Posted Ranaana Srivastava 21st March 2017
The Guardian
The ceilings soar impressively high, the stained-glass windows are exquisite, and the satin-adorned pews stretch majestically to the dignified altar. Amid the silence punctuated by the barest of sobs, I spot doctors whom I have long lost track of. And row upon row of nurses, still tight years later. As we wait for the service to begin, we imagine we are all silently interrogating our memories about each other. Time parted us for decades before we have gathered in such dreadful circumstances.
“I wanted you to hear it from me,” a colleague had said, audibly upset on the phone. I nearly collided with the pavement when I heard.
She was wonderful, the speakers confirm that morning. Her boss delivers an impassioned eulogy about an inspired clinician and a devoted mother to the children who sometimes tagged along on weekend rounds. Her best friend recalls their last conversation that ended with the doctor saying to the nurse, “Go home, don’t work so hard.”
Her husband quietly expresses gratitude for their years together and grief for the stolen ones. Her parents sit mutely, heads hung low, suddenly and irrevocably aged. A slideshow of pictures, depicting ordinary things – licking ice-cream, dropping off the kids, medical graduation, the first day of internship – suddenly turned unmistakably poignant. The audience is frozen in a horrible dream.
Outside, there is more heartbreak. “We have to say goodbye to Mummy, just us,” the children’s father says softly. We, the gathered, hold our breath lest it makes a sound. Gently, under the flowers she so loved, she is lifted into the car. It’s soon a mere dot on the road. There are refreshments but the crowd disperses awkwardly, wordlessly, not trusting ourselves to speak.
We had known each other well enough in our early days, biding time on endless night shifts, watching dawn break, praying that the nurses would save the next page for the day crew. Later, our lives diverged, each assuming the other was successful, busy and content. The final time I saw her was shortly before she died.
It had been a fractious day; I felt brittle, from a distance she looked happy. What would have happened if we had stopped to talk?
If she had asked, “How are you?” I’d almost certainly have smiled, “Fine.”
And if I had asked, “How are you?”
Could she conceivably have replied, “Suicidal”?
After the gut-wrenching news of her suicide starts the inevitable soul-searching. It was a bad boss. No, a troubled marriage. Parenting had taken its toll. Or her disagreeable colleagues. She seemed so normal in the days leading up to it. No, far from it. She was upset, anxious, disillusioned. The only thing you learn is that for someone who was surrounded by observant and intelligent people, no one really knew much at all. No one knew what went through the mind of a vibrant and capable doctor in the prime of her life, who one day decided that life wasn’t worth living anymore.
Unfortunately, this isn’t the first time I have encountered the suicide of a colleague. Some I had known personally; others were brought close through mutual patients, and still others I would never get to meet because they had ended their life before starting a new rotation. In every instance, other doctors did not realise the depth of their colleague’s mental anguish. “I wondered about her but didn’t want to intrude,” someone ruefully recalled. “I didn’t think it was possible,” reflected another.
Four junior doctors have taken their lives in the past six months in Australia. In my busy hospital, I observe a roundabout of students, residents and specialists in difficulty. But how much difficulty? When they say they’re having a bad time, is it a bad week, a dreadful year, or a tortured life? Are they upset about a rejected grant or do they deem their very existence worthless? Forced smiles and tough hides abound in the workplace, where always being “fine” is a badge of honour. This is why it can be so difficult to distinguish doctors who will indeed be fine from those who need help.
There is ample evidence for the high rates of mental illness in doctors, several times greater compared with other professions and the general population. These figures are quoted so frequently at every orientation that awareness should not be an issue. Practically every institution has an employee assistance program that offers confidential help. Some offer free psychiatric evaluation and counselling. And as with other informal medical consults, many psychiatrists will help a colleague in distress, making access to high-quality help less of an issue for doctors than many others.
Armed with knowledge and surrounded by advice, why do doctors commit suicide at an alarmingly high rate?
I sometimes fear it may be because as a profession, we are reluctant to swallow the evidence. And if we can’t accept the evidence we can’t help ourselves or others. We can have an intellectual discussion about anxiety, depression or suicide and we can apply the knowledge to our patients but identifying vulnerability in our own self is altogether different. No matter how many times we hear it, it still doesn’t seem possible that we, or someone like us, could have a mental illness. The consequences seem so vast, the repercussions so numerous that perhaps it’s better to not know the truthful response to “Are you OK?”
Discrimination, bullying and harassment in medicine are unfortunately never far from the headlines, but thanks to brave people who have risked their career, a victimised doctor has more support than ever before. Nonetheless, a career in medicine means always having to keep up with something, whether it’s the latest research, the newest drugs, the next exam or the upcoming promotion. Doctors would like to be perfect at all of these and are genuinely puzzled when life deals them disappointment. It seems ludicrous now but I was dumbfounded when I got my first mark that wasn’t a distinction. Twenty years later, I realised nothing had changed when my registrar failed his specialist exam and told me that “even the walls” were laughing.
When doctors are depressed, their sense of personal failure is compounded by the suspicion that they somehow lack the ability to pull themselves together. The “well” among them can’t understand how the same stressful hospital ward, the same demanding colleagues, the same rocky tenure track can make some of us angry, others sleepless, and yet others suicidal.
In these pressured times, few doctors would be strangers to a variation of the message, “Heard you’re sick. There’s no cover so let us know whether to cancel your patients.” There is no call more disheartening than one that professes to care about the doctor but can seem like a veiled complaint that says, “If you’re sick, we all suffer.” But while it’s quite easy to tell your colleagues you have pneumonia or a migraine, doctors say the disclosure of mental illness poses a real threat – to license and insurance, career and reputation. The diagnosis invokes not only sadness but also ignominy, which may be why there are so few well-publicised stories of doctors with mental illness.
For much of my career, I have watched policies, promises and campaigns about combating mental illness and suicide in doctors. Our knowledge is evolving and with it, ways of managing mental illness, but with many lives lost each year, we don’t have the luxury of time.
Since we can’t always read the suffering of our colleagues, humanity in all our professional dealings and concern and compassion for every colleague must be a priority. As well as this, a healthy dose of introspection about how we judge doctors with a mental illness and why we judge them differently, arguably more poorly, than our patients.
When it comes to mental illness, we hear a lot from the experts but not enough from the sufferers. But in fact, nothing would be more welcome than the insights of doctors who have endured mental suffering and worse, been on the brink of suicide. What healed them and who helped them? What could their colleagues have said or done differently at the time? What workplace adjustments would have meant the most? These stories are clearly among us – hearing them could illuminate the dark corners of our understanding and help link theory and practice.
As a profession, we must do more than lament our dead colleagues. Dealing effectively with mental illness and halting suicide among doctors requires curiosity, compassion and practical support. Most importantly, it requires the humility to realise that in the long span of a career, none of us are immune and those doctors whom we help today could end up saving our life tomorrow.
- In Australia, the crisis support service Lifeline is on 13 11 14. In the UK, the Samaritans can be contacted on 116 123. In the US, the National Suicide Prevention Hotline is 1-800-273-8255.
