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“Four of my colleagues have died of suicide. It’s horrible, particularly the young people just starting off in their career.”
“In my region, I know of five GPs [who] have died by suicide in the last 20 years.”
“There was one morning I honestly thought it would be easier if I was just dead. I reported my passive death wish to OT but it was dismissed and I was deemed fit to keep working. It was hell. I would be dead if it wasn’t for my mother.”
These are just some of the comments of doctors that the Medical Independent (MI) spoke to for this article on suicide in the medical profession. A complex and sensitive topic, every suicide is an individual tragedy underpinned by unique personal issues and circumstances. However, it is well established that the rate of suicide in the medical profession is significantly higher than the general population and is one of the highest of any professional occupation.
So why is this and what is being done in Ireland specifically to address the issue?
Contributory factors for the higher suicide risk in doctors include perfectionist personalities that are unforgiving of error, medical workplace stresses and the potential for extreme burnout, higher rates of relationship breakdowns, barriers to care, including the stigma and shame of asking for help, and, importantly, the prevalence of often untreated mental health issues.
As well as being more likely to attempt to take their own lives, doctors are much more likely to complete the act, given their medical knowledge and access to means, one expert in the area pointed out to MI.
Although there is plenty of international research on the issue, there is no Irish data. One US study suggests the overall suicide rate among doctors is between 28 and 40 per 100,000, compared to 12.3 per 100,000 in the general population, while another US study put the rate for female doctors at 2.5-to-four times that of women in the general population. Around 400 doctors die by suicide annually in the US, the size of a large medical school class, every year.
Last year, 392 people died by suicide in Ireland, according to provisional data from the Central Statistics Office (CSO), which declined a request from MI to provide a breakdown of its statistics to show how many were medical practitioners.
A CSO spokesperson said the Office was not completely satisfied with its healthcare profession coding and as the numbers involved are so small, it felt releasing a breakdown of healthcare staff, even over a ten-year period, could potentially reveal the identity of some who had died this way.
However, Dr Ide Delargy, Clinical Lead of the Practitioner Health Matters Programme (PHMP), believes that Irish data on doctor suicide rates is needed to see how we compare to other countries and to help efforts to address the issue.
“We know doctors have higher suicide rates than the general public and other professions and any interventions that can reduce that rate have to be attempted. What we don’t have in Ireland are statistics, so we have no baseline; we don’t know the numbers, so any knowledge we have around doctor death is anecdotal and it is likely to be an under-recording,” according to Dr Delargy.
She added that she had spoken to Consultant Psychiatrist Dr Justin Brophy, former advisor to the HSE’s National Office for Suicide Prevention (NOSP), about the need to collect such data, which could help determine if any impact has been made as a result of the current interventions being provided.
Dr Brophy confirmed to MI that the Health Research Board is currently funding research on health professionals and suicide in Ireland and it is hoped to have the relevant data in the next few years. He pointed out that there is nothing to suggest to date that Irish doctors are more at risk of suicide than their international counterparts, despite the highly pressurised working environment in the Irish health system with its current recruitment and retention problems.
However, he acknowledged the significant strain this situation is putting on our medical workforce.
The particular health behaviours of doctors are a key risk factor for suicide — they tend to not practice what they preach with regards to minding their own health, noted Dr Brophy, who is also Chair of the Forum of Irish Postgraduate Medical Training Bodies.
He pointed out that doctors are more likely to experience common mental health issues such as depression, anxiety, bipolar disorder and substance misuse, but are often less likely to seek treatment.
Depression in high-functioning individuals like doctors is harder to diagnose and easier to miss, with potentially tragic consequences, according to Dr Brophy.
International research has confirmed that the rate of depressive disorders among healthcare workers is over twice that of the general population. In a survey of almost 8,000 US surgeons, 30 per cent screened positive for symptoms of depression, with rates of depression increasing as workload increased. In a follow-up article, the authors noted that 6.3 per cent of these doctors had experienced suicidal thoughts in the previous year, but just 26 per cent of those were seeking professional help. Making a medical error was significantly associated with suicidal thoughts.
A recent Irish study of 1,750 hospital doctors in Ireland led by Dr Blánaid Hayes, Research Department, RCPI, and published in BMJ Open, found that over a third of the surveyed doctors (35 per cent) had experienced psychological distress, and severe/extremely severe symptoms of depression, anxiety and stress were evident in 7.2 per cent, 6.1 per cent and 9.5 per cent of participants, respectively.
A UK study that analysed 38 doctors’ suicides over a three-year period found that most were suffering from a psychiatric disorder at the time of their death, with depression the most common diagnosis.
“I think there is less attention paid to the mental health of doctors, notwithstanding their workplace pressures,” Dr Brophy said.
“It is a fairly newly-acknowledged issue in the profession, and while all the professional bodies are moving more into the wellbeing and health protection of doctors, there is still a fundamental difficulty for doctors to recognise their own healthcare difficulties, because they are so blinkered in regards to their own health; they don’t see what is under their nose. And the stigma and fear in relation to the declaration of mental ill health, no matter how normal and how routine, is that it will somehow damage them professionally. So doctors tend not only to under-recognise, but they don’t seek help sufficiently or through normal channels. That said, I think there is growing awareness of the Practitioner Health Matters [Programme]. I think it needs to grow and will grow further.”
Some doctors told MI that their experiences of seeking help from their employers and superiors were very poor, and they were essentially told ‘to get on with it’. Dr Brophy said while he was aware of such cases, he felt it was important to stress that this is not the norm. “There are very good colleagues looking after people in an exemplary fashion but it still does happen that doctors get a very poor response from colleagues and that is appalling when that happens, as people have no idea how vulnerable a person is at that point, how brave they are to have signalled that, to have trusted somebody. That is a huge act of trust. And for that to be dismissed is worse than crushing; it is actually dangerous, as that person can pull back from help-seeking and not trust others and themselves and lose faith in the professional services that are available. I think if someone has that experience, the Medical Council should know of it. It is poor professional practice if that happens.
“If a colleague is on your team and asks for help, you are always a doctor in that capacity; you are not just a supervisor or a colleague. You have serious clinical responsibilities and to abdicate them is very serious.”
Dr Justin Brophy
The key to the matter is being aware of and sensitive to colleagues’ mental health and mental wellbeing, Dr Brophy maintained. “It is not about being alert to suicide risk; you can’t live your professional life wondering about suicide risk in colleagues. But you can live your professional life being sensitive to the professional wellbeing of yourself and colleagues. That is the real message… the smallest message of support and encouragement from a colleague is so important and so valued. People don’t realise how much it is needed and how effective it is.”
‘In my case I was very lucky to come out the other side’
Dr X is a senior doctor who attempted to take their own life some years ago. They spoke to MI anonymously about their experiences and thoughts on the issue.
“In my case it [suicide attempt] was triggered by two things — a marital breakdown, which started a cascade where I lost my job and then access to my family, my house and assets. Then I ended up working somewhere where I didn’t want to work, I was overworked and then that brought me to that decision [suicide]. Also, when you go down that path, you are likely to come to the attention of the Medical Council and the fear of being exposed by the Council, of being struck off. That would be the last straw. So in my case it was a cascade, but the trigger was the marital breakdown.
“There is a misconception in the media about suicide. It is not an emotional decision; it is a calculated one. You calculate the situation and come to a clinical decision that it is an option that you can take. That was the case for me. It was a rational decision that any rational-thinking person would take in that moment in time, I believe. It was a relief when I made that decision, that I had a choice and I could work towards that choice. At that stage, you hide it, as you don’t want anyone to take that choice away from you.
“Most doctors don’t tend to seek help. And doctors have access to painless suicide. That is very important, because you know exactly what you need to do, and you can do it without failing and relatively painlessly. That is I why I think doctors choose suicide more often — because they have access to means to do that painlessly.
“Another factor, which isn’t really talked about that much, is that doctors have a very inflated ego I think, myself included, due to the positions we hold and the salary and so on. So when you suddenly lose your ego, you lose your self-image and I felt when I lost my ego, there was no point [in continuing]. Faced with a big fall from grace, losing your life doesn’t seem as important as losing your ego at that point. So with people who are not so narcissistic, they wouldn’t get that self-loss, I think. Fear of being struck off was what pushed me in the end.
“In my case, I did go through with it but I survived, I had a miscalculation and was admitted to hospital. I’m not sure now thinking back, was that intentional or not, but I had full intent to do it. I had disposed of my assets and everything and had it carefully planned and I felt a big relief about that. I was very disappointed to have failed, because I felt I had lost my chance.
“In my case though, I was very lucky. I started a new relationship very shortly after and had a family and haven’t looked back since. I didn’t think that was a possibility before [the attempt] — you can’t see the options that are there.
“I have to say the Medical Council Health Committee were very good to me. They offered me 100 per cent support. They didn’t strike me off; they gave me the chance to come back to work and back to my normal routine. I have a family now and my job and financial stability. So those were the two most important things; once I got them back, I got my ego back.
“I think employers in general fail to act in these situations. I had been in extreme distress for a long time beforehand. It took me four years to reach the stage where I was suicidal. I was clearly under a lot of stress and strain. The hospitals are unable to detect the red flags and while doctors will hide them, the markers are there — things like constantly being tired at work, working very long hours, staying late, not wanting to go home or having a home to go to, sleeping rough at work. The mental illness comes first; the workload doesn’t trigger it. To me, work was a relief from reality, from my situation where I had lost family, home, money. But the work I was doing was so excessive, it should have alerted someone that there was a problem. Employers don’t act or are afraid to. I’ve seen it with other doctors.
“I think like pilots, doctors should be monitored and have check-ups and their personal situation monitored because patient safety comes before doctors’ confidentiality. Behind serious errors, more often than not, there is a personal problem. That may be controversial, but that is what I think.”
If you have been affected by any of the issues raised in this feature, please contact the PHMP through www.practitionerhealth.ie or Tel: 01 2970356 or the Samaritans at Freephone 116 123.
Fitness to practise
Fear of professional repercussions is another key reason doctors are often reluctant to seek help, while being under the attention (ie, investigation of a complaint) of a regulatory body is known to be a risk factor for suicide in doctors.
While again there is no published Irish data on this phenomenon, in a study of 38 doctors who took their own lives in England and Wales between 1991 and 1993, 71 per cent had significant problems at work. Seven were facing complaints and in five cases, this appeared to be a key factor leading to suicide.
The UK’s General Medical Council (GMC) has published a report based on a review of cases where doctors took their own lives while under its fitness to practise procedures between 2005 and 2013.
During the period under review, there were 28 reported cases in the GMC’s records where a doctor died by suicide or suspected suicide while under their investigation procedures.
The case reviews showed that many of the doctors who died by suicide suffered from a recognised mental disorder, most commonly depressive illness, bipolar disorder and personality disorder. A number also had drug and/or alcohol addictions. Other factors that may have contributed to their deaths included marriage breakdown, financial hardship, the involvement of the police and the impact of the GMC investigation. The report made a series of recommendations to address the findings of the review and try to reduce the risk of suicide in doctors under investigation.
In response to queries from MI about what supports it provides and any planned research in the area, the Irish Medical Council said it was aware that dealing with complaints, clinical negligence claims, disciplinary matters and other medico-legal issues can add considerably to doctors’ stress levels. “With this in mind, we have undertaken research in the Medical Council, gaining feedback from doctors regarding their experiences to inform our planning in appropriately supporting doctors into the future. This is due to be published in 2019.”
The Council has produced a guide and online resource to help doctors dealing with complaints and undergoing the complaints process, with a case officer system to support doctors through the process also in operation.
The Council told MI it is currently engaging in a joint initiative with the PHMP, as part of the NOSP’s Connecting for Life strategy, to explore what processes could be established or adopted to enhance the capacity of professional bodies to support professional suicide prevention efforts. Last September, this newspaper reported that the Council was reviewing its written communications to registrants in the context of doctor health and wellbeing.
The Medical Council’s Health Committee also specifically supports and monitors individual doctors who have medical issues that may impair their practice or harm patients. Generally, doctors are referred directly or reported to its service.
Doctors really fear coming to the attention the Council and being referred to the Health Committee, Dr Brophy acknowledged, but he stressed that it does its utmost to restore the health of ill doctors and get them back to work safely.
“While in theory you only get to the Health Committee because of some concern in regards to your practice, if you do get referred, you are in very safe and very good hands, that is important to say, and doctors need to know that” (see panel for one doctor’s experience with the Council’s Health Committee).
There are many more routine avenues of help and treatment for doctors in distress, Dr Brophy noted.
Firstly, these should include doctors’ own healthcare practitioner, while the HSE and training bodies all have, or are in the process of putting in place, practitioner wellbeing programmes and supports, he said.
There is also the dedicated services of the PHMP, which provides free, confidential treatment for health professionals (doctors, dentists and pharmacists) in Ireland who have mental health or addiction issues, and is keen to raise awareness of its existence.
NCHDs, consultants and GPs made up 75 per cent of referrals to the programme. The PHMP helped 48 practitioners in its second year of operation in 2017, a 53 per cent increase on the 47 people it treated over its first 18 months of operation during 2015/16.
During 2017, 28 practitioners presented with mental health issues, 14 with substance misuse issues, while six presented with both. Depression, anxiety, stress and burnout were recurring issues for all those with mental health problems.
Dr Delargy confirmed the numbers availing of the PHMP’s services again doubled in 2018, with approximately 100 doctors receiving assistance.
She stressed that the programme is strictly confidential, is not aligned with employers, the Medical Council or any other agency, and is funded by the professional training and representative bodies.
“We offer a safe, non-judgmental space where people can come to discuss their issues without fear of repercussions in terms of career progression or employment or consequences with the Medical Council,” according to Dr Delargy.
“We have developed expertise in managing doctors in difficulty, as doctors can be difficult to treat and manage.
“While we are cognisant of the fact that all doctors should have their own GP, and should have occupational health available to them through their employers, we know with mental health and addiction there is a shame and stigma attached to having to declare those types of problems, which can prevent doctors from using these services, but we offer a confidential space where they can say that safely — something different to some other services.”
She confirmed the PHMP has treated “a number of doctors who had suicidal ideation and were highly distressed”.
“I would confidently say we have saved some lives in that regard… Being able to intervene with people who are suffering in that way has helped prevent them from taking the more serious option of suicide. So the PHMP has a serious role in trying to address practitioner suicide.”
In May 2018, the PHMP also partnered with the NOSP to launch a pilot initiative to raise awareness of mental health and suicide risk in the healthcare sector.
The initiative utilised the Green Ribbon Mental Health Campaign as a platform to reach specifically into the healthcare sector to signpost and encourage referral for mental health difficulties and suicide risk to appropriate services and affirm help-seeking and hope.
Dr Delargy encouraged any doctors who feel they could benefit from the PHMP’s services to get in contact, and for doctors to make any colleagues they feel to be in distress aware of its services. She is particularly keen that doctors do not feel they have to wait until they experience a major crisis to come forward and ask for help: “We are really promoting early intervention. You can come forward — don’t wait, don’t delay, don’t complicate matters; seek help early. We can help you.”
Progress since #24nomore?
Dr Anthony O’Connor, Consultant Gastroenterologist, Tallaght Hospital Dublin, triggered the #24nomore campaign against excessive NCHD working hours back in 2013, after a column he wrote in MI, which followed the suicides of two trainee doctors who had been working extremely long hours in a Dublin hospital. Has anything changed since then does he think?
“It is a not a job anymore that is conducive to having good mental health. The effect on a hospital when a young doctor in particular takes their own life ripples around the place and maybe that department does something, but nothing changes. Everything just carries on as it was…
“Yes, we did do a lot around the time [of #24nomore], we got shifts shortened which was a good thing and people are maybe more able to think and talk about things but I certainly have to be convinced really that for all the good work and studies that have been done by people like Dr Ide Delargy and Dr Blánaid Hayes, I have to be convinced that anybody really cares…I think a lot of people are quite heedless about how their decisions and actions might impact on doctors’ mental health.”
Like many doctors he is critical of the naming of doctors who are undergoing fitness to practise hearings or who have had mental health issues in the media, and he feels there is a lot of hostility towards doctors in the media and the general public currently, with little thought to the impact on their mental health.