Doctors are generally acknowledged to be intelligent. We are trained to care for the human body, and are considered the experts on it and how to take care of it. And we care deeply about people and would never knowingly harm them. Indeed, our Hippocratic oath says to “First, do no harm”. So why are doctors killing themselves?
The statistics are shocking
The statistics are shocking. Rates of suicide among doctors are quoted as being up to 3.4 times higher than the general population for men and up to 5.7 times higher for women.(1) A meta-analysis in 2004 found lower numbers than this, at 1.41 for men, and 2.27 for women(2), but whatever the numbers, the rates are higher than normal, not lower. And these are the numbers we know about. There is such a stigma and shame around suicide that we usually don’t acknowledge this as the cause of death, and obituaries use euphemisms such as “died suddenly”, “taken from us too early”, “in tragic circumstances”, “passed away sadly and unexpectedly”, so the rates are probably higher than the statistics show.
This is an indictment of our noble profession; that those who have made it their life’s work to care for others, seem unable to care for themselves, even to the point of not being able to keep themselves alive. How on earth has this come to be?
In other professions, if one work-related death occurs, everything stops until the cause is found and rectified. Without blaming or shaming any one individual. In medicine, it is now regarded as so ‘normal’ that some of us will become so exhausted, depressed, and given up on life that we will kill ourselves, that it is delivered in student lectures as just another list of statistics you have to learn and regurgitate if you want to pass your exams. No attempt has been made to see it as anything other than a personal failing or weakness, an inability to have “what it takes”.
We need to ask: Why are doctors committing suicide? Why do we even call it that? We commit crimes, not suicide. Why do we become so desperate that we see no other option than to take our own lives, in complete violation of everything we stand for?
Perhaps we could also ask: Why does it not happen more often? Suicides are but the tip of the iceberg of the exhaustion, anxiety, depression, burnout, and hopelessness that is plaguing modern medicine.
Doctors are not superhuman
We seem to have become used to seeing doctors as superhuman – as capable of doing without food, drink, sleep and a normal human social life for long periods of time; as not being affected by human misery and suffering, and the gamut of emotions people go through in the face of illness and disease, that they have to deal with every day – as if we were naturally imbued with these qualities or we have been somehow trained to develop them, but is that true? The trouble with the ‘doctor as superhero’ image is that when we falter and fail, as humans do, we are somehow blamed for this as a personal weakness, that we weren’t up to the job, rather than stopping to see if the system we are working in has some part to play.
For doctors are people too – normal, kind, caring, people, with all the weaknesses and great strengths that other people have, no more, no less – and we are treating them as less, and expecting them to be more.
Why do we:
- Not have rules that regulate the number of hours we can work before we have to take a break?
- Work such long hours in a day?
- Work so many days in a row, when it is well known that fatigue takes a toll on the human body and that a person is affected by fatigue as much as if they had been drinking? (3)
- Expect doctors to just keep going, no matter what?
- Blame them personally if they cannot?
- Blame them if they make a mistake because they are tired?
- Assume that they are guilty if someone else blames them for something?
The normal rules of Occupational Health & Safety, the Law, and common sense, are not applied to us.
The culture of medicine is cruel:
- The selection process favours mental activity at the expense of all else, including the body we are supposed to be learning to care for;
- The system of training fosters competition over collaboration and focusses on the passing of exams via the regurgitation of learned knowledge, rather than the development of people who will practise the art and science of true medicine;
- The way we are worked is in complete disregard of our own health, wellbeing and lives;
- We are treated as expendable pawns in a system that preserves itself at all costs;
- The way we are with each other is competitive and harsh, rather than open, honest and supportive.
And if we are struggling, and would like to seek help, the normal rules do not apply here either. If a ‘normal’ person comes to see us professionally, we are bound to protect their confidence, so they can in fact have confidence in us and know that they can seek help without fear of consequences. Yet if a fellow doctor comes to see us, and we deem that they are ‘impaired’ in some way, we are obliged to report them to a governing body that we know will treat them as if they are guilty of a major criminal offence, possibly strip them of their right to practise medicine, and place humiliating conditions on their practice if they are allowed to continue, including exposing them to trial by media. Is it any wonder that doctors are not seeking formal help, but hiding the fact that they are struggling, and are self-diagnosing and self-medicating, often compounding their original problems, and in fact putting themselves and the public at greater risk than if non-punitive, confidential help were still available.
There is such a shame and stigma around doctors being ill. Sickness is somehow seen as a personal failing and a betrayal of our colleagues. We feel unable to call in sick at work, even when we know we are posing a health risk to others, if we are contagious, or just temporarily incapable of doing our work and at increased risk of making an error. We would never insist that ‘normal’ people work under these conditions, yet we push ourselves to show up at work, no matter how ill we are feeling.
We are hiding the fact that we have made a mistake for fear of retribution, and this is having flow on effects throughout the medical system. And doctors are being scapegoated if things go wrong, even when no wrong has been done, as evidenced by the recent story of the doctor who tried to kill himself after being told he would lose his job after the death of a young woman from influenza.(4)
We work in a system that increasingly holds the doctor responsible for everything. We as a society are becoming more irresponsible, and we as individuals are becoming more irresponsible. We think we have the right to eat, drink, and otherwise live as we please, and when the inevitable consequences occur, as in the 90-95% of cancers that are lifestyle related,(5) we think we have the right to go to the doctor and ask to be fixed at once, and if they cannot, or if we experience side-effects of the treatment, we think we have the right to blame the doctor personally for this, and to complain about them officially or sue them.
Conventional medicine so obviously does not have all the answers, as evidenced by our rising rates of illness and disease, and our inability to deal with the increasing complexity of multi-symptomatic and multi-systematic chronic disease these days.(6) Yet if we dare to offer lifestyle advice to our patients, we will be censured now, as was Dr Gary Fettke, even though we consider this part of our duty of care as doctors, and even though the evidence shows that the vast majority of chronic disease is lifestyle related.
Is it any wonder?
Is it any wonder, with all these pressures and stresses, that doctors’ rates of ill mental health – of anxiety, depression, exhaustion, burnout and suicidality – are greater than those of the average person?(7) And is it any wonder that when we just cannot take it any more, doctors think that the simplest solution is to kill themselves.
At that point, we must have no understanding of the human carnage we are leaving behind.
- If taking a day off work is such a disaster, what is the cost of taking a life?
- If we care about our patients so deeply, do we consider the impact this will have on them; that the person they trust with their health, their life, cannot take care of their own? What example does this set for our patients? Does this cause some of them to give up on life too, if even their doctor cannot cope?
- And how will our family and friends feel? Thinking that they will be better off without us is a lie that is fed to us, to make us feel better about what we are planning to do.
- We leave in our wake an enormous amount of sadness and suffering, which is surely not intentional, for people who promised to “First, do no harm.”
“First, do no harm” starts with us
If we truly care about people, this has to include ourselves and our colleagues. “First, do no harm” starts with us.
We have to learn to appreciate ourselves, just as we are, without expecting ourselves to be perfect, and to care deeply for ourselves, so that we build a healthy body that can work in a diseased system, we don’t take the pressures of the job so personally, we do stand up for ourselves and each other in the face of a system that asks us to work at our own expense, and so that we don’t feel personally devastated if we do make a mistake or if someone tries to blame us for their own lack of responsibility.
And if we are thinking of doing ourselves harm, we have to be able to seek help, without fear of recrimination or retribution, before it is too late.
I have lost two dear friends and colleagues to suicide. This is not a life experience I would wish on anyone. Two beautiful, bright, deeply caring, funny, tender, loving people, who were adored by friends, family, colleagues and patients alike. Two people dead, way before their time. And I have known other colleagues who have “died suddenly” at home or in car “accidents” which may well have been deliberate too.
It is time we all came together to deal with this problem of doctor suicides, bringing it out into the open as has been done most courageously in recent times by the families left behind,(8) and dealing with it, without shame or stigma. We need to stand together and call out the abusive nature of the system we are working in, and our part in allowing it to continue, and start making changes in the way we treat ourselves, supporting ourselves and each other, which will lead to true and lasting changes in the system, from within.
So what can we do?
We cannot change the culture and the systems of medicine overnight, although we certainly need to work together to effect true change, which is long overdue.
We can change the way we are with ourselves and each other.
Medicine as a culture has become uncaring, but we are not.
We went into medicine because we care deeply about people. But somewhere along the way, we forgot to (or were trained not to) care for ourselves.
But how can we possibly care for others if we are not first caring for ourselves?
We have a duty of care to care for ourselves. “First, do no harm” applies to us, first.
In medicine, as in life, we serve as role models. As parents, we model behaviours that our children tend to adopt, even when we tell them not to. And the same goes for our patients. We can say what we like, but are we living in a way that truly models good health for them? Are we eating well, exercising regularly, sleeping soundly? Are we full of vitality and joy? Do we love our work? Do we love being with people? They can see and feel all of this, and will either be inspired by us, to live in a more caring way themselves, or see that if even we cannot live well, how can they possibly hope to do so, and then dig deeper into their own self-destructive behaviours.
We have a duty of care to care for our patients by living lives that inspire them.
And we have a duty of care for each other, to keep an eye out for each other, to notice that someone is struggling, to reach out and help them, to bring them back into the fold. To care for them, and truly support them, not condemn and isolate them.
We cannot change the systems overnight, but we can change the way we are with each other. For far too long now we have allowed ourselves to be pitted against each other. The competitive nature of us as individuals has allowed ‘the system’ to drive a wedge between us, to keep us divided so that we do not stand together for true change.
Doctors as a unified group are a powerful force for change, and this is known. Great effort goes into keeping us separate and small, for we could make a huge difference to our communities, our systems and the world if we stood united and strong.
It is time that we started to truly care, for ourselves and for each other, and to stand together, as one, for true change.
This article was first published in the Medical Journal of Australia, on 12 June 2017