How healthcare makes doctors mentally ill

My friend, Dr. Zeshan Qureshi, just delivered this TEDx talk in New Zealand. Dr. Qureshi is a paediatrician in the UK with a lifesaving message for us all:

Our healthcare systems are making doctors mentally ill

I am a children’s doctor and I’m going to talk to you about the sick people I see. Not the patients, but my colleagues by my side. Tragically, I have attended the funeral of children that have died under my care. But equally tragically, I have attended the funerals of my colleagues—of doctors that were perfectly medically fit and well that took their lives by suicide. The rate of suicide amongst doctors is double that of the general population. America alone loses the equivalent of an entire medical school cohort a year to suicide. And that’s just the tip of the iceberg with depression, anxiety, post-traumatic stress disorder, burnout, drug and alcohol dependence all reaching near epidemic proportions.

We need to take urgent action because so much of this burden is entirely preventable. What are the solutions? Well some of them are so straightforward you don’t need to have been in hospital to be able to figure them out. You don’t need to be a doctor. First, we need enough doctors to do the job that’s asked of us.

My colleague—she was working a 72-hour shift. Horrific in of itself; you don’t really do that in most other industries. But on top of that, she was so overworked, so under-supported that in the whole 72 hours she only got six hours of rest. And not even a bed to sleep in, but a hard floor. You wouldn’t even treat a criminal like that.

But in the NHS where I work in the UK, I have never worked in a hospital that’s been fully staffed. We regularly come in early, leave late, skip our breaks, don’t eat, maybe not even drink. It’s absolutely exhausting, and it’s no surprise, given the fact that there are ten thousand doctors less than we want in the NHS. A hundred thousand less staff than we want in the NHS.

Burnout is inevitable and there’s a moral case for us hiring more staff to solve that problem. But if you don’t take that moral argument, there’s a strong economic case as well for the hospitals. I worked a really busy night shift in the Emergency Department and I was so exhausted by the end of it that when I went to sit in my car to drive home, I fell asleep. I wasn’t fit to drive a car. I wouldn’t have been fit to fly a plane or to drive a truck. Yet two hours previously, a little girl arrived in the Emergency Department not breathing and I had to make those decisions as to what we did to save her life.

Now how is that fair on me as a practitioner to be forced to make those decisions in a state of exhaustion? More importantly, that mother, she’s brought her child in at her time of crisis. She deserves and wants the best possible service and we’re not able to give it to them. And for the hospital, I don’t understand why it makes sense for them to make that kind of a risk when it comes to children’s lives.

Burnt out staff leads to increased costs, decreased productivity, decreased patient satisfaction and crucially decreased quality of care. So, it doesn’t make sense. What can we do about it? Well, start from the beginning. Medical school is consistently oversubscribed yet we artificially limit the number of places in medical schools. We need to liberalize that to account for the demand and staff in the future. The hospitals themselves—it’s simple, they need more staff and better working conditions. People working less hours, more flexible hours and then their needs being catered for on a day-to-day basis.

And then what do we do on those days when there’s a mismatch between the amount of work required and staff? Well, hospitals need to pay what it takes to get that emergency cover to help deal with the workload. And there needs to be a much lower threshold to cancel non-urgent work to allow doctors to work in safe conditions.

And what should we do as individual doctors when we’re in that situation, where there’s too much work to do, for our own wellbeing? We should be able to say ‘no’ and say ‘no’ much more readily. It’s difficult when you’ve got sick people around you, but the reality is, you’re sabotaging yourself and you’re harming yourself.

In London, over four years, there was a 160% increase in sick days taken by doctors and that is partly attributable to the fact that we’re pushing ourselves beyond our limit because we feel obliged to. We feel the sense of vocation to do so. But we have to look after ourselves in order to be productive in the long run.

However, this isn’t purely an issue of staffing and of working conditions. Medicine by its very nature involves facing human suffering and death at an intimate level where you feel a sense of responsibility for things when they go wrong. Thankfully, most people here will have never seen a baby die. I’ve seen two babies die in just one day. Now the families that have just gone through that tragedy—they’re not going back to work the next day, the next week, the next month—maybe not ever, and nobody would ask them to. But what about the staff, the staff that are there with the parents screaming, petrified as to what’s happening. It’s the staff that see that baby with that tiny glimpse of possible life doing everything they can to try and bring them back. The staff that go through that horrific process of saying, “I’m sorry we couldn’t save your child.”

After that shift, I had no space to grieve and to breathe. In fact, I went straight on to six further night shifts. For me, it was too much. I broke down. I couldn’t cope. And the burden that we experience is immense. I’ve seen babies that have been murdered. I’ve seen children that have been abused in manners that you wouldn’t want to imagine. There are difficult communication scenarios too. Imagine telling a child that they have cancer. You’d have to be close to a sociopath to be able to process all of those emotions without any degree of harm felt to you.

What are the solutions? Well, I’ve had some people say things to me like: “You just have to turn your emotions off at work.” They presented it as a choice between being human and being a doctor. For me, I am human, and I am a doctor. Both of those need to be preserved in my job.

There are lots and lots of things that can be done in the workplace to try and make it a better environment for dealing with these kinds of situations. One thing that is particularly important to me is the support of my colleagues, of people going through similar things around me on a day-to-day basis.

But in medicine nowadays, how well do we even know our colleagues? Take the cardiac arrest team. This is the team of staff that come together when a patient, or in my case, a child, is really sick. You would think that we trained together, we work together, we relax together, we debrief together. Well, what if I said to you that sometimes I’m meeting people from this team for the first time over that sick child. And then sometimes I don’t even see them again afterwards, with no space to process those lingering emotions and those doubts.

It’s difficult and it’s hard because even though we want to be able to debrief and that’s our gold standard, there often isn’t felt to be time and other clinical priorities take precedence. But even on a day-to-day basis, I spoke to a doctor the other day who had been working in a job for four months and his boss didn’t even know his name, let alone his struggles. And this leads to doctors suffering in isolation.

How do we solve this? Well, we need to prioritize bringing the team together. We need cross-disciplinary training and we need to prioritize debriefing in a meaningful way with the team involved and on the same day, even if it is busy because it’s so important for people being able to process what’s going on. But as I said with staffing, even if we do have the perfect team dynamics and other factors in hospital, the fact remains—we are dealing with a very emotionally intense job. And people will be in situations whereby they can’t process fully their emotions without the help of specialists: their friends and their colleagues and their own processing powers aren’t enough.

Medicine is an incredibly difficult place to do this. We are trained to be healers not sufferers. Imagine for me as a doctor; it’d be very hard for me to tell Dr Harris that I’ve got possible depression, because I went to medical school with him, or to tell Dr Fitzpatrick that I might have anxiety, who might be on an employment panel for me in the future. There’s so much stigma and people present late. How do I know? I have suffered myself. I probably could have got help a bit earlier than I did. That was a mistake. But I’m not the only person that has done that. And when it happens to doctor after doctor after doctor, then it’s not a problem with the individuals—it’s a problem with the system.

I’m very lucky—I had good people that helped me, I made a full recovery and I’m on the stage here speaking to you. But other people aren’t so lucky. They’re still sick or in a worst-case scenario in graveyards. So how do we address this? Things that are effective and that are increasingly being prioritized are sources of support that allow for anonymity and ease of access.

There’s lots of examples. I’ll give you two. One is a social media community called Tea & Empathy. 24 hours a day, seven days a week, you can access this, and thousands of doctors will support you, whatever your problem might be. Completely anonymously if you choose it to be that way. Or the practitioners’ health programme. This is again in the UK a service where you can anonymously and confidentially refer yourself to see specialists one-on-one for problems with mental health and addiction.

And this program was so in need that they had to close their doors for six weeks just to catch up on the backlog of people that needed help and support. However, there is still a huge unmet demand. If there was a drug that doubled the rate of suicide, it would be a scandal. It would be taken off the market immediately and an urgent intervention be put in place.

What do I think is needed? I believe that every doctor regardless of what their assessment of their mental health is should get routine psychological support for dealing with this traumatic world that we are working in. So that they don’t have to come forward while suffering to say we need help. And that truly will be able to bypass stigma because you’d have a safe, anonymous space to talk.

The Hippocratic oath was recently changed—the oath that we take when we graduate medical school—from purely talking about looking after patients to also looking after your health and your own wellbeing. But we have to go further.

We have to think about governments and hospitals being accountable. And if they don’t respond to the moral and the economic arguments, perhaps they should be held accountable through courts for how they treat their employees. One psychiatrist said to me that if the NHS was a coal mine, it would have been shut down years ago.

Perhaps we should treat doctors with that same respect. We are expecting extreme resilience in the context of a catastrophic emotional burden on top of working ridiculous hours from our doctors. We need healthy doctors to have healthy patients.

So, let’s improve the situation at work in terms of staffing and resourcing. But let’s also normalize psychological support and end this absurdity whereby hospitals are making doctors sick.

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I’m thankful that physicians like Dr. Qureshi are speaking out against the injustice of medical training and practice that harms the very soul and psyche of our healers. Though I’m no fan of “physician burnout”—a victim-blaming term that identifies the doctor as the problem when clearly the healthcare systems sets our physicians up to fail. To end our doctor suicide epidemic, we must stop blaming doctors and eradicate human rights violations in medicine. Ensure doctors are protected by the same laws that protect all other citizens—labor laws that allow rest between shifts and guaranteed confidentiality when seeking mental health care. Doctors who receive routine mental health care are likely the healthiest most well-adjusted physicians. So let’s allow—even encourage—doctors to debrief after traumatic cases, to cry, grieve, and share their feelings—without fear of punishment. Don’t you agree?

Contact Dr. Qureshi here and/or leave your comments below.