Mental Illness, particularly in the workplace, remains a stigma. It is time for attitudes toward mental illness to change, and we cannot ignore the doctors who suffer.
A push for mental health
Earlier this year, former prime minister David Cameron pledged a mental health revolution of almost a billion pounds. Whilst this proposed outlay is welcome, it must be matched by a proactive change to the stigma attached to mental health in media, the workplace, and at home.
Mental health and doctors
Professor Debbie Cohen of Cardiff surveyed almost 2000 doctors this year and found that 60% had experienced mental illness in the UK (82% in England alone). In the general population, the rate is 28%. Doctors experience the same range of problems as everyone else, but the cocktail of work, exams, academia, family and relationships lowers the threshold for illness. Many have perfectionist traits which lead to doubt and self-criticism when things go wrong, leading to a self-perpetuating cycle.
Worryingly, more young doctors are being diagnosed with mental health problems. There may not be a pre-existing illness: After 25-year old junior doctor Rose Polge tragically committed suicide in February 2016, her family described a young lady with an infectious enthusiasm for life and no previous mental health problems, but long hours and work-related anxiety contributed to her decision to end her life.
Extreme stress early on
Doctors are as susceptible to mental problems as the general population. However, particularly early on in their careers, they face a unique combination of challenges. These include the need to develop countless skills within a short period (for which university education can never fully prepare) and service burdens in a chronically under-resourced environment, only more challenging for those with family or caring roles. Early junior doctors shifts are usually incompatible with outside interests, and losing day-to-day balance can unearth mental health struggles.
Doctors face a societal and professional weight compelling them to ignore difficulties. A cultural idiosyncracy of willing martyrdom exists, in which doctors feel it their role to attend work regardless of fitness. This is less prevalent in other countries, for example Australia and New Zealand, where attitudes towards sickness are more rational.
Fewer professions stigmatise mental health disorders more prominently than medicine. In the Cardiff study, 41% of doctors with mental illness said that they would not disclose it. Doctors are not supposed to get ill, and seeking help is weakness which imperils trust in the practitioner’s ability to do his/her job. This featured in the heartbreaking suicide of GP Wendy Potts in November 2015 after a patient read her blog on living with Bipolar Disorder and complained to the surgery.
Some doctors find changing roles from helper to patient unnatural, others find treatment from a colleague embarrassing. Often the prevailing fear is of a career-threatening “black mark” on a permanent record: Doctors must labour through appraisals and assessments, and competition for jobs and training posts can be ferocious.
A culture of fear
A 2008 Department of Health report said:
“Doctors may fear that acknowledging the need for help will damage their career prospects or lead to scrutiny of their fitness to practise”
This happened in the case of Dr Dakhsha Emson, who killed herself and her baby during a relapse of bipolar disorder in 2000. A stirring tribute from her husband reflected a talented doctor and a successful medical career. However, worry of colleagues and patients finding out when she was applying for consultant posts led to a lack of treatment. The report highlighted a:
“Widespread stigma against mental illness in the NHS”
This stigma can arise as early as medical school, fostered by a triad of competitiveness, fear and uncertainty. Students sometimes receive conflicting information about mental health, and may fear disclosing illness. Pastoral care can be arbitrary, often with little demarcation between disciplinary roles and support roles. Some universities have introduced “fitness to practice” hearings to monitor student behaviour, fostering a culture of castigation.
For some doctors, this culture is epitomised by the General Medical Council (GMC), whose role is to protect the health and safety of the public. All doctors with mental health issues are required to notify regarding their problems, which are investigated under the same procedures as misconduct and poor performance. Subsequent fitness to practise processes are required to be declared on application forms for jobs. These can sometimes be beneficial, for example recommending support. However, often they are described as harrowing experiences, and the duress of investigation affects doctors personally and professionally.
The toll can sometimes be too much, between 2005 and 2013 there were 28 reported cases of suicides following investigation. One of those was GP Belinda Brewe, describing the process:
“threatening and isolating”, eroding “self-confidence and self-belief”.
- The NHS needs continued active campaigns to encourage openness, tackle stigma and promote healthy working practice.
- Medical schools should be proactive in support and awareness: counselling services, pastoral care positions and peer support.
- The insight that doctors with mental health problems have when treating their patients should be valued.
A doctor who has a mental health disorder might put his patient at risk, but a doctor hiding or in denial because of a culture of fear will put his patient at risk.
- http://www.php.nhs.uk NHS Practitioner Health Programme, free and confidential health service allowing doctors to self-refer.