Suicide in Healthcare – a personal problem or systemic failure?

Suicide in Healthcare – a personal problem or systemic failure?

Several years ago I worked with a temporary dental assistant. A garrulous young woman, she was full of stories about dentists she had worked with over the years.

One story has stuck with me, etched in my mind forever. She told of a day spent in a particularly busy practice. The waiting room was full to overflowing with people as the dentist ran so late that minutes could not even start to measure how far behind he had fallen. Suddenly, and inexplicably, he got up from what he was doing and walked out of the room. He had not completed the procedure. He spoke to no one as he walked past the waiting room crowd and out of the entrance door. He did not return.

Sometime later it was found that he had walked to the closest railway track, climbed the high safety barriers and had thrown himself under a train. He did not survive.

The dental assistant laughed uproariously at this point. I sat mute with horror, unable to digest either this man’s violent death by suicide, or her mirth about it. This story sat too close to the bone, touching on every raw point about what it feels like to reach such a level of despair that suicide seems like the only reasonable course of action to fix the problem that a doctor or dentist believes their life has become. It also reveals the serious issue, that the suicide of healthcare professionals is not treated with the respect, care and urgency that is required.

Something is seriously amiss in the state of being of our healthcare providers.

The press have highlighted it with recent reports on the suicide of young doctors[1, 2], but they have, to use the worn out analogy, only touched the tip of an immense iceberg that is blighting the medical and dental fields.

It is incredible that it took the suicide of the young and talented Australian doctor Chloe Abbott to bring media focus to the grossly neglected chasm between the demands we place on doctors to always be of service and always get it right, and their capacity to meet these demands.[3] Her death was particularly shocking because she was a passionate and articulate advocate for the health of trainee doctors. It was also believed that she had a glittering path to a successful future laid before her.

Her suicide highlighted the stark gap between everyone’s fantasies and the painful and deeply worrying truth.

The media’s coverage enabled us to wonder at how such a lovely and intelligent young woman could reach the point that taking her own life seemed the only viable option? How could she, with her apparently close knit and caring family, take this course of action?

And what is going on in medicine that so many young doctors and healthcare professionals, worldwide, are taking their lives?

The media have only touched on the rate of suicide for doctors of all ages. This rate is reported to be substantially higher than for non-medically qualified people: in the US, male doctors die by suicide twice as often as men from the general population; a female doctor is three times more likely to take her own life than a woman who is not a doctor.[4] Although a recently published Australian study did not indicate a greater rate for male doctors when compared to the general population, it did agree with the US findings that female doctors have a substantially greater rate of suicide than non-medical women.[5]

It is important, in attempting to understand this problem, to be aware of the culture of medicine and dentistry; this gives some vital clues as to why they suicide. If we do not look at the whole environment in which doctors and dentists practice, we will be ignorant to the breadth and depth of the problem of ill mental health and the currently normalised levels of suffering in the healthcare professions.

  • Scant regard has been paid to the mental and physical health of doctors and dentists.[6] The laissez-faire attitude to their wellbeing starts the moment they commence training and continues until (and beyond) their retirement. As a practitioner you are expected to work your way through the rigours of professional life on your own. And there is a culture of denial in medicine and dentistry about the extent of the problem of suicide. There is a very evident lack of communication within professional bodies to their members, and from professional bodies to the public. Although in Australia the Doctor’s Health Advisory Service[7] has been available to doctors and dentists for decades, it was a very well kept secret. Until very recently you had to be aware of the existence of this service to find it and discovering the contact details for this service online was no simple matter.
    We must be very honest about this. It was the media who highlighted the problem of young doctor suicide, and not the medical profession. It is public reporting that has forced the medical regulatory authorities and professional bodies to make any moves towards seriously and openly addressing the issue of practitioner suffering. The Australian Medical Association’s (AMA’s) obituary to Dr Chloe Abbott was a testament to this attitude.[8] In this letter, published on the AMA NSW website, she was lauded for her relentless advocacy for reform in medical training. There was no word on the fact that she took her own life. No word on the fact that in spite of her work on behalf of her colleagues in training, she could not save herself. It could be claimed that this omission was made out of respect for the family, but it was her family who went to the media and told the story of Chloe’s death, and the culture in medicine that pushed her to make this choice.[9] It was the wife of Dr Andrew Bryant (an older Australian doctor, nearing retirement) who reported his suicide to the media.[10] She tried to make sense of why he had chosen this course of action. Again, the AMA had nothing to say on the subject. What both cases highlight is a culture that tries to gloss over the alarming number of practitioners who have fallen over the brink because they cannot cope with the demands of practice: this only increases the sense of shame and isolation in members who are struggling. It is telling that families have taken the problem to the public realm in the knowledge that their loved ones are not alone in the struggles doctors and dentists face. Those families also know that the silence is only making the problem worse.
  • There is a gap in the reporting of older doctor and dentist suicide, as these deaths seem to be regarded of less public interest or less of a tragedy.[10] This is a disgraceful omission. It marginalises and dismisses the older person who, approaching the middle or end of their working life, has hit a point of unassuageable mental anguish. These men and women are swept under the carpet as an anomaly, a failure that really ought be basking at the peak of their career, if only they were a better doctor, more successful, or more resilient. They are written off as broken people, as though the medical and dental cultures had no part to play in their problem. In omitting their stories, the complete picture of what happens to a doctor or dentist over the length of their career is not being painted. The fact is that young people who aspire to practise medicine and dentistry are not being told the whole truth, and the public are not made aware of the toll practitioners pay over the years of practise, and the lack of effective support for suffering healthcare professionals.

  • A vacuum exists in the measuring and reporting of suicide in dentistry.[11, 12, 13, 14] It is a long-standing joke (of sorts) that dentistry has one of the highest suicide rates in the healthcare professions, yet when one attempts to research the numbers very little data is available. Dentists often hear stories like the one that opened the article, spoken of in hushed and embarrassed tones. Or they have friends who take their lives. Virtually none of these deaths are reported to the public, at least in a meaningful and impactful way that exposes the levels of despair in dental professionals and the reasons behind it. Whilst we do not seriously and respectfully acknowledge the suicide of dentists, it is a problem that will not be effectively dealt with.

  • The focus on suicide (as poor as it is) neglects the large numbers of practitioners who are suffering emotional distress on a daily basis.[5] Some have recognisable mental health conditions such as depression and/or anxiety. Some do not, but they suffer from a malaise that makes professional life a grim endurance course, and a day-to-day grind that wears down, demoralises and exhausts the person. They do not fit any diagnostic criteria, but their professional life is a source of misery. Many experience the condition of ‘burnout’ – the catch-all term that is supposed to make sense of this suffering but gives us no clue as to what takes some people to that point, nor how it can be resolved. These people are the ‘walking wounded’, the ‘impaired practitioner’. Some of them buckle down and just get on with it from day to day. They might never take their own life, but their suffering is an impediment to the quality of their practice and the quality of their life. Medicine and dentistry suffer as a whole when substantial numbers of members end up in this drudgerous state, ‘hating’ what they do.

  • Some doctors and dentists describe feeling trapped by their professional training. They are highly qualified through a prolonged, arduous and expensive process, and their capacities do not lend themselves to any other field of endeavour. The person who finds themselves unhappy in their choice of career must either depart very early on and waste the heavy investment of money and time (measured in many years), and train again from scratch, or they must buckle down and hope it will somehow get better. This is not a wise approach to the dilemma and the lack of honesty within the professions about it leaves people feeling abandoned to manage it as best they can.

  • Addiction is a disturbingly common coping mechanism in both professions, made easier because they have ready access to drugs. The addiction may be to anaesthetic agents, alcohol, prescription drugs and/or street drugs. This is an under-acknowledged problem in medicine and dentistry. Addiction is not a just personal problem. It has far reaching impacts on staff, patients and colleagues. Patients are placed at risk from underperforming, impaired practitioners. Staff and colleagues bear the brunt of poor and/or irregular attendance at work, mood swings, and risk-taking behaviours.

  • Mandatory reporting has exacerbated a climate of mistrust and fear in medicine and dentistry, a climate in which doctors and dentists already fear each other’s judgement and approbation. It is a requirement under mandatory reporting legislation that a doctor or dentist must file a report about any colleague that they consider impaired or a risk to patients.[15] The laws about mandatory reporting in Australia were laid down in reaction to a psychiatrically impaired surgeon who caused great harm to a large number of his patients.[16] This was a dreadful incident, but attempts to prevent its recurrence have led to uncalculated consequences. Doctors and dentists have become afraid to talk frankly about their depression, anxiety or burnout to psychologists, counsellors or their colleagues and friends, just in case they have publicly announced conditions placed on their registration, or they are rendered unfit to practice and hence cannot work at all. This has driven struggling professionals into a lonely, silent and fearful ‘underground’, as they hold their psychological distress close to their chest. The head of the medical board of Australia, Dr Joanne Flynn, has admitted that the thresholds for mandatory reporting have been widely misunderstood.[17] The Medical Board took very little care to address this until their gross deficiencies were exposed by the media. The outcomes of this blatant mismanagement, in terms of impact on suicide risk, have not been reported.

  • Doctors and dentists tend to be outcome driven, high achievers.[18, 19] This is a substantial problem when working with the human body and human beings, which are by nature highly unpredictable. The most carefully and skilfully conducted procedure may fail, simply because there are factors that cannot be controlled. Perfectionists (common in both professions) struggle with this reality. Training in both professions exacerbates this problem. It values narrowly measured clinical success above all else, and colleagues openly judge each other by outcomes. ‘Failure’ is not tolerated. So when errors and failures occur, as they must, it erodes the sense of worth of the doctor/dentist who is utterly dependant on constant success for any sense of worth they have. A tendency to depression, anxiety or despair is intensified.

This is a non-exhaustive list of the many factors that impact on healthcare professionals. The demoralising and protracted training, and the retribution based medico-legal complaints handling process have not been touched upon because each one is worthy of an article in itself. When all of these factors are taken into consideration it is little wonder that suicide becomes a ‘reasonable’ and ‘sensible’ option to a struggling person who believes they have nowhere to turn. In the imagination of a demoralised doctor, their death is a blessing to a world they perceive to be better off without them.

As a dentist, I have been touched by two suicides and witnessed the unmeasurable outfalls that their deaths produced. In one case, a skilled medical specialist and member of my family walked away from his wife, teenage children and his life, disappearing into the bush. He was never seen again . . . no body was found to be buried. His wife, children, mother and siblings live on; nothing can balm their grief. His shocked colleagues talked around his death – mature, successful men who could not find the words to broach the subject.

In another instance, I worked in the practice of a man who took his life with one of his favourite hunting guns. His staff and patients bore the grief and shock, as the gossip of his ending spread throughout town. Grizzled old men cried over his loss. Everyone puzzled over why such a well-liked, handsome and outwardly successful man would choose such a violent ending. It was a nightmarish environment to work in. His death sat like a spectre in the corner of the room, dominating everyone’s spoken and unspoken thoughts; a wound that could not heal.

This reveals that the suicide of a doctor or a dentist has far reaching consequences that the statistics cannot begin to measure. It devastates their families, filling their lives with an unanswerable “why”. It impacts profoundly on colleagues, making painfully real the consequences of ignoring depression and anxiety.

It profoundly affects and destabilises their patients and the whole community in which they lived and worked.

For if these people – who are held in the highest regard and respect, who are deemed to be highly intelligent, skilled and trained to the highest order, and who understand the intimate workings of the human body – are not able to develop stable mental health and are not able to recognise the danger signs and seek appropriate assistance, what hope is there for the rest of us?

Right now, the hot topic in medicine is resilience training, as though the building of hardier doctors will stop the suicides. It is hard to say whether dentistry is better or worse off – resilience is not even discussed in the thick atmosphere of denial that pervades this profession. Developing resilience in people is like trying, too late, to reinforce the foundations of a completed building. Even the best result will always be a poor attempt to compensate for the strength that ought to have been considered and designed in, well before a brick was laid.

To make doctors and dentists resilient has become a neat way to avoid addressing the whole failing system of medicine and dentistry, from education, and overburdened systems, through to the challenge of retirement and the emptiness this can bring.

All we are attempting to do is push the problem back onto the practitioners and produce people who yield more before they break; we blame them for being too weak and use their bodies and minds to cushion the entrenched structural failures.

We must extend our gaze wider and penetrate deeper to find the roots to this problem. Systemic change is essential, but at the current rate of reform, little will be seen in our lifetimes if we wait for the systems to catch up.

For true and lasting change to occur it must take place from within and crucially, without the professions. But first we have to be willing to see the scale of the problem and its impacts in their entirety.

  • Healthcare regulators will need to evolve themselves from draconian overseers with their inadequately executed mandate of ‘protecting the public’, into organisations that care for their practitioners and the public equally. There is seemingly no likelihood of this happening within the next 10 – 20 years; even public government Inquiries have yielded no understanding of consequence in these regulators, and no will to change. It is up to members to unrelentingly call for change.

  • Doctors and dentists themselves will need to become far more aware of and honest about their state of being, and far more willing to call out the systemic problems that load them with unacceptable levels of tension. They need to stop normalising their stress and angst, and look at the results of the judgement they wield against themselves and each other. They also need to take personal action, and realise that the world does not end when they admit how tired, anxious and stressed they have become. They do not need to bury their feelings under a toughened mantle of resilience, rather develop the honesty that allows them to value their sensitivity as an indicator that something is wrong and needs to change. They will also need to be far more open and proactive with each other.

In too many practices, doctors and dentists watch from afar as their colleagues enter into a physical and/or psychological nosedive. Reception staff and dental assistants do the same, withdrawing when stepping forward is called for. Denial, it seems, is easier than overcoming embarrassment and asking how a person is going, and do they need support? It is incredible how rarely this level of care occurs between healthcare professionals and within practices – the attention they give to patients they deny each other. Perhaps this stems from the fact they deny this level of care and attention to themselves. It is aided by an overwhelming sense of shame in the face of struggle that is not innate, but it is common to too many people.

If we want to get very real about the problem of doctor and dentist suicide, we also need to look to a time well before that person became a healthcare professional, and before they entered university. The nature of a doctor or dentist is formed early on; the ambition, the perfectionism and dependence upon success for the attainment of self-worth are well entrenched before the training starts.

This harks to the way we raise our children and educate them, the way we fill them with images of how they must be in life and what they must attain to be regarded as worthy. Every person is told what success means, and they are not allowed to find the truth (or not) of this for themselves. We demand high marks, expect nothing less than straight A’s and a guaranteed path to university admission. Medicine and dentistry draw from the highest-ranking students, selecting what is commonly and unhelpfully referred to as the Type A personality; the sort of people who place high levels of demand upon themselves and cannot settle for less. The fact that this is unrealistic and produces self-harming behaviour shows that this is not a natural way of being, nevertheless we have geared the entire education system towards normalising and championing competition, damaging perfectionism, and complete lack of care for each other.

The price for this is paid society-wide.

To stop this process seems insurmountably huge, almost impossible. Where do we even start? How can we even imagine that the band-aid of resilience could impact on the problem?

We have all invested deeply in and disempowered ourselves to the very systems that are harming some of the most successful, astute and intelligent people in the world.

Are we willing to see that doctor and dentist suicide is the outward sign of the failure of these human made structures? It seems that for now doctors and dentists are canaries in the coal mine of human life. They sit at the extreme end of the spectrum – their suicides not just highlighting the failures in the healthcare and education systems, but in the entire system of human life.

Are we, as individuals, humble and wise enough to apply ourselves to the slow and steady turn, what can only be called the re-turn, to a simpler, more honest and loving approach to ourselves, to each other and to life as a whole?

The fact is that systems do not lead change, people do. As people change, the systems must follow.

It is beyond the scope of this article to offer every answer to this immense dilemma. Nor does it need to when this website offers the keys to all that can and must be done – every stepping-stone on the path to restoration of a whole, loving and true human being is on offer here. Far from the unrealistic, aspirational and callous solutions that simply are not working, this site offers a rich and practical resource from which every person can draw. Slowly and steadily applied, these principles bring the change we yearn for, in a true and sustained way.

Whether we choose to pay attention and apply these offerings to our life is entirely up to us. But when we consider the depth of suffering that is experienced by our doctors and dentists – the people whose role it is to care for others – it is clear that the current standards by which human life operates are not working.

Dare we ignore this pain and suffering, and keep going as we are? Or do we embrace steady unfolding change for the benefit of all?

Where to get help

Doctors Health Advisory Service

  • In NSW and ACT call 02 9437 6552
  • In Victoria and Tasmania call 03 9495 6011
  • In Queensland call 07 3833 4352
  • In NT and SA call 08 8366 0250
  • In WA call 08 9321 3098
  • In NZ call 0800 471 2654

Beyond Blue help line 1300 22 4636

Lifeline Crisis Support and Suicide Prevention 13 11 14

References:

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    Anon, (2017). Available at: https://www.sbs.com.au/ondemand/video/961485891867/insight-s2017-ep16-critical-care [Accessed 7 Aug. 2017].

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    Arlington, K. (2017). [online] Available at: http://www.smh.com.au/national/health/suicide-in-the-medical-profession-if-were-not-well-how-can-we-look-after-our-patients-20170531-gwh7iy.html [Accessed 7 Aug. 2017].

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    Worthington, E. and MacKenzie, P. (2017). Doctor suicides prompt calls for overhaul of mandatory reporting laws. [online] ABC News. Available at: http://www.abc.net.au/news/2017-04-13/doctor-suicides-prompt-calls-for-overhaul/8443842 [Accessed 7 Aug. 2017].

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    Kirkey, S. (2017). Wounded healers. National Post. [online] Available at: http://nationalpost.com/features/wounded-healers [Accessed 8 Aug. 2017].

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    Milner, A., Maheen, H., Bismark, M. and Spittal, M. (2016). Suicide by health professionals: a retrospective mortality study in Australia, 2001–2012. The Medical Journal of Australia, 205(6), pp.260-265.

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    Elliott, L., Tan, J. and Norris, S. (2017). The Mental Health of Doctors - a systematic literature review. [online] Resources.beyondblue.org.au. Available at: http://resources.beyondblue.org.au/prism/file?token=BL/0823 [Accessed 7 Aug. 2017].

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    Dhas.org.au. (2017). Doctors' Health Advisory Service - Telephone Help Line to offer personal advice to practitioners and students facing difficulties. [online] Available at: http://dhas.org.au [Accessed 8 Aug. 2017].

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    AMA NSW. (2017). Dr Chloe Abbott: Champion For Young Doctors. [online] Available at: https://www.amansw.com.au/dr-chloe-abbott-champion-for-young-doctors/ [Accessed 7 Aug. 2017].

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    Aubusson, K. (2017). 'She was eaten alive': Chloe Abbott's sister Micaela's message for the next generation of doctors. SMH. [online] Available at: http://www.smh.com.au/national/health/she-was-eaten-alive-dr-chloe-abbotts-sister-micaelas-message-for-the-next-generation-of-doctors-20170704-gx4jt3.html [Accessed 7 Aug. 2017].

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    http://www.smh.com.au/queensland/i-didnt-see-it-coming-wife-of-brisbane-doctor-writes-letter-about-his-suicide-20170511-gw2ef2.html

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    Sancho, F. and Ruiz, C. (2010). Risk of suicide amongst dentists: myth or reality?. Int Dent J, 60(6), pp.411-8.

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    Lange, B., Dunning, D. and Fung, E. (2012). Suicide rate in the dental profession: Fact or myth and coping strategies. Dental Hypotheses, 3(4), p.164.

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    Gawel, R. (2017). Suicide and Dentistry: Myths, Realities, and Prevention. [online] Dentistrytoday.com. Available at: http://www.dentistrytoday.com/news/todays-dental-news/item/1098-suicide-and-dentistry-myths-realities-and-prevention [Accessed 7 Aug. 2017].

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    McIntosh, W., Spies, E., Stone, D., Lokey, C., Trudeau, A. and Bartholow, B. (2016). Suicide Rates by Occupational Group — 17 States, 2012. [online] Centres for Disease Control and Prevention. Available at: https://www.cdc.gov/mmwr/volumes/65/wr/mm6525a1.htm?s_cid=mm6525a1_w#T1_down [Accessed 7 Aug. 2017].

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    Bismark, M. M., Morris, J. M. and Clarke, C. (2014), Mandatory reporting of impaired medical practitioners: protecting patients, supporting practitioners. Intern Med J, 44: 1165–1169. doi:10.1111/imj.12613

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    Smith, P. (2017). Mandatory reporting needs reform. [online] Australian Doctor. Available at: https://www.australiandoctor.com.au/news/news-insight/mandatory-reporting-needs-reform [Accessed 8 Aug. 2017].

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    Are mandatory reporting laws a barrier to help doctors with mental health issues?, (2017). [TV programme] Insight: SBS.

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    Sanbrook, M. (2017). Why Doctors Kill Themselves - Battling The Dark Side of Medicine. [online] Psych Scene Hub. Available at: http://psychscenehub.com/psychinsights/doctors-kill-battling-dark-side-medicine/ [Accessed 8 Aug. 2017].

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    Myers, M. (2011). Physician Suicide and Resilience: Diagnostic, Therapeutic and Moral Imperatives. World Medical Journal, 57(3), pp. 90-97.

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MedicineExhaustionSelf-worthStressIll healthSicknessBurnout

  • By Dr Rachel Mascord, Dentist, writer and observer of life

  • Photography: Joseph Barker

    To sketch, paint and question life. To cook, laugh and wonder why. To hug, hum and appreciate the sky, to look into another's eyes. These are some of the reasons Joseph loves life and is inspired to contribute to this amazing site.