NOSP in talks with Medical Council

James Fogarty reports for the Medical Independent from the College of Psychiatrists of Ireland Spring Conference 2018.

Physician suicide is catastrophic for not only the individual doctor’s family and friends, but also for their patients, the Spring Meeting of the College of Psychiatrists was told. At the meeting, which was held in Athlone, Consultant Psychiatrist Dr Justin Brophy stressed the need for doctors to care for one another, especially in the context of challenging working environments.

During his presentation on doctor suicides, Dr Brophy, who is clinical advisor to the National Office of Suicide Prevention (NOSP), said there are about 400 physician suicides in the US every year, the equivalent of one medical school output per annum.

“There is a growing awareness and alarm globally around this,” he said, citing efforts by the Association of American Medical Colleges, JAMA, and The Lancet to address the escalating crisis of depression, burnout and suicide among doctors.

Doctors, as well as other medical professionals, are at high-risk of suicide, as they have both the knowledge and access to means to take their lives.

According to the proportional mortality ratio (PMR), male doctors are at a high-risk of suicide; however, this is contradicted by the standardised mortality ratio (SMR), which indicated that the risk was low.

Yet according to a 2008 paper by Meltzer et al, there was a higher incidence of suicide among female health professionals in the UK. In Australia, a higher suicide rate in female versus male doctors was also found in 79 doctor suicides in Australia. The suicide risk for female doctors is a particular problem, the meeting heard, as they had significantly higher rates than those in the educational profession.

More recent data from Australia has indicated that the suicide rate may be rising, in both male and female doctors, to such an extent that both genders may have a greater suicide rate than the general population. Again this research indicated that there was a disproportionately higher risk in females.

For psychiatrists, there was perhaps slightly higher risk, said Dr Brophy, but he added that the specialty does very well in surveys of general professional happiness.

He also cautioned that the profession needed to be mindful of retired colleagues and that the number of suicides among healthcare professionals as an occupational group as a whole was not known.

Medical students are also at risk, with suicide being the most common cause of death for the group after accidents.

“That extends to interns as well,” he said. Prospective medical students and residents were also very unlikely to disclose a history of depression because of the fear of how it might impact on their career.

The issue of burnout and doctor mental health received widespread media coverage following the IMO conference, where it was estimated that one-third of doctors in hospitals were suffering from burnout.

Several factors contribute to this including: Workplace bullying, oversight and scrutiny, coupled with an increasing workload. Also, greater bureaucracy means that doctors were spending more time at the ‘screen’ than with their patients.

This was worrying as the “one thing that protects us in this maelstrom is patient contact”, said Dr Brophy.

Other factors include the immersion in human suffering, an ever-present part of a doctor’s work, as well as the “dread” of making mistakes. Debt is also a growing issue for doctors, who are borrowing to fund their medical education. This was particularly relevant to graduate entrants.

“Ironically the EWTD [European Working Time Directive] hasn’t necessarily improved job satisfaction in graduates,” said Dr Brophy. “There is a disruption to continuous patient care and seeing people through an episode of illness.”

While he stressed that he is not a supporter of long working hours, “the idea that we can pop in and pop out of medical care in a shift-work paradigm is not helpful to our mental or physical health”.

Doctors also have a number of occupation-specific hazards and doctors at job-transition points are especially exposed to risk. Authors have found that most resident suicides took place during the months of July to September and January to March

Career progression obstacles can also trap doctors in unhealthy working environments “because people get into a sense of jeopardy and they tolerate and take on more stress”. Many doctors are also very pessimistic of recovery, particularly non-psychiatrists.

Furthermore, complaints to the Medical Council or employers can take the joy from medicine and as doctors are very judgemental of themselves, complaints can cause doctors to shut down their emotional availability. It can also lead to avoiding patients “which is the worst thing for us to do”, said Dr Brophy.

“It is in everyone’s interest that these doctors are dealt with compassionately and receive the appropriate support because burnt-out, unhappy, depressed, and compassion-depleted doctors make more mistakes.”

This, unfortunately, can lead to a situation of multiple jeopardy where the physician is being investigated by multiple bodies. Even when resolved, the stigma of complaint can linger a long time.

The UK GMC reported that there were 28 doctor suicides over eight years before the fitness to practise committees, which caused a reform in GMC procedures.

“And we have begun an important discussion under my auspices in NOSP. We’re speaking to the Medical Council, Dental Council and the pharmacy regulator, to try and ensure that investigator processes here meet high and compassionate standards of care for those subject to that.”

Contrary to public opinion, doctors are no more or, no less likely to suffer from depression, anxiety and substance misuse “but sleep deprivation particularly for young trainee doctors is a big driver of mood dysregulation. Depression in high-functioning people is often well-masked and compensated for”.

This means that as doctors are “masters of disguise” when they do reach out for help it is generally in extremis.

Dr Brophy also highlighted the lack of self-compassion and peer-compassion in the medical profession. “We judge ourselves very harshly and we judge our colleagues equally harshly,” he said. “We must look after each other.”

During the question and answer session, the role of the Medical Council as a stressor was highlighted. Dr Brophy again stated that the NOPS is in dialogue with all the medical, dental and pharmacist regulators regarding all of their procedures.

“The councils are open and we intend to begin a detailed process to try and look at not just disciplinary and fitness to practise procedures,” he said. Doctors as a profession just want fairness, “and all we want is that”, he added.