Our doctors are not immune to burnout and depression
The death by suicide of two junior hospital doctors in Ireland in 2013 shocked the medical community and may have come as a surprise to the general public. After all, doctors are regarded and powerful and resilient, well educated, well paid and with excellent prospects of promotion. Apart from individual tragedies that make the headlines, there is little information on the mental health of doctors practising in Ireland and even less on their risk of suicide. The Royal College of Physicians in Ireland is currently engaging in a large national study of the well-being of hospital doctors.
The first part of this study was published last October in BMJ Open. Conducted using face-to-face interviews, it found that consultants were most concerned with the quality of healthcare management and its impact on service. They were also concerned about the quality of care they provide and they felt undervalued within the negative sociocultural environment that they work. Doctors in training had broadly similar concerns and they struggled with the interface between career demands and personal life. This work is ongoing and in a study to be published, hopefully later this year, Dr Blanaid Hayes, occupational health physician at Beaumont Hospital and Gillian Walsh, research manager, will provide hard data on the extent of burnout, depression and anxiety in a sample of 3,000 doctors practising in Ireland.
In other countries such data is already available. In New Zealand, a study in 2009 found that the one in five consultants experienced high burnout levels; working long hours and having low job satisfaction were associated with this. On the other hand, the authors reported that: "An unexpected proportion of consultants experience robust emotional well-being and healthy work engagement". In a more recent study of all psychiatrists in New Zealand, stress and burnout were measured in 2005 and 2008. One third scored high on burnout at the two time points but in Canada (2001) a much higher proportion (80pc) scored positively.
While burnout is important, depression among physicians is an even more important issue since it is associated with suicide. The lifetime risk of depression among female and male doctors in Britain is between 10 and 20pc and not very different from that of the general population. In Canada, the figure is 23pc. The impact of depression among doctors can have serious personal consequences, but also impacts on patients. For the person attending a doctor who is suffering with depression, there is a risk of mistakes being made. An otherwise empathic doctor may appear brusque and antagonise the patient. The doctor may turn to alcohol or substances and the ultimate consequence may be suicide.
Doctors, dentists and vets have the highest suicide rates among the professions. This is especially true of female doctors, who are uniquely at risk. Rates are the same as male doctors and 130pc higher than the female suicide rate in the general population. Why female doctors are especially at risk is speculative but may be related to the struggle to balance family and professional commitments. More generally, the risk factors for suicide in doctors more generally are multiple. Like everybody there are some who have an inherent risk of depression that is unrelated to their profession. Then there are the long hours that doctors work, although these have to some extent been mitigated by the European Working Time Directive which limits the number of hours worked at any one time and is now operational in Ireland.
The sense of helplessness that many feel in the face of poorly considered management decisions and the pressure to increasingly conform to treatment and risk protocols imposed by management lessens one's sense of agency. Patients' and families' expectations, often unrealistic, can lead to self-blame among doctors, while the ever-present threat of litigation that hovers over every doctor is too much for some.
If and when doctors seek treatment for depression, they may be under treated. From a misplaced sense of collegiality, inquiries about substance misuse, about marital or other relationships, and about difficulties with their practice may be eschewed, while doctors as patients may themselves be less than forthcoming. In Ireland, our health service is in tatters and there are deep veins of dissatisfaction within the medical profession with the state of affairs. For that reason alone, all Irish doctors are working in an environment that increases our risk of a range of mental health problems.
The study by the College of Physicians is timely and the results of the next phase will provide information that will assist us in managing depression among our colleagues. Doctors, contrary to public perception, are not invincible.
Health & Living