other doctors.
‘It is important all doctors realise that
the threshold for requiring a mandatory
report is high, and is only reached when an Ashna Basu
impaired doctor is placing the public at risk @ashnabasua
of substantial harm,’ she said. ‘It should Strength in knowing that you are not alone - galvanises a movement +
not deter us from seeking help and support drives change. Let your juniors know that you struggle too. #MH4docs
when we need it.’

Good Practice Issue 8, August 2017 9

DOCTORS’ MENTAL HEALTH

General practice and other services

Mandatory Dr Leanne Rowe, a GP and co-author of

First do no harm: Being a resilient doctor in
the 21st century, believes a vital first step
reporting for healthcare professionals being able to
properly address any mental health issues
Four types of notifiable conduct is a seemingly simple, yet surprisingly
must be reported to the Australian under-utilised one.
Health Practitioner Regulation ‘I’m trying to encourage all doctors to
Agency (AHPRA). have a regular preventive health assessment
It is notifiable when a practitioner every year,’ she told Good Practice. ‘That is
has: practised while intoxicated by important for a number of reasons – everyone
alcohol or drugs; engaged in sexual should have a health screening based on the
misconduct in connection with the RACGP’s Red Book [Guidelines for preventive
practice of their profession; placed activities in general practice], including mental
the public at risk of substantial health screening. If mental health screening is
harm because they have an undertaken routinely, it is non-stigmatised.
impairment; or placed the public ‘Routine health assessments are also an
at risk of harm because they have opportunity for doctors to build a trusting
practised in a way that constitutes a relationship with their own GP, which makes it
significant departure from accepted easier for them to access good care if they hit Dr Leanne Rowe believes healthcare professionals
professional standards. challenges down the track. It makes it easier should undertake an annual preventive health
assessment, including mental health screening, in
While many Australian healthcare to access confidential mental health care with order to help de-stigmatise the process.
professionals have said fear of a trusted person, particularly in a crisis.
being reported and potentially ‘Around 50% of doctors don’t have their
deregistered prevents them from own GP. I think we as a profession should ‘I expressly address things like the
discussing mental health with a be pushing for a campaign for every doctor temptation to self-refer and self-prescribe,
doctor, the threshold for mandatory to have their own trusted GP. Not just and talk about boundaries around that.
reporting is higher than some may someone you might see once in five years, ‘We then create a set of informal rules
believe. The Medical Board of but someone you see at least annually so you around how the doctor–patient relationship
Australia told Good Practice that: have some continuity of care. will work, which is not that dissimilar to what I
• a doctor experiencing anxiety or ‘It’s quite a simple strategy, but I think it’s would do with every patient.
depression who is being treated very effective.’ ‘Most of the time people say, “I’m really
by another practitioner and is It is important to note, however, that the grateful for that. I don’t want you to treat
following their doctor’s advice ability to treat other doctors is a skill unto me like a doctor, I want you to treat me
does not meet the threshold for a itself. Dr Johnson has found managing like a patient”.’
mandatory report doctors the same as she would any other Beyond their own trusted GP, Australian
• a doctor who seeks help for patient, with some caveats, can be an primary healthcare professionals can also
stress or burnout does not meet effective approach. access the RACGP’s GP Support Program.
the definition of impairment under ‘I say to doctors upfront that I’m going Designed to help maintain the wellbeing of
the law unless their capacity to to assume you don’t know all the stuff that doctors anywhere in the country, the program
practise is significantly affected you probably do know, because it’s a bigger provides professional advice to help with a
• diagnoses of a physical risk – for me – assuming that you do know range of issues, including work pressure,
illness and/or mental illness, something, but later finding you haven’t anxiety and depression, traumatic incidents,
such as seeking support for thought of it,’ she said. grief and loss, alcohol and drug issues, and
substance misuse, are not in ‘The second part of that conversation is to more. (Refer to breakout on page 7 for
themselves reportable. say that you also bring a lot of expertise and more information.)
Seeking treatment does knowledge and I would really encourage you Doctors can also make use of a number
not mean a practitioner’s to talk to me about that. of expanded health services as part of the
registration is at risk
• a treating doctor is only required
to make a mandatory report
if their doctor-patient has an Simone Ross
impairment that has placed the @Simone_Ross1
public at risk of substantial harm.
Image Leanne Rowe

It’s okay to not be okay. Acceptance and support seeking is

Visit www.ahpra.gov.au for key for both students and professionals. #crazysocks4docs @
more information. ACRRM @yourAMSA

10 Good Practice Issue 8, August 2017

 adam castricum
@ACastricum beyondblue
We as entire profession must tackle this with compassion and respect.
Culture must change @ACSEP_ #crazysocks4docs survey
The 2013 beyondblue National
Mental Health Survey of Doctors
MBA’s national health program, which was doctors and others in the profession the best and Medical Students found
rolled out in 2016. possible help to competently undertake what that up to 21% of respondents
The Doctors’ Health Services, or ‘drs4drs’, will always remain a fundamental aspect of reported a history of depression,
are designed to offer confidential health-related people’s lives. while 6% had an existing
triage, advice and referral services; follow-up ‘To be honest, I don’t think we can make diagnosis. Approximately 9% of
services, including support and advocacy in healthcare less stressful, inasmuch as people doctors experienced an anxiety
returning to work; education, awareness-raising will have serious illnesses, people will die, bad disorder (compared to 5.9%
and advice; training to support doctors to treat things will happen. That’s the nature of a lot of of the population) and 3.7%
other doctors; and facilitation of support groups. acute healthcare,’ she said. reported a current diagnosis
‘The [MBA] encourages all doctors to take ‘We have to work on supporting each other, (compared to 2.7% of the
care of themselves, and look out for each other supporting our young doctors to develop the population). The most common
and seek help when they need it,’ Dr Flynn skills to cope with that, and I think sometimes sources of work-related stress
said. ‘We fund the Doctors’ Health Services to we fall short there.’ were the need to balance work
make it easier to access health services, and to and personal responsibilities
make sure that help and support is available in * Not his real name. (26.8%), too much to do at
each state and territory.’ work (25%), responsibility at
Reference work (20.8%), long work hours
Dr Johnson believes the realities of a life
in healthcare are such that these types of 1. Australian Health Practitioner Regulation Agency. (19.5%), and fear of making
Mandatory reporting. Canberra: AHPRA. Available at www. mistakes (18.7%).
services must be expanded upon, and more ahpra.gov.au/Notifications/Make-a-complaint/Mandatory-
should be established, in order to provide notifications.aspx [Accessed 6 July 2017].

GPs, as front line defenders of Australia’s health are best placed to

change the shape of Australia. By looking after your own mental and
physical wellbeing you are better equipped to help your patients.

Regular exercise may increase

the level of brain serotonin
Studies have shown that yoga breathing exercises are beneficial
for depression and reducing stress and anxiety.
4948

Reference: www.blackdoginstitute.org.au

To find out more visit gp17.com.au/shaping-australia

Good Practice Issue 8, August 2017 11