Staff should receive the same compassion they give to their patients
For the past decade I have been a doctors’ doctor, heading up a confidential (within limits) self-referral service for doctors with mental health and addiction problems (the Practitioner Health Programme or PHP). Our service was established after the suicide of a young psychiatrist, Dr Daksha Emson, who, before she killed herself, also killed her three month old baby. The subsequent investigation highlighted the unique barriers doctors had in accessing care when mentally unwell and the personal, professional, and institutional stigma they faced over and above other individuals.
Last week another junior doctor was reported to have apparently taken his own life in Taunton, Somerset. Sadly, suicide among doctors is a serious problem. Across the world, in all health systems (whether publicly or privately funded) and across time, the rates of suicide among doctors have been found to be higher compared to the general population or other professional groups. Women have higher suicide rates than men, and doctors working in emergency specialties (anaesthesia, emergency medicine, and intensive care) have higher rates than their non-emergency counterparts.
The causes of suicide among doctors mirror those of the general population. Depression or other mental illness and misuse of drugs and/or alcohol increase the risk. For doctors, the aetiological factors leading to mental illness might include traumatic life events—a medical degree does not exempt doctors from marital breakdown, illness, or loss—but risks also include profession-specific risk factors, such as easy access to dangerous drugs and the stress of complaints or investigations.
Suicides, of course, are not just statistics. Since 2009 at PHP, a small number of our patients have died by their own hands; each death is a personal tragedy. We remember them all and mourn them. Even if our care has been exemplary, we berate ourselves for not doing enough, for not spotting the signs, for not being there at that moment the doctor decided to take their own life. We try to learn from each case and what we could have done to prevent their deaths.
There have been calls, including by Rachel Clarke and Martin McKee, for all suicides of junior doctors to be identified and investigated, with an explicit focus on the part that workplace pressures might have played. I am not sure that this is the way forward.
As with the deaths in our service, an individual’s decision to kill themselves is always multifactorial—and the doctor’s personal vulnerabilities (personality, family history, early life events) are important contributors. At the individual level, whether work is a causative or protective factor in suicide is extremely difficult to ascertain. There is substantial evidence that work, overall (at a population level), is a protective factor—those in work have a lower rate of mental illness and suicide than those not in work. However, the proximity to death, despair, and disability—especially for younger doctors—could be a significant risk factor for depression and, in turn, for suicide. This, however, would hold for other professional groups, including nurses, who do not have a comparatively high rate of suicide.
This is not to excuse the workplace or to try and minimise the stresses created by working in the NHS. The NHS has high levels of sick leave due to mental illness compared to the UK average. In August 2015, Lord Prior made reference to the toxic bullying culture in the NHS and Simon Stevens, chief executive of the NHS, talked of the need to improve the mental and physical health of NHS staff. Irrespective of whether or not working in the NHS is intrinsically linked to high rates of suicide, the importance of making the working environment as mentally safe as possible cannot be underestimated.
Clearly, the vast majority of doctors do not kill themselves and most doctors thrive in their working environment. But each death is a tragedy, which sends repercussions through the system and has the risk of creating contagion. Going forward, we have to halt the decline in morale among junior (and not so junior) doctors. This will mean addressing many systemic issues that are creating unhappiness: tackling the culture of naming, blaming, and shaming and the constant denigration of NHS staff by the press; allowing doctors to maintain a sensible work-life balance; and not ignoring the basic needs of staff who give their all to patients are also important.
We have to restore doctors’ collective self-esteem by treating them as intelligent adults and not naughty school children and by creating a culture in which their skills can flourish. Finally, we have to ensure that all NHS staff receive the same compassion that they, rightly, are expected to give to their patients.
Clare Gerada is the medical director of Practitioners Health Programme and GP Health Service. PHP is a confidential, free, self-referral service available to any doctor or dentist living in London and GPH (launched in 2017) is available to any general practitioner (ST1 to one year post retirement) in England.
Competing interests: Nothing further to declare.