January 25, 2017

After The Fall - Mental Health and Medical School

I know this is going to be structured in a looser or less coherent way than my usual posts (if they are coherent at all).

What’s prompted me to post is, firstly that I need to get back into the swing of things after a lengthy absence, and secondly that something pretty full-on has been happening.

I mean really, it’s been happening for at least decades if not longer. Healthcare workers and in particular, doctors and medical students, are as a group in a constant state of risk with mental health and susbtance abuse (which often go hand in hand).

(I’ve had my own struggles of course, within the workplace and without, much but not all of it gender related.)

What’s happened recently is that a doctor in Sydney died under tragic circumstances (read between the lines: it is almost certainly what you think it is). It’s someone who I’m not sure if I knew, but certainly I tutored students in that year of {medical school name redacted}, and it is someone who my colleagues and friends have either gone to university or school with.

Around the last couple of years at least two people I know of from the same medical school have turned out to have major substance abuse issues and probably major mental health issues. One of them was a student of mine.

These were highly achieving people at medical school, prize winners, intelligent, though with varying degrees of engagement and various personality traits. My student in particular I could see was lacking stimulation - I made an effort to engage him as best as possible because I knew that his career would either take off dramatically or take a nose-dive. It seems it did the latter, despite my (limited) efforts.

I can’t really say that I was a central figure in any of these people’s student lives. I was just a clinical tutor (and still am, at a different medical school). And honestly, I really liked the clinical school I dealt with, I liked the staff and felt like they gave a shit.

But maybe it was the structure of the course= much of it that it shares with the many other medical schools in Australia and overseas. There’s a list of annual prizes that’s a page long and it’s a highly sought after university. It’s a very competitive environment in some ways, but in others a large degree of self-direction with fairly minimal guidance is the rule these days. University is about learning how to learn, of course, and medical school is part apprenticeship, part scholarship. I don’t think it’s necessarily about lack of academic guidance, but going into such a career, there is a huge degree to which mentoring needs to play a larger role.

For example, much of the death that I have seen as a doctor or a medical student, for example, has been brushed off by other doctors. Sometimes people laugh. How is laughing after a traumatic arrest call where someone dies in any way appropriate? Or you go and certify the death of someone who is your age (23) as an intern with limited experience, and the guy’s head is split open, his brains on show, eye hanging out of its socket, and the only people who will listen and show empathy are the nurses - because actually they have a culture of at least having a (brief and not overwhelming) sit-down-chat-with-a-cup-of-tea after traumatic events like this (note the evidence doesn’t support formal debriefing as such). The sheer volume of death we see as healthcare workers is thought to contribute to mental health outcomes- in particular suicide- due to desensitisation to death and due to PTSD. Appropriate mentoring and leadership needs to exist in regards to this side, rather than it being brushed off as it being just another day’ or a joke or something that you should just get the fuck on with.

Our role as mentors (and as doctors) involves a lot of pastoral care, and there is something emotional and perhaps spiritual that we need to provide our juniors. That I think is one thing that is lacking often.

The pursuit of these highfalutin academic prizes is probably unnecessary too. Some degree of marks is needed so that one can tailor one’s effort level and calibrate how hard one works at university (if you scrape through maybe you need to work harder), but is it really necessary to know that you got an 83% vs an 84%? Is it necessary to get the Princess Duchess Mary III award for medical excellence? How the hell does academic performance correlate to performance as a doctor? I’ll give you a clue: it doesn’t. There is no correlation. There are people who repeated years in med school and failed exams who are eminent and respected professors of medicine and surgery, and prize winners who are expelled from the profession, or who are simply incompetent, and vice versa.

Then there is the transition from school to university. That can be hard. Even many post-graduate students have gone straight from school to a bachelor’s degree to post-graduate medicine. Most of that is unavoidable, and I don’t think that extending the time at university or time to finish is necessarily of any value.

I also think that selection criteria fail to weed out problem doctors- by which I mean those with malignant narcissism (as opposed to healthy or well-compensated narcissism) and sociopathy who actually score higher on interviews than people with normal psychology. I would much rather have a socially awkward or autism spectrum medical colleague who is well supported than someone with a severe untreated cluster B personality disorder who is unlikely to get help, have insight or in the case of sociopaths, who actually get worse with therapy.

Depression and anxiety are such taboo subjects when it comes to doctors, but you know unlike sociopathy, those are two very treatable conditions, and medical school and the medical profession induce depression and anxiety at dangerous levels even in people who are previously pretty healthy. This taboo however makes it very hard for people to get help or to take appropriate time off. People are understandably anxious about seeking help, and are also worried about confidentiality when it comes to workplace counselling. Plus finding time to attend appointments can be very difficult.

Heck, even being LGBTIQ can be taboo. I work in a place where actually most of the LGBTIQ people are very closeted because of workplace culture. I love working here but it was very confronting transitioning at work under those circumstances. Still, it went much better than expected. But now I hear about some really awful things that my peers have to listen to especially because a loud minority of people think they can just mouth off about homo/bi/transphobic bullshit openly.

Then what about work as a doctor? It’s at times brutal, with crushing and unbelievable amounts of stress (having little to no control at times, very hierarchical, sometimes working with unreasonable and abusive colleagues) with very lengthy work hours. On the plus side we don’t work the 80+ hours of week that is standard for US hospital doctors - for the most part (vascular and neurosurgical doctors work these kinds of hours). But we still don’t really have safe work hours across the board. It’s actually probably better if we have more trainees and junior staff and have maybe an extra year of training if needed in exchange for something closer resembling a 40 hour work week and without 14 hour shifts.

Continuing on that subject, the lack of redundancy and sick leave cover is also a big issue. I get the flu almost every year. Almost every year I actually get quite sick for a week every year. How does that impact my colleagues? Quite a lot. There is no cover for me, and I’m a registrar. My intern or resident can’t make enough of the decisions and my bosses aren’t around enough. Unfortunately I’m not easily replaced on days like that. So then people get really angry and sometimes vindictive if one is off sick. That pressure needs to be taken off. The mortality rate for a patient in hospital who gets the flu from a healthcare worker is more than 10% (remember, they’re already sick). We actually can’t afford to be pressuring doctors and other healthcare workers into turning up when they have a communicable illness, let alone worsening their general health and mental health.

I’ll tell you what though- people can become a target of institutional bullying easily if they identify themselves as being at risk’ or having mental health issues. Depending on the workplace of course.

And heck, I know all this and I still sometimes get angry when someone calls in sick all the time. I get annoyed when people under-perform and don’t take the advice to seek help. When people don’t get help or don’t engage with the help offered. When the system makes punishes you if you say you need help (this happens). When someone’s issues aren’t dealt with and they continue to put other people’s careers and lives at risk by proxy not just their own.

And I feel stressed and guilty right now because I don’t know if I could have done anything for my former students and my colleagues. Whether I have contributed significantly to their now completely irreversible situations that are sometimes unsalvageable. And what I should do now.

I think about contacting the {redacted medical school} but here’s the rub:

What will the system do to me as a person highlighting a significant system issue, when the system is dysfunctional enough that it doesn’t tolerate whistle-blowing well?

I suspect that I’m not quite subject to the same set of rules if I’m sort of an outsider and I’m somewhat senior.

But the truth is that I do not know. And I am scared.


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