How can I tell you what I have done? Let me start with a doorway. I am looking in at a patient handcuffed to the rails of a hospital bed, arms spread out in a crucifixion pose. The prison guards who have brought the patient to the hospital explain what has happened. I hide my horror behind my calm and neutral doctor face as I unfurl crepe bandages from self-inflicted wounds. Just another set of wounds to add to all the others in my head, the weeping pressure sores of nursing home residents, the gangrenous toes that you can smell from the other side of the room. The job of a doctor in training is unspeakable. It is hard to find the words to describe what we do. It is hard to work out whom to tell. We cannot speak of these things to people outside medicine because it is too traumatic, too graphic, too much. But we cannot speak of these things within medicine, either, because it is not enough, it is just the job we do, hardly worth commenting on. When I started working as a doctor last year in a metropolitan public hospital in Sydney, rotating through the emergency department and the surgical and medical wards, as all doctors do in their first year of practice in Australia, my experiences were no better or worse than those of any of my colleagues. Nor are they dissimilar to the experiences of junior doctors around the world. But we are speaking about these things now, where I am from, because my colleagues are killing themselves. It has long been recognized that physicians are more likely than the general population to kill themselves, especially if they are female. A meta-analysis of studies around the world on doctor suicide found that female doctors were more than twice as likely as the general population to die this way. Younger doctors are particularly vulnerable. In the United States an estimated average of 28 percent of medical residents show signs of depression during training, making them around three times more likely to be depressed than similarly aged Americans. A 2013 survey of Australian doctors by the mental health nonprofit organization Beyond Blue found that young doctors worked longer hours than their older colleagues, in some cases up to 50 hours or more per week on average. Younger doctors were also more psychologically distressed and more burned out, and thought about suicide more often. Here in Sydney we have lost three colleagues in the last seven months alone. There are many theories about why doctors kill themselves with such frequency. It is often suggested it is about our access to lethal means, although to me this does not ring true because it implies the act is controlled and clinical. This is not true of many of the doctor suicides I know about, which were brutal. To really understand the suicide problem, we need to consider the issue more broadly and question the simmering distress and burnout among doctors in the early years of their careers. This is particularly of interest to me now that, in my second year of practice as a doctor, I am working in mental health. Suicide is my day job. With my doctor colleagues in a variety of fields, we are starting to talk about the trauma we face, which we must remind ourselves can be real trauma. Rape threats from patients. The ethical problem of knowing we are getting illegal migrants just well enough for the government to deport them. Having to decide whether to forcibly sedate a teenager who is threatening to smash up the emergency department or to watch and wait, knowing full well that what we are watching and waiting for is a nurse to be kicked or bitten, again. These horrors come to feel normal, and the normal world recedes into distant strangeness. On a recent weekend I took a Pilates class. We stretched and bent and complained about our stressful week. But how can I share anything of my week lightly? Stress seems the wrong word. On the walk home, I browsed a housewares shop. I wanted to swipe all the rose-gold salad servers and marble cheese plates off the table, smash them to bits. Who let this other world exist? How can we reconcile the two? As doctors who are more stoic than I will tell you, there is some inevitability to the difficulty of our jobs. Blood and urine and human suffering cannot be escaped. We must face death and our shame for the times we couldn’t hold death back for long enough. We need to know a lot, and that takes time, and that time will be stolen from time that should be spent with children, novels, friends, the ocean. We will make mistakes. But as we talk about the ways we can halt the progression from distress to burnout to mental illness to death, we are realizing that not all of our suffering is inevitable. There are practical changes that can be made. We know we could improve doctor well-being with better working hours and by changing practices that leave doctors in fear of being branded “impaired” if they seek help for mental distress. In the aftermath of recent suicides, these are exactly the things that are being proposed in my home state. And Royal Prince Alfred Hospital in Sydney is rolling out a program for the well-being of doctors in training, which includes mindfulness and resilience training, and personal training for physical health. Those who have created the program note that when doctors develop skills to manage their own well-being, it makes it easier for them to teach these skills to patients. Beyond such practical steps, there is the matter of medical culture that must be addressed. The unrelenting, unforgiving culture of medicine that weighs its junior members down with debt and duty. Medicine says you chose this, so don’t complain. Medicine says stop being selfish and think of the patients. Medicine says just one more year and the worst will be over, and medicine keeps saying that year after year. We need to let go of our shiny doctor selves and accept the vulnerability, doubt and imperfection within, rather than try to obliterate it. We need to find kindness for ourselves, our medical and nursing colleagues, and our patients because sometimes that is the only thing that makes this path bearable. We need a medical culture that sees humanity as a precondition for being a good doctor, not an obstacle. Source
