A perfect storm: towards reducing the risk of suicide in the medical profession

Helping doctors build resilience may be protective against burnout and suicide in times of personal hardship

Having successive generations of doctors in one family — a “medical pedigree” — was once a source of great pride. As the daughter of a doctor and now a mother, I am surprised to find myself hoping my own children do not follow in my footsteps. This is not because of my own career dissatisfaction. In fact, my work is immensely rewarding, but recently, I have been reflecting on the hardships a medical career entails: the gruelling training pathway, the complex medical culture and the constant battle to achieve a work–life balance. I have now witnessed the devastating personal consequences when the rocky road seems impossible to navigate. Over a matter of months, two female junior doctors committed suicide, and more recently, suicide entered my inner circle with the death of one my close male colleagues. Such stories are not unusual in our profession. I do not claim any expertise in this field, but what seems clear to me is that inherent traits in the individuals who choose a career in medicine, and often create excellent doctors, also set them up for high rates of distress. We have a medical workforce that has gone through rapid evolutionary change, and if we combine these factors with exposure to dysfunctional aspects of our medical culture or personal stressors, we have ingredients for a perfect storm.

The scope of the problem

The statistics on doctor suicide are horrifying. In a large meta-analysis, the rate for male doctor suicide was 1.41 (95% confidence interval [CI], 1.21–1.65) compared with the general population, while female doctors fared worse, with a rate of 2.27 (95% CI, 1.9–2.73).1 In the United States, about 400 doctors commit suicide every year.2 Doctors in training appear to be particularly susceptible. In recent Australian surveys, one in five medical students reported suicidal ideation in the preceding 12 months, while 50% of junior doctors experience moderate to high levels of distress.3,4

Factors contributing to suicide risk

The individual

Perfectionism is rife among doctors. However, the very character trait that can contribute to success can also be a downfall in others. Maladaptive perfectionism refers to individuals experiencing distress over perceived personal or family failings (often unrealistic), and is associated with anxiety, depression, perceived burdensomeness and suicidal behaviour.5 Perfectionism, often thought just to reflect a high expectation of oneself, may also be associated with criticism of others’ work performance or behaviour.

On the other hand, resilience is an important protective characteristic that can help defend against burnout and suicide in times of personal hardship.6 A study in the United Kingdom found higher grit scores among consultants compared with trainees.7 This result may suggest weeding out of ill-suited junior doctors,7 and certainly, individuals who identify with a calling to medicine have shown higher career satisfaction.8 It may also suggest that resilience can be learned during training.7

It is well accepted how important a healthy work–life balance is for physical and mental wellbeing and for productivity. Family and social supports help protect against burnout, and better doctor health is associated with better patient care.6 In the 2013 beyondblue National Mental Health Survey of Doctors and Medical Students, balancing work and personal responsibilities was the most common reported source of stress.9 However, among the medical workforce, work–life balance is poorly practised and modelled. In fact, there is a subtle undertone rampant within the medical fraternity, in which late-night emails, missing a child’s school concert, publishing multiple articles a year, and not taking annual leave become unvoiced indicators of a truly committed doctor.

The conflict of motherhood and training is perhaps the one most discussed by female trainees. At present, junior doctors are older and many face a “ticking biological clock” as they complete training. Many pregnant trainees will do their best to hide their growing abdomen at a job interview. They are faced with divulging their “secret” if offered a job and then risk ill-will from their prospective employers. I have seen others at more advanced stages of pregnancy feeling pressure to prove they can come back to work as early as possible after delivery. Overall, work–family conflict is higher for female doctors, who often do more at home than their male counterparts, and this has been correlated with increased risk of depression and burnout and reduced career advancement for women within medicine.10

Depression and substance misuse are all too common among medical professionals.6 However, substantial barriers exist in affected doctors accessing help. An ingrained fear of showing weakness and burdening others is juxtaposed against a deep-seated drive to help others. Lack of time, fear of stigma and being reported to medical authorities are other barriers — which are not irrational, given studies revealing that medical professionals hold concerns over the competency of colleagues with mental health disorders.3,6

The medical culture and system

Collegiality is at risk of extinction — perhaps a consequence of reduced working hours and increasing home demands in an older, expanding junior doctor workforce, who are now experiencing unhealthy high levels of peer competition. In addition, one-third of junior doctors have experienced workplace bullying, particularly affecting women.4 As gruelling as I recall basic physician training, there was never a sense of anxiety among my peers about future job opportunities in our chosen specialties. That is no longer a reality. In 1999, the Australian Medical Association introduced a National Code of Practice on safe working hours, but in practice, this is a misnomer.11 Junior doctors now find themselves undertaking significant research projects, even higher degrees, to increase their chances to secure a training position. The pressure to perform keeps building, the fear of failure is a constant threat. While consultant support has been linked with lower rates of junior doctor burnout, senior doctors are now supervising a larger pool of rotating trainees.12 The chance to establish meaningful informal mentoring connections is now difficult, and the trend in formal matched mentoring programs may not have the impact many wish for.

Mandatory reporting of impaired practitioners, introduced nationally in 2010, has the potential to jeopardise a doctor’s career. However, significant under-reporting of impaired colleagues may be occurring, arising out of respect for colleagues and uncertainty about reporting obligations.13 Yet, according to the 2013 beyondblue survey, concern about reporting is one of the most common barriers precluding doctors from seeking mental health treatment.9 In an important step forward, Health Ministers at a recent meeting of the Council of Australian Governments Health Council have agreed to remove mandatory reporting of doctors by their treating health practitioners.

What needs to be done: a personal view

There is not one solution; what is required is a system-wide change. At the individual level, we all have a responsibility to invest in activities that will support our physical and mental health, and model such behaviour to junior colleagues. Doctors need to learn how to be kinder to themselves and extend compassion towards the struggles of both junior and senior colleagues.

Medical schools have a responsibility to select not just on academic performance but use increasingly sophisticated aptitude testing. Regular enquiry into the mental health of medical students should be a high priority, and ongoing support should be offered to students at risk. Cognitive behavioural therapy, both face-to-face and internet-based programs, has shown reductions in distress associated with maladaptive perfectionism in medical students.14,15 Resilience can also be taught and modelled.7 In one study examining various strategies to reduce burnout among doctors, including stress management programs and mindfulness-based exercises, only a resilience teaching session showed significant benefit.7

Doctor wellbeing programs, modelled successfully by the Mayo Clinic for many years, need to be mandated within our hospital system in an environment of confidentiality.16 Workplace flexibility needs to be adopted at an individual level, as has occurred in other industries. Formal peer support networks set up within hospitals could improve the recognition of at-risk doctors. Peer support leaders should be specifically trained in how to counsel and manage colleagues who are facing difficulty.

Workforce planning needs to be coordinated at the college level, with close involvement of university and government stakeholders. Our system now faces a growing bottleneck at the advanced training level, resulting from increased numbers of medical graduates over the past decade. Support with career navigation and modelling of alternative professional pathways may assist in reducing junior doctor distress. In addition, colleges need to assist in building increased capacity within the system, such as a pool of rotating advanced trainees in each specialty shared among hospitals to cover maternity and extended sick leave. At present, it is left to trainees to find a solution, such as job sharing arrangements.

Finally, we all need to build back collegiality into our workplaces. Managing our own busy lives can come at the cost of losing the opportunity to really connect with our junior doctors and colleagues. The Mayo Clinic’s Colleagues Meeting to Promote and Sustain Satisfaction (COMPASS) groups have shown reduced burnout among participating physicians.16 We have recently established a Women in Medicine group at St Vincent’s Hospital. It is hoped that such informal meetings will create an environment where concerns can be voiced without fear of repercussion, where healthy support can be provided and authentic mentor relationships given space to evolve.