I have been thinking a lot lately about depression. More specifically, about doctors and depression.
I find myself drawn to the obituary pages of the BMJ, curious about doctors who have come and gone. There have been a number of young doctors recently who have died, and it provokes a strange, pronounced empathy in me, which I have tried to analyse. There is the sense of waste that always accompanies the death of someone young: some have families of their own and others don’t, perhaps haven’t had time, but they are all somebody’s son or daughter. But it is more than that.
It is the sense of recognition that for all their efforts, and we know their efforts, no-one in our profession could help them. It strikes at the core of that infallibility we somehow adopt unconsciously that helps to distance us from our patients but which is ultimately no defence at all. I find myself trying to understand how a doctor could die themselves of metastatic melanoma at 29.
How could that happen in this day and age to someone on the inside? I fear the answer is: all too easily. I don’t know the individual circumstances of this particular doctor, and of course melanoma may be hidden, but I am beginning to think that being a doctor is in itself a risk factor. The stress, the responsibility, the system.
You are trained to survive, not to make a fuss, to push your physical or psychological doubts away – it would be awkward to consult a GP about something that may be nothing. Or perhaps you can never get time off when you want to, you are covering rota gaps, you are exhausted trying to juggle personal and work life, so you leave it. Until it catches up with you and for some, tragically it is too late. Then there are the obituaries where there is no cause, an absence. An omission which makes you stop. You don’t know, but you suspect. A sense of shame begins to start, and you wonder how it could have come to that. There is a sense of guilt when you acknowledge that yes it could, all too easily. This is the dark stain spreading at the heart of medicine, and we are going to have to use our collective energies to name it and stop it or we will have blood (our own) on our hands.
We do it for patients – what exactly is the reluctance to show the same concern for your colleagues?
Caroline Elton is a psychologist who works with doctors who have ‘failed’, and has had more experience than most into what goes wrong. She details some of the doctors who have ended up in her care at various stages in their careers in her book ‘Also Human’.
She writes about a young, very talented medical student who was in the top for all her academic exams but who came in the last quartile for her SJT (situational judgement test), so was sent to train miles away from any of her friends and family. As a result, she couldn’t cope with the extra demands of her first year and became very seriously depressed.
Caroline Elton wonders how someone could not have picked up on the disparity between this student’s two scores and foreseen that there may have been a problem and offered support at that stage. There are many other sobering cases sketched, some of endemic racism or sexism or other kinds of bullying, but the common thread seems to be that no-one is taking responsibility for the personal welfare of trainees or employees. When people are numbers, it is easy to dehumanise them, and the mentality is there right from the start.
If your own medical school is not going to care, the administration staff in control of your four-month rotations at different hospitals certainly aren’t. If you haven’t been aware of the recent publicity around Joanna Poole’s compilation of 400 ‘petty tortures’ undergone by junior doctors on Twitter, I urge you to read them. The small details of annual leave not being granted for weddings or funerals gathered together in one place become amplified to a resonant scream from the ‘junior’ ranks. They are surely the canaries in the coalmine? The lack of control over your working life, the capped pay, the pressure, the lack of understanding shown by managers – isn’t that what the Whitehall study was all about? Are we really going to sit by and let this happen?
As GPs I think we are uniquely placed to change the culture. Partners are powerful managers of culture and can take care of their employees if they want to, even working in a constrained system. If you don’t have daily meetings for all doctors working that day, make it your number one priority. We were once the pioneers of psychological good health in practising medicine as the first adopters of Balint groups – we should be again. If a doctor goes off with depression, what system are you instituting to support them, to find out whether the job played a role, and to grade their return?
We do it for patients – what exactly is the reluctance to show the same concern for your colleagues? It is perverse and needs to change.
Clare Gerarda has been saying this for a while and doing something about it, but she should not be a lone voice. If this was not enough to make a doctor vulnerable to depression, there is finally the personal cost of caring. There is a process of self-extinction at work in our daily professional lives, it is a one-way conversation. It is a debt that builds up which must be repaid.The ability of any doctor to repay it depends in turn on the care they receive themselves.
Caroline Elton calls it the ‘first law of human dynamics’. The emotional energy required to care cannot be created or destroyed, it can only be transformed from one form to another. The whole profession is in danger of running down the supply – we need to put it back. Who knows where it could lead? It could be the best thing you have ever done. A virtuous circle. So we should start small and start today.
Dr Charlotte Alexander is a GP in Surrey