‘If you study even the smallest bit of science, you will realize that, for all practical purposes, we are nothing. We’re basically monkeys on a small rock, orbiting a small, backwards star in a huge galaxy, which is an absolutely staggeringly gigantic universe, which itself may be part of a gigantic multiverse. This universe has been around for probably 10 billion years or more, and will be around for tens of billions of years afterwards. So your existence, my existence, is just infinitesimal…this is such a short and precious life, it is really important that you don’t spend it being unhappy. There is no excuse for spending most of your life in misery. You’ve only got 70 years out of the 50 billion or however long the universe is going to be around.’
Naval Ravikant in Tools of Titans, by Tim Ferris
In the past year I have been thinking about how to help reduce rates of stress, burnout, and suicide amongst doctors, and to increase their wellbeing. As a doctor talking about this issue, I do have a sense of not wanting to make a storm in a teacup. I don’t want to dramatise the situation, as serious as it is. I feel it deserves to be approached with gravitas and pragmatism, without any hint of emotion.
But then, I think, ‘What the f**k? Why are doctors killing themselves?’ It’s a privileged position to be a doctor in the west, no matter which way you look at it. It means that the person has had access to excellent education, has personal attributes to undertake this arduous education, and are, in most cases, guaranteed a job for life, with salaries that are dependable and will provide a secure income. If the doctors are committing suicide, who is going to look after the suffering?
Working in psychiatry, I am faced with suicidality on a daily basis. Suicidality as a symptom of mental illness. Suicidality as an expression of emotional overwhelm and distress. Suicidality with explicable causative factors, and suicidality in the most unlikely of places. The fact is, suicide is one of the saddest plights of the human experience. That one act, or thoughts of, tells a thousand stories of helplessness, hopelessness, guilt, fear, anger, rejection, isolation. It is so contrary to what we consider to be the essence of our human-ness: being hope-finding, meaning-creating, resilience-expressing animals. The act separates us from non-homo sapiens (as far as I know). Something about our exquisitely developed prefrontal cortices which have endowed us with the ability for abstract thought, executive decision-making, and meta-cognition, has also made us vulnerable to states of nihilistic hopelessness.
So why do doctors get to this stage? What are the causes for the preceeding burnout and chronic stress? A recent systematic literature review, reported in Medscape, states that physicians experience the highest suicide rate of any profession, more than twice that of the general population, and over 400 doctors a year suicide in the US. The Australia beyondblue study of medical student and doctor mental wellbeing in 2013 identified that 24.8% of physicians had thoughts of suicide prior to the past 12 months, and 10.4% had thoughts within the last 12 months.
So, here are a summary of what I think are the main factors contributing to chronic stress and burnout, in no particular order:
- Doctors have an inherently stressful job. Buddhist philosophy suggests that our main motivation in our natural state is escaping suffering – which, ironically, it argues, creates more suffering. This helps us to understand and empathise with others if we accept that everyone is just doing their best to escape suffering. We can all probably see this in our lives: we work to have money to avoid going hungry or being homeless; we maintain strong social bonds to avoid loneliness. A doctor’s (and many other professions’, some of whom have similar issues with burnout) job is intrinsically tied to engaging in the depths of human suffering. Day in, day out, the job requires engaging with people’s pain, unhappiness, loneliness, fear, worry, depression, and disappointment.
- Lack of autonomy. Doctors exist in a constant tension between a) the resources available to them from the health provider; b) what a patient wants; c) what a patient needs; d) what a patient can afford, or what a provider will pay for a patient; e) legislative and social expectations of what health should/should not do.
- Complexity of healthcare delivery. Long gone are the days when a patient attends for a straightforward prescription, or for a surgery – or neither if they cannot afford them. A doctor must dance a complex rhumba which involves a multitude of invested stakeholders. These are informed by international, national, and local recommendations and protocols; by the payers for the health service; by the local service’s resources; by the patient’s wishes. And this often requires a decision to be made in a short period of time looking at an individual patient with their unique requirements and biopsychosocial factors affecting their illness experience. The paradox of choice in treatment is increasing at break-neck speed, and humans struggle to keep up.
- Sandwiching. Related to the above. A term I use to describe doctors being caught between patients and the service or provider or political power behind them, and having to mediate that complex relationship.
- Evolving nature of healthcare delivery. Doctors are having to become adept practitioners of a new digital world. Again, instead of dealing with the individual patient in front of her, the doctor now has to refer to, record, and involve a litany of digital material via electronic health records. Whilst the glitches are many as they are embedded, many doctors would agree that it may benefit patient care in the long run. But another layer of administration has been added to doctors’ jobs.
- Leadership. Leadership within healthcare often comes from a) clinicians who have been in the game a long time, but may not have had formal management training; or, b) non-medical managers who transfer management skills from other sectors. I would argue that management does need to be taught, it is not an intrinsic character trait, and I would argue that healthcare is different from most other sectors in that the commodification of health has multiple ethical and moral considerations. This is not to say that these divides are not successfully crossed; but a lack on either front can exacerbate the stressful expectations of doctors.
- Personality types that self-select for medicine. This is perhaps the biggest generalisation here but most good doctors (and we are still working out how to screen that ‘good’ and define what it means), have traits that are associated with high rates of conscientiousness, diligence, integrity, and empathy. These are also traits which are associated with neurosis in its original form: excessive anxiety or obsessiveness. Laissez-faire, non-obsessive doctors tend to come up against issues very early on in their careers which can have negative effects on patient care. These traits emphasise the, ‘I better not get this wrong’, ‘what if XYZ happens? How do I prevent this?’, or, ‘the negative sequelae of this action – or lack of action – could – or could not be – XYZ.’ Essentially, medicine requires working with vast swathes of uncertainty and uknowns, and reassuring a patient in the midst of that, and finding out what can be known, actioning it, and avoiding complications in that course of action.
- Shiftwork. There is no need to reiterate the multiple studies and bodies of evidence which outline how bad shiftwork is for physical and mental health in the long run. Now imagine handling an apnoeic (not breathing) neonate at 3am, or repairing a bleeding aneurysm, or talking down a psychotic patient. The effects are inevitable.
- Work intensity and competing demands. After five to eight years of undergraduate study, doctors embark on a baptism of fire into life as a junior doctor. This can be anywhere from one to four years, which is then followed by training under a specialist pathway (general practice, psychiatry, general surgery, ophthalmology, etc), which can range anywhere from three to 8 years. Many specialties require onerous exams – which must be studied for for months whilst working full-time, and costs thousands of dollars at a time, paid from a trainee doctor’s salary. Resits are incredibly demoralising as doctors have put their lives on hold to study for them. Many will also have research requirements, which may need to be done on top of the ‘day’ job, or may need time away from the training scheme with a reduced salary. Many doctors will be starting a family during this time, which puts a particular pressure on female trainees (in general), who have to decide how much (if any) time to take away from time-limited training schemes. People are also doing other life ‘stuff’ expected in their respective societies: getting on the property ladder, for example. And many have other commitments: carer role for children or a spouse or a parent with a serious illness. All the while working in a job with shiftwork and all the issues listed above.
- The normalisation of chronic stress and vicarious trauma. Finally, doctors are exposed to trauma on a daily basis. This may involve the death of children, or losing a patient unexpectedly, or watching people decline through chronic illness. It can involve seeing people self-harm, and listening to endless stories of every type of abuse under the sun. It can involve hearing about and observing some of the darkest parts of humanity. Unfortunately, the evolution of the culture within medicine has been centuries in the making. There is a hardening and desensitisation expected. The fragile, flimsy line between self-preservation and displaying compassion and empathy is often trodden upon and unrecognisable. People glorify the hours and disasters and trauma and awfulness at times, as a way of coping. Burnt out colleagues, often those who have been in the game a long time, have become so depersonalised and emotionally exhausted themselves that they lack insight into their own dearth of emotional connection. They then externalise anyone else’s difficulty processing something, or a throw away comment about the amount of hours worked, as being a sign of ‘not coping’ and advise them to suck it up because, ‘When I was a junior doctor I worked 110 hours a week.’ I often feel like holding up a mirror and saying, ‘Yes. Yes you did.’ The evidence suggests that even with improvement in absolute working hours for some doctors, that stress and burnout have increased. In light of the above issues, I understand why.
It may sound rather bleak, but my own burnout has receded far enough that I have hope. I believe that human connection amongst colleagues can provide relief and strength. I believe that radical transparency, as described by Ray Dalio, can save us from repeating the closed-up, ever-more-cautious, more overwhelmed by the paradox of choice that the modern medical paradigm presents. I believe that medical culture can change. I believe that its leaders can adapt. I believe that empowered patients can better share the risk and unknownness of their own health and healthcare. I believe that AI and VR can get to a stage that some of the mechanised parts of modern medicine – digital health records, diagnostic algorithms contained in doctors’ heads – can become part of the doctor-patient interaction. Doctors are humans, and their humanness needs to be prized and protected. Patients deserve nothing less when they see their healthcare provider. As Naval Ravikant said, we have so little time in which to live. Let’s make it count, and make it enjoyable.