Doctors with mental health problems — time for attitudes to change
by Nima Ghadiri
On the 11th of January 2016, United Kingdom’s prime minister David Cameron pledged a revolution in mental health treatment, promising almost a billion pounds of investment to enhance mental health services across the country. Much of the expenditure will be spent in important areas such as emergency departments, new or expectant mothers and teenagers with eating disorders. This outlay is welcome, yet it needs to be matched by a proactive change in the stigma attached to mental health difficulties. In no profession is this stigma more prominent than in medicine, where the number of young doctors being diagnosed with mental health problems is increasingly drastically every year.
Doctors are no different to the rest of the population in terms of intrinsic susceptibility to mental health problems. However, they face a societal and professional burden which compels them to ignore their difficulties. Such challenges are not exclusive to doctors: other health and service professionals may have identical burdens. In other industries, such as aviation, pilots may take extreme measures to hide even mild illnesses in order to avoid career-threatening scrutiny. The result is an inexplicable situation in which pilots will not seek help and put themselves and their passengers at risk. The tragic events of Germanwings Flight 9525 in March 2015 could have been circumvented if Andreas Lubitz did not feel that he had to “hide his illness from his employers” and was able to seek simple and consistent therapy.
Nevertheless, it is doctors who are more likely than any other profession to have mental health problems. The range of problems in doctors is the same as the general public, but they can be exacerbated by the combined pressures of work, exams, academia, family and relationships. Many doctors have perfectionist traits which can lead to doubt and self-criticism when things go wrong. This in turn may produce a self-perpetuating cycle that initiates or worsens mental health problems.
In the NHS, a cultural idiosyncracy exists amongst doctors, which contributes to both physical and mental illness. This is the state of willing martyrdom, in which doctors feel it their role to display presenteeism and attend work, regardless of whether or not they are fit. This unhealthy approach is less prevalent in other countries, for example Australia and New Zealand, where attitudes towards sickness from work are more rational and doctors do not feel the pressure to project an aura of invincibility.
A number of reasons can explain why doctors have a tendency to bury their illness under the carpet. One reason is society’s attitude towards doctors — they are not supposed to get ill, and seeking help is a sign of weakness. Another reason is the difficulty in switching to a patient role — some doctors find the required change in mindset unnatural, others find being treated by a colleague embarrassing. Perhaps the most prevalent reason is the fear of a “black mark” on a doctor’s record: Doctors at all stages have to jump through many evaluation hoops and the competition for training and jobs can be so fierce that they avoid any potential negative factors which might hamper their applications.
A report from the Department of Health in 2008 highlighted this unfortunate situation: “doctors may fear that acknowledging the need for help will damage their career prospects or lead to scrutiny of their fitness to practise”. Sadly, the pressure on doctors to avoid any attention to mental health problems has resulted in a number of high-profile tragic cases. In 2000 Dr Daksha Emson, who suffered from bipolar affective disorder, killed herself and her baby during a relapse of her disease. The DOH’s report included a tribute from her husband, which reflected a talented doctor with a successful medical career. However, her fear of colleagues and patients finding out about her condition, at a time in her career when she was applying for consultant posts, led to a lack of formal and consistent treatment. The report highlighted a “widespread stigma against mental illness in the NHS”.
Even in medical school, the stigma of mental illness is perpetuated. Medical schools provide a microcosm of the NHS, and with this comes the triad of competitiveness, fear and uncertainty. Medical students may receive conflicting information about mental health issues, and may fear disclosing any illness which could hinder academic progress. Pastoral care for medical students can be arbitrary, and often the demarcation between medical staff with disciplinary roles and those with support roles can be blurred. To monitor student behaviour, some medical schools have introduced “fitness to practice” hearings, which further instil fear in future doctors.
In the minds of many doctors, the culture of fear and castigation is epitomised by the General Medical Council (GMC). The main focus of this entity (which consists of six medical and six non-medical members) is to protect the health and safety of the public by registering and monitoring doctors. All doctors with mental health issues are required as part of their registration to notify the GMC. The GMC then makes a decision about whether to investigate or not. Mental health problems are investigated under the same procedures as misconduct and poor performance, and any subsequent fitness to practise processes are required to be declared on application forms for jobs.
Sometimes, these hearings can yield positive results, for example by recommending structured support for struggling doctors. However, often they are described as harrowing and punitive experiences, and those who run the gauntlet feel the stigma of being investigated affecting them both personally and professionally. Sadly, the toll can be too much for the doctor, and between 2005 and 2013 there have been 28 reported cases of doctor suicides following GMC investigation. One of those who committed suicide was GP Belinda Brewer in 2007, describing the process as “threatening and isolating”, and “erodes self-confidence and self-belief”.
There are few formal pathways or specialist services to help doctors with mental health problems. In response to the 2008 DOH report, the Practitioner Health Programme (PHP) was created in London, which is free and confidential, and allows doctors to refer themselves without their GPs being aware. Support groups do exist: The Doctors’ Support Network was set up by doctors who have themselves had problems, and offers a confidential self-help group for doctors helping each other in the recovery process. The BMA counselling service offers a 24-hour confidential support line for doctors and medical students.
With current reports of a sharp rise in young doctors seeking help for mental health disorders, there is a need for an open and frank discussion about mental health in the medical profession. A doctor who has a mental health disorder might put his patient at risk, but a doctor hiding or in denial about a mental health disorder will put his patient at risk.
What needs to happen:
- Doctors need assurance of confidentiality. Concerns such as not being seen by their own patients need to be addressed, for example by out-of-hour care. Doctors need to be treated as patients, not as colleagues.
- The NHS needs to have a role in promoting healthy working practice and in tackling stigma. This should include active campaign to encourage openness and break down the culture of denial.
- Medical schools need to have a proactive role in support and awareness early, be it access to counselling services, specific staff in pastoral care positions or peer support.
- Indeed, not only should this not be taboo, but the insight that doctors with mental health problems have when treating their patients should be valued. In Harper Lee’s “To Kill a Mockingbird”, Atticus Finch says you never really understand a person “until you climb into his skin and walk around in it.”
Doctors in need for support: Where to go:
BMA Counselling Service — www.bma.org.uk/doctorsfordoctors 24 hour confidential support line for doctors and medical students, with access to trained counsellors. 08459 200 169 (landline: 01455 254 189)
www.php.nhs.uk — London-based NHS Practitioner Health Programme — Free and confidential self-referral services for doctors with a mental health, addiction or physical health problem affecting their work.
http://www.dsn.org.uk/ — Doctors Support Network — Charity set up by doctors with experience of mental health problems to support others. Online support forum
http://www.support4doctors.org/ — Support 4 Doctors
http://sick-doctors-trust.co.uk/ — Sick Doctors Trust: 0370 444 5163 Support for doctors who are affected by drugs or alcohol
http://www.samaritans.org/ — The Samaritans
BMA list of websites for doctors in difficulty with specific problems: http://www.bma.org.uk/support-at-work/doctors-well-being/websites-for-doctors-in-difficulty
References:
1) BMJ: Doctors’ health matters: http://www.bmj.com/content/337/bmj.a2527
2) Mental Health Foundation. Mental health statistics. 2001.www.mentalhealth.org.uk/help-information/mental-health-statistics/UK-worldwide/.
3) Time to Change. Attitudes to mental illness. 2013 research report. 2014. www.time-to-change.org.uk/sites/default/files/121168_Attitudes_to_mental_illness_2013_report.pdf.
4) General Medical Council and Medical Schools Council. Supporting medical students with mental health conditions. 2013. www.gmc-uk.org/Supporting_students_with_mental_health_conditions_1114.pdf_53047904.pdf.
5) British Medical Association. Reasonable adjustments for disabled students and doctors in training. http://bma.org.uk/practical-support-at-work/doctors-well-being/reasonable-adjustments .