Saturday, October 28, 2017

Why and How are Doctors and Medical Students so Depressed? And What Can WE Do About it?

The day I got into medicine, was the greatest day of my life. 

I'm sure many medical students and doctors would tell you the exact same thing...

For me it was personal. 

I'd always wanted to study medicine. What better job was there? You could save lives and live in relative comfort your entire life. I'd get to emulate my childhood hero growing up, Captain Hawkeye Pierce from M.A.S.H. 

But after leukaemia struck my life... it became personal. 

I wanted to help people as I'd been helped. It was my doctor's words; that "The Good News Is You're 17 and You Have Leukaemia, but the Bad News is You're 17, And You Have Leukaemia..." and his actions that got me to believe that I actually had a chance in this... It was another patients' words the day before my transplant that really sunk in, and changed my life. Imagine being in a position to do that for people everyday!

My first day in medicine was one of the most joyful of my life. 

I was so excited to finally be in a position to give back, and so delighted to be alongside so many other people who cared just as me. 

But as time went on... things changed. 

For me, and for many of my classmates too. 



As I progressed through the course, I got more and more burdened with work, and more and more dissatisfied, and indoctrinated (pardon the pun) into the collective Group-Think of modern medicine. One which emphasised speed over accuracy, marks over competence. One which measured success through KPIs such as reduced wait times and greater efficiency rather than reduced morbility and morbidity, and higher patient satisfaction and involvement. As I feel many in this profession feel at some point. 


And this in a population who are most educated about mental illness, and the fact that they are illnesses, not just an abstract constructs or "excuses," as many still widely suggest and believe. Somehow still, amongst those with depression or severe symptoms of depression, only 15% of medical students actually get help... For doctors... the rates are even lower

Why is this happening though? 

Aren't these people being paid heaps? 


How I imagined life would be after med.

Aren't they close to services? 


Don't they know the risks of the disease, and how altered biochemistry can alter your very mental state - your very person? 

Well, there are many reasons why. 

Various personality traits and attitudes make doctors more likely to suffer from depression. 

Perfectionism, hints of narcissism in some, compulsiveness in others, martyrism in most, and disparaging views of vulnerability are all commonplace. 
Facing death, watching good people suffer, and losing the battle over and over again also burdens doctors. Burnout from stress affects 45% of doctors, ladies and senior physicians in particular. And as this article puts so poignantly, Osler, the founder of the first American residency program, advocating for equanimity in physicians, was perhaps the largest contributor to all this... 

Many doctors feel that showing weakness is a failure on their part. A failure.

If they're not steady under pressure, how can they serve their patients? 

And that can be a tough burden to bear...

400 doctors take their own lives in America alone.
An entire medical school's worth...

Junior doctors and medical students have similarly sky-high rates of depression and suicide ideation (the 10% figure is a conservative estimate; studies in my nation show , but have the added pressure of exams and the weight of expectations on their shoulders too. 
Furthermore, other factors, such as living on their own for the first time, often overseas for many students (where the added pressure of maintaining a steady income is another burden), high levels of student debt, and the sheer pressure of the course and succeeding itself plagues many students. 

Many of my medical student and junior doctors friends complain about many of the above stresses. Many feel medicine takes over their lives. In a time where they should be out and enjoying their life, many students, as well as doctors, regret not enjoying life more. And many feel disillusioned too. They feel they were misled about what medicine actually was. About the impact they have. About the difference they make. So many of my friends express this in particular. But the toxic, competitive hospital environment, where specialty spots are limited, the medical heirachy is emphasised (and perpetuated by older doctors in an "If I went through it, they should too" manner) and bullying is rife, also pushes many young meddies over the edge. 

Very recently, in my country, Australia, 
3 junior doctors took their lives within one week


One of those young doctors, a passionate advocate for medical students took her own life. 


THREE. YOUNG. LIVES...

With so much to look forward to.

In. One. Week. 

2 people I knew took their own life last year. 
1 was an old school mate of mine. 


What can we do about it then? I guess that's the question that remains. 

Well, dealing with how doctors perceive themselves and mental illness is one step in the right direction. 

This great TED Talk, one of the highest rated of all time I believe, discusses the expectation of doctor perfection, and how this counter-intuitively actually worsens patient outcomes. 




When doctors feel they have to be perfect, that their mistakes are their fault, a great burden is placed on their head. 

It's important to be competent, don't get me wrong. But this unreal expectation of perfection is what, as Brian Goldman points out here, is only harming doctors more. 

We're not learning from it right now. There's no mandatory reporting of issues or near misses in hospitals. More recently, at a quality and safety lecture I attended, I learned there was one in our hospitals in my state in Australia, but that it was under-utilized, and something feared by doctors, as opposed to the learning tool it was intended to be. 

Something as simple as a place for doctors to confess mistakes, and seek sympathy from other doctors, could change the lives of hundreds of thousands of silently suffering, perfection seeking, burned out medicos. And it could improve patient outcomes too. 

Of course, it needs to be a done in a sensitive manner. Perhaps confidentially, with identification being made impossible. Though it's horrible that some die due to lapses in doctors' concentration, as pointed out in this article, overworked doctors, facing physical and emotional stress, are less competent ones. Hundreds of thousands will die due to medical error this year alone - medical error is estimated to be the third highest killer in the American medical system. 

The numbers are alarming, to be sure. But not learning from mistakes, not making diagnostic/prescribing/treatment processes better, and not giving doctors a place to vent, and relax, is only going to increase this number if anything. 



A great TED talk by a very interesting man - Atul Gawande (highly recommend his books on medicine and how to fix it), discussing a simple process which reduced mortality in surgeries by as much as 40% - a checklist. These little innovations and improvements are necessary to accomplish the end goal of saving more lives and reducing suffering!  


But reducing medical error alone isn't the only way we can ease doctors' strife. 

Loss is something many doctors have to face too. 


I can only imagine how going to work everyday, knowing that you're going to witness suffering, pain and death can be soul-wrenching. I certainly do feel disillusioned when walking through wards and seeing the same story, of a seemingly nice person, suddenly finding their health deteriorating, and then, in most cases, having some scars from all this tail them for life. 


It wasn’t easy. It never is at first. Especially when it’s someone you’ve really connected with.

I can’t imagine how you doctors can deal with it. This is how I dealt, and deal with mine though...

When George passed… I was devastated. It shouldn’t have happened. Not just because he was so young, not just because he’d left a baby behind, but because it was so sudden. So unexpected. Just so unfair.

And I was bereaved. Inconsolable. But silently suffering. For weeks.

I didn’t realise it at the time, but I was going through depression. That was the first time I did. That someone so young, innocent, someone who I’d helped grow to overcome so many battles and someone who I thought would make it could go so soon made me question why bother at all? In the face of so much struggle, so much of which that we couldn’t resolve… Why bother facing anything at all? It didn’t make sense.




I stayed that way for weeks. Scrolling down Facebook, watching Youtube video after Youtube video… unfeeling, uncaring. Questioning why continue at all? Until one day, I talked to someone about it. My father. He came up and hugged me from behind, and just held me.

And I asked him, “why do we bother?” He’d sensed I was going through something. He didn’t know why. But he did. A parent’s intuition maybe.

He said, “Nikhil. Look. Everyone in this world will die someday.” An abrupt start to what I’d expected would be an inspiring, or inappropriate joke, something frequently gushing from his mouth to be sure. But he continued, “We can’t control that. What we can control, is what we do in our lives. We focus on doing our responsibility, and that’s all, as best as we can. And where we can, we leave this place a better state than we found it in.”

I saw then, something I believe is a fundamental truth of humanity.

The feeling of helping someone, of being an active member of a community, in the essential sense of the connection that humans need to survive. 

I'd always wanted to help people. It was just the right thing to do, it seemed. It's why I'd wanted to do medicine. Cancer just cemented that. But I realised that it also is the best thing you can do, not just for others, but also yourself. 

Because that feeling of putting a smile on someone's face, or easing someone's struggles... unlike things like fame, money, power, men or women - all those things we seem to desire most in life, that can never be taken away from you. That will never seem meaningless. That's something you can always do.

And I want to share 1 unwaverable truth to all the doctors, medical staff, and regular people out there reading this...


No matter how dire things seem, no matter how much you feel like you're just a cog in this machine which keeps churning out pain and death, no matter how much you feel hope, and powerless - YOU CAN, and DO, ALWAYS MAKE A DIFFERENCE.
No matter what the outcome.
Because what made my doctors special wasn't the medical calls they made or their knowledge and prowess, what made my doctors REALLY special to me was the times they'd talk about my biking progress or my basketball before an appointment (that alone mitigated the 1 - 2 hour wait to see them)... the time one doctor walked alongside me and chatted on the way to a lung plural biopsy which I knew was gonna hurt. It was the time my doctor decided to write in to the medical entrance board and allow me to sit the exams that would allow me to become a med student. THAT'S WHAT MADE THEM SPECIAL... to ME.

I've sat down with men who were dying's families and held their hands as they knew they were about to go, and been told by their family that that night we played snakes and ladders a few days before he passed was something he remembered on his deathbed itself. That the barbecue one friend had on father's day, when a companion of mine in hospital had finally gotten gate-leave on Father's day was the best barbecue and one of the best meals he'd had in his life. But to those reading this, I also want you to know also that you don't have to go this far to create change. Because the little things are Huge. They not only give fleeting happiness to your patients, your small gestures, and make you feel HUGELY cared for too as a patient... something that I realised I hadn't felt when I had severe, suicidal depression for a year until I visited my old doctor, who'd treated me first (thank God I didn't take that jump on that day.)... They also make you realise, at a doctor, that YOU ARE making a difference.That YOU DO matter... Those little acts of kindness reinvigorate you.
And if you take that opportunity to be the light in peoples' darkest day, instead of going into work everyday thinking "Oh here we go, another 12 hour shift where I'm looking after people I can't even listen to me, yet alone help or save", "you'll be thinking, "whose day can I make... whose pain can I ease... whose LIFE can I change?" And that's huge. It's the difference between this being a job and a profession. It's the difference between being run down or turning to alcohol or drugs to get by, and feeling fulfilled. It's the difference between life and death. So go out there and take every opportunity you can to do it. When you have a spare few minutes, take a few moments to see what allied health services around you can do to help improve quality of life for your patients and refer people to social workers to see how you can improve their lifestyles. They've made huge changes to my life, and so many others. It takes a median of 15 years for people to go see a pain clinic, for instance. Let's fix that.


A reason why people won't come in when they need to - "Oh why wait that long for something that won't help anyway"
And if you still feel sometimes down despite it all, please, do get help. The biggest reasons doctors don't seek help is fear for their career, or what their peers will think about them. If that's you, let me tell you this. I'm a man who used his mind to find a way of smiling, despite his cancer, 3 days after being told he'd had it at 17. I'm a man who's ridden 200km 2 months after chemo for cancer charity. I'm a man one who's running 2 social enterprises, one of which will save HUNDREDS OF THOUSANDS and BILLIONS in healthcare expenditure and most importantly... I'm man who found a way to smile after he'd been told he'd relapsed and that palliative care was a very good option in JUST 10 MINUTES...

But I still couldn't outthink depression. I still was miserable, despite my fighting against it and willing myself on, again and again. I still went into that deep dark place of wondering what's my point in my mind when the pain I face struck. If others think are thinking you're weak... then they'd better have done more than me. Otherwise, whoever is or would, is someone who doesn't understand something that should be basic knowledge. Someone judgemental and incapable of thinking outside the tiny little box that guides their life experience. Someone beneath your concern, someone who you wouldn't want to befriend anyway. Someone you shouldn't worry about, or let get into your way to becoming the most content version of yourself - something you do deserve, no matter what depression makes you feel otherwise. I say this because one of the other biggest reasons we don't get help is because we're embarrassed.


Sometimes that person is yourself. Most of us are strong people. We power on. We've gotten through gruelling pre-med studies, then through medical schools and internship and everything that comes with the job, or in the struggle to get there. We can beat this. Or we can't be one of those losers or sadsacks or whiners who suffers. We just get on with it. Scraping by, as some of us always have. But getting help isn't the "weak" option. You don't get anything out of beating it. Why risk proving it to yourself, or put it off, or dismiss it as unnecessary, or just chinning up, and putting on a facade when you can get help to get you through it. And I can tell you that when I got help, this all changed. Instead of walking in front of a train that day, I decided to walk across the street from the lab I worked in to see my old doctor, tired, cramping and feeling so alone. And thankfully, he was there. He just sat there, talked, and acted as any person would for another. He did what any doctor should do. He cared for me. As well as took care of me. He sent me to emergency, something you guys reading on mostly likely wouldn't have to do, and I saw a psychiatrist. When I saw her, she said I wasn't despondent, and didn't need admitting, but would require therapy, for some time. When I asked about an SSRI (I'd noticed something was wrong for weeks), I remembered tbere was a drug I'd looked up for my unexplainable, untreatable cramping called duloxetine. I suggested it instead of the one she'd prescribed... and on day 2 of it... I not only lost this fog that was clouding my brain for a year every single day that I now know was depression, I also stopped feeling the pain. I'd felt as good as I had for years! Since before cancer. But it wasn't just a drug that got me there, and got me to stay there. It was talking to someone about it. My psychiatrist, he mainly does psychotherapy. Indeed, his goal is to minimise drugs (indeed, I've eliminated all of my psychiatric;neurological ones for that depression currently), and I recommend seeing someone who does too - maybe a psychologist, perhaps your nations' doctor - doctor help line or mental health service (something I found out at that national doctors' conference that we did for the first time). It seems confronting to do - open yourself up and admit things that you've never admitted before - to others or yourself - but the very things that make it seem confronting are the very reasons why it's great. What you say, can never leave his or her office. You'll never see them in day to day life, or even have to see them again if you don't want to. They are literally professionals at their jobs. And whatever you say to them, they legally can't disclose to anyone! I encourage you to take that first step of reaching out to one, if you haven't before, and think you may benefit. And finally, I'd like to say thanks. You may not hear it a lot as doctors. It seems we patients are becoming less and less grateful over the years, but you guys really to matter to us. You see 20, 30, some of you, even 50 or 60 (in India, that's common according to my Uncle), but we only see 1. It seems like a huge burden when you put it that way. But it's also a huge opportunity. I hope what I've said convinces you to seize it with all your heart. Nikhil

If you'd like to talk. I'm always here.
Suicide hotlines: 13 11 14 - Lifeline Australia. Add a +61 after your international dialing requirement and punch this number if you don't have an alternative.

American: https://suicidepreventionlifeline.org

UK: Samaritins: 116 123


And I'd like to announce what I'm doing for the first time on this blog. I've started up a social enterprise that'll, as said above, save hundreds of thousands and billions of dollars a year! Check it out at www.gettosleepeasy.org - here's what it is. 






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