GRACE UNDER PRESSURE: One of the most traumatic events of my life occurred at a country hospital on an Easter. I was in my first term of my second year, so I’d been a doctor for thirteen months. This hospital, being on the highway, every now and again has massive horrible accidents. They had a massive horrible accident and I was the doctor for the hospital. It was absolute bedlam; it was like being in a warzone. Even now I think about it I think I want to cry.
I saw people die who shouldn’t have died because I didn’t have the skills or I had—I mean, the one that still makes me…the little two year old came in still in the car seat with an obvious fractured head. It was like being in a warzone, one of them had a hole in their lung and the lung was basically compressed and they couldn’t breathe and I’m thinking, “Where is everybody?” The specialists are still at home waiting for the second phone call and of course I’m drowning in blood. I think looking back I did the best job I possibly could but I felt, of course, responsible. It was absolute hell.
Amongst all of this I never got relief. Literally the whole of Easter. My body starts shutting down, I start throwing up. On the Tuesday the medical admin opens up again. By this stage I’m going, “Where is the other doctor?” I’m ringing up and they go, “Oh she’s not coming back.” I said to them, “Patients are at risk because I am just traumatised beyond belief. I haven’t slept, I haven’t eaten, I’m just not functioning and you need to do something for the sake of the patients, not necessarily me.” I got no support at all from that.
Point of the story is then when you come back in again to apply for your job the next year, you come in for an interview and there was a very intimidating long table with five very high-level doctors at the table. You’re a little bit anxious when you’re walking in that door. Before I even crossed to the table where the seat was one of them said to me, “Oh, so you’re that whinger from the country hospital.”
MIC CAVAZZINI: Welcome to Pomegranate Health, a podcast for physicians of the RACP.
You’ve just heard a scene from the play Grace Under Pressure, scripted word-for-word from interviews with doctors and nurses. The play originated from a series of workshops to help medical students deal with the stressors and relationships of the hospital environment. It’s showing at the Seymour Centre in Sydney from the 25th October as part of mental health month, and in today’s episode we’re taking up this story as well.
Just recently the World Medical Association updated the Declaration of Geneva to include the clause, “I will attend my own health, well-being, and abilities in order to provide care of the highest standard.” This is in recognition of the familiar and chilling figures about burnout, depression and suicide in the health workforce.
The rates are typically twofold higher than they are in the general population, according to studies from New Zealand, Australia and around the world. The causes given for psychiatric distress are the gruelling hours, the unforgiving culture and the stigma associated with admitting to mental health issues. This episode examines how the system might be shaped to improve physician wellbeing.
Dr Hilton Koppe starts us off on the theme of perfectionism and the fear of making mistakes.
HILTON KOPPE: So my name’s Hilton Koppe, I’m a GP in Lennox Head in Northern New South Wales and also have been involved in medical education.
The focus of the teaching is to get a better understanding about what happens in the patient doctor relationship, what it means to be a doctor or lifestyle choices. So if someone has a lot of themselves invested in their work and something doesn’t go well or they perceive that they’ve made a mistake then that is a personal identity issue or a personal crisis. It’s a wonderful career, but it’s tainted a little bit by the pressure of caring for people, in the medical sense, that I really care for in a personal sense as well.
MIC CAVAZZINI: You wrote an interesting piece for Australian Family Physician where you described moments of a sort of compassion fatigue that emerges sometimes, or a “cone of silence” that you might use to shield you emotionally from the trials of your patient. How did this affect your therapeutic relationship with the patient?
HILTON KOPPE: I guess earlier on in my career it was very difficult for me, and as time went on I realised that if I took on everyone’s problems as mine then I would very soon be not very helpful to anyone, including to myself. So there’s that idea of the cone of silence which comes from Get Smart, the idea being that I can hear what they’re saying and I get the sense of the emotion behind it but I’m trying not to let that emotion enter into me. So the cone helps me to keep doing the work at an appropriate level.
How do you train for it though? It’s very difficult but it’s necessary, I believe, to have regular reflective practice to review my own personal response to what’s going on in my working life.
GEOFF TOOGOOD: You know, it is demanding and you’re making continual decisions throughout the day that are important for that patient, and then the next patient, and then the next patient, and then the next patient. So it’s not only the fear or making a mistake, it’s accumulative responsibility over time that weighs you down and you eventually fill up your cup.
MIC CAVAZZINI: Geoff Toogood is a cardiologist in Victoria’s Mornington Peninsula. In 2013 he suffered a severe period of depression at the height of his career leading the cardiology department at Frankston Hospital.
GEOFF TOOGOOD: I think as you get more senior you’re less likely to tolerate failure in yourself and also, you often take on more administrative roles which is very difficult in the modern sort of medical world now. Relationship with management and sort of administrative tasking is becoming more onerous and more, I don’t know abrasive, I guess, in some ways.
And then the perception from the community and the patients you see is a very high standard upon yourself. Because of the internet patients are more engaged in their care, which is quite reasonable of course, but there’s a lot more…scrutiny I guess is the better word, of your practice. Some of it’s appropriate, some of it’s probably the wrong sort of scrutiny and we doctors are very, you know they’re great at criticising themselves.
MIC CAVAZZINI: General practitioner Margaret Kay is medical director of the Queensland Doctors’ Health Program. Her research looks at how medical culture and legislation affects help-seeking among health professionals. She says that doctors in training can be particularly overburdened as they establish their career in a field that suits them.
MARGARET KAY: So firstly, when you’re a junior doctor you’re not really able to say, “Look I want to do just that little piece.” So obviously if you’re not really keen on surgery and you end up doing an awful lot of surgery in your early years, it’s not until later on that you actually get to even identify what you love and then embrace that. So clearly as you go through your career, you’re actually able to craft your career more specifically into an area that you actually feel really comfortable with.
MIC CAVAZZINI: At the Australasian Doctors’ Health Conference, Julie Chilton presented some figures suggesting that both medical students and interns show greatly increased rates of psychiatric distress and suicide ideation within months of starting their programs. But then she said, “Well what do you expect when you put overachieving individuals in a system where it’s impossible to live up to past expectations or admit imperfection?”
MARGARET KAY: I do think that she’s absolutely right with the point that she makes. We have a number of individuals who enter medicine who are automatically highly stressed because that’s actually how they’ve got through life, through their exams, through their—they’re just on high alert. They’ve managed extremely well. They’ve been the top of every exam basically that they’ve sat and then they move into medicine.
And when they move into medicine they’re with all their peers who have actually been high achievers as well and suddenly they’re the average in the pack. And being confronted with being average is really difficult when you’ve spent your whole life being the best. But if you’re average in the best, then maybe that’s not a bad thing, but no one tells you that. So I think we could craft some of the messages for the junior doctors and address those expectations overtly rather than let them just work it out for themselves.
GEOFF TOOGOOD: Look, I think there are fewer and fewer places relative to the number of trainees and the competition now is that people are filling up their CVs with extraordinary amount of, you know, research and other competencies. You know, you’re virtually having this high level of competition every working year of your life from very early on in medical school to when you’re very senior as a doctor. And I’m not sure many careers have such an intense degree of scrutiny, competition throughout the whole career.
MIC CAVAZZINI: Here are a couple more scenes from the play Grace Under Pressure.
GRACE UNDER PRESSURE: Just working hours, you could call that a form of bullying if you like. When I was an intern at a hospital in 1980, we worked 80 hours the first week and 120 hours the second week. And I remember going to the CEO at the time and saying, “Look, we’re doing an average of 100 hours a week and we’re being paid for 55. Surely we should be paid for more.” And he said, “Oh no, well you’re only doing so many hours because you’re young and you’re so slow so we can only pay you for what you should be able to do in 55 hours.” Which was classical spin. Absolute nonsense.
GRACE UNDER PRESSURE: It’s a shocker, it should be illegal. My dad works for—he’s a lawyer who works for mining companies and he says in no other industry would that be allowed. Ever heard of a doctors’ strike? It can’t be done because the patients suffer and doctors would prefer that their patients didn’t suffer and that they suffered.
And also everybody’s got in their mind that it’s a temporary problem because once you finish training, you know you’ve only got to do this for seven years, it’s not forever so you don’t need to fight for your rights because it’s going to end soon. But the hours are better now for doctors than it used to be, so there’s this culture of “Well, we did it, suck it up—it’s not as bad as it used to be.”
MARGARET KAY: We automatically come out with these statements and we don’t realise the impact it has on that individual who was for one moment revelling in the fact that they were going to breathe for a day. And it’s these sorts of things that need to be called for what they are. They’re not evil in themselves. But the impact of them needs to be understood.
MIC CAVAZZINI: Yeah, you surveyed Queensland physicians and found that they worked on average 76 minutes overtime every day but only 30 percent of all of those overtime hours were claimed back. What does that say about the culture that promotes this?
MARGARET KAY: Yes I think you’re looking at the AMAQ survey when you’re doing that, with the Council of Doctors in Training? Yes, so there were a lot of doctors who couldn’t even articulate how many hours they’ve actually been at the hospital. They just know they kind of got there about seven because that’s when they usually get there and they kind of left when they finished seeing their patients at eleven at night. And you know, they may have only been rostered eight until five that day.
MIC CAVAZZINI: The survey showed that overtime hours were higher amongst junior doctors who often gave as an explanation for not claiming back the hours, the concern that it would negatively impact on their supervisor’s reference—or the perception that it was all their own fault for being inefficient.
MARGARET KAY: Yes. And we don’t even know how many times that perception is actually a real outcome because I’ve had senior doctors absolutely shocked that someone who’s under their care, under their supervision, would actually think that. Because they are more than willing to pay, they tell me. So somewhere in the system we again need to understand why people feel like that even if it’s not real, or why people don’t realise that it is real when they’re in charge and they actually could do something about it, they’re not actually understanding that it’s real. Which is actually not just a complex huge building or hospital health service, it’s actually even within the individual teams within the hospital they’re all different. It’s how it feels to the junior doctor at that moment in time.
GEOFF TOOGOOD: You know, it was awful in our days and I don’t see why they should put up with an awful workload. I think the burnout does occur because of the long hours but the intensity as well. You know, it’s an intense workload, you kind of walk out at the end of the day and you wonder where the day’s gone, you know what I mean? So you don’t realise some of the decisions you’re making through the day.
Also if you’ve had a sleepless night on call, you’re still expected to turn back up at work you know the next day and that makes it very difficult because, I mean, when does a junior doctor or senior doctor actually do what they also need to do which is like, be a person which is what the patient wants to come and see? You know what I mean? Someone that’s in the community with their family, doing normal things. You know, people want a doctor that bleeds and hurts like everybody else. So the more stressed, the more burnt out doctors are—you’re losing a little bit of humanness to your treatment.
HILTON KOPPE: I got some very good advice from one of the cardiologists I was working with, who is a resident at Hornsby Hospital, and he said to me, “Hilton when you start off in practice start working the number of hours a week that you would like to work once you’re well-established. Don’t start working every hour possible and think that you’ll be able to cut back down the track because it’s almost impossible to cut back.” And I pretty much managed to follow that through, but I couldn’t have done that while during my training time. And so I fully understand that during the time as an intern resident, registrar, the hours are not able to be set by the doctors but once finished in their training and setting up their own practice I think it’s possible to give some thought to that.
GRACE UNDER PRESSURE: So I was very mindful not to be mean to interns because I remembered what it felt like. If they got it completely wrong I probably said, “Hey I’m going to stop you there, these are the five things I need every time you call. Do you mind going away and calling back in ten minutes with these five things? Thanks very much, see you later.”
I think I did well until right at the end when I was over the peak myself, completely burnt out and angry. I was mean to everybody. I was behaving in a way that I thought I never would. An intern would ring me and it wasn’t fast enough for me, it wasn’t concise enough. I was busy, I was trying to do a very important conversation with a patient and I would say, “Can you at least give me the correct name for God’s sake! Look, just call me back in five minutes!”—and I’d hang up.” Belittling I think is the best word for it and I knew where it had come from. I’d been belittled by a lot of people throughout my whole training, and so you pick up those behaviours.
MARGARET KAY: I’m Margaret Kay and I’m medical director for the Queensland Doctors’ Health Program. So there are times when people are actually using belittlement inappropriately when they’re actually meaning to teach. Because you have a whole group of doctors who are trained to be doctors and very little of our doctors training is actually teaching us to teach.
You know you can be a very good doctor who’s very good at doing an endoscopy and you might actually end up then in a team when you’re the senior person in that team. And your leadership skills may not necessarily be the leadership skills that actually enable you to communicate in a way that’s actually gentle and, dare I say, with compassion with the team that you’re working with even if you’re good at communicating with your patients.
So we have people who are in different roles with the wrong skills and they’re often actually given training from business organisations who don’t understand the contextualisation of those skills into a medical team. So I think there’s a lot that can be done with actually understanding the roles, even understanding what bullying is. A lot of doctors just haven’t read that legislation.
MIC CAVAZZINI: It was interesting, one of the women attending your workshop at the Doctors’ Health Conference said, “We consultants are also working long hours and skipping meals and stressed out so if we’re a bit curt when we hand over a patient is that necessarily bullying or…?”
MARGARET KAY: Yes, of course, we can turn around and actually say something that’s a bit curt of course because we’re human, because we’ve just actually been seeing something that’s stressful or we’ve told bad news to a patient or for whatever reason. But being human is also about understanding how we are in the space with another human being. Once we actually realise that we’re having a negative effect with our comments, we should actually reflect on how we said something and actually acknowledge that: “Oh look, I think I sounded a bit sharp then.”
So if we show the leadership, being kind, showing compassion to our staff, then that will set the leadership for the registrars to their juniors, for the juniors to the medical students that are coming through and we will actually find that we have a change in the culture.
GEOFF TOOGOOD: Unfortunately I think there is an ingrained culture in medicine often of denigrating colleagues and particularly junior doctors. And that’s humiliating. And that you know it’s not something said in the heat of a tricky situation, you know, it’s deliberate and that’s very destructive for a person.
In my mid-forties to late forties was when I had a first episode of severe depression and delayed getting help for a variety of reasons. You know embarrassment and sort of, how could I be a doctor and fall down and be severely depressed and everyone else is coping with what’s going on? Around that time I was going through a divorce, I was also a little bit ill and I had significant workplace stress and issues in probably not getting the support I needed.
You do boil a little slowly, so if someone took you and put you in that head space suddenly you would go and get help instantly but because it’s sort of slow you think, “Oh look, I’ll probably be all right if I just do this,” but I sort of didn’t share with anyone what was going on. I used the Beyond Blue website which had a checklist about depression, there’s like 15 points of which I scored pretty much maximum on 14. Eventually I saw a local doctor. I was started anti-depressants, got counselling from a psychologist and then I recovered pretty well to come back to work.
The second time when I was early fifties, I couldn’t stop like the freefall into severe depression. I was intensely suicidal and you know what I learnt between the first and second one is to have all these safety nets and things and that probably saved my life.
MIC CAVAZZINI: In Australia, national law obliges health practitioners to report peers whom they deem to have a health impairment that puts the public at substantial risk of harm. This so-called mandatory reporting law has been criticised as erecting a barrier to help-seeking and Western Australia has refused to implement it. This is supported by the 2013 Beyond Blue survey about the mental health of doctors. Over half of respondents said they’d be concerned about confidentiality during a consultation and a third were worried that a mental health condition would affect their registration and career progression. Geoff Toogood is sympathetic to this view.
GEOFF TOOGOOD: I was fearful that someone would report me. I wasn’t fearful of my local doctor or my psychiatrist but I was fearful someone else would do it, you know—someone other than my treating clinician.
MIC CAVAZZINI: And yeah, some have said that the codes of professionalism should be enough to encourage you know reporting and self-reporting without having to mandate it.
GEOFF TOOGOOD: Yes. I think that’s right. I mean, I myself took time off and if you’re taking time off work and you’re not a danger to the patient and you’re getting, seeking treatment there is no need to be reported. If your doctor believes you’re fit to go back to work at this level of workload, that’s a clinical decision.
MARGARET KAY: There’s no doubt in my mind that there is a perception by a number of people who are unwell that they can’t seek help because there is mandatory reporting obligations. Now whether or not that’s a reality or whether it’s a perception is neither here nor there if it’s going to stop that individual person from actually accessing care. And I know that people are flying over to Western Australia to seek their care there. How ineffective is that?
I would encourage anyone who feels that they’re vulnerable from their mental health perspective to go and see their GP early rather than late. They’re far less likely to be reported if they’re seeking care early rather than late.
MIC CAVAZZINI: And apart from the fear of career progression and that kind of thing, what about the stigma associated with mental health issues? In some of these surveys the doctors report that they would be embarrassed to be seen by their colleagues as having a mental health disorder; that they’re worried their patients might not think them competent to practice.
MARGARET KAY: Yes. Yes, well in fact the Beyond Blue study actually showed that in fact doctors do think that of the doctors who have mental health issues and isn’t it sad that that’s the case? And isn’t it sad that doctors who are actually educated about mental health issues will actually think that about other doctors? Because it’s suggests that they also think that about their patients.
If we showed leadership, as physicians should in this area, I think maybe we’ll change the culture in our community and actually get our head around how we should perceive someone with a mental health problem.
GEOFF TOOGOOD: I still think there’s a stigma against mental health in the medical profession. It was somewhat difficult to get leave for my mental health issue but having a kind of a neurological episode, which I did—transient global amnesia—where I actually had a clinical sort of organic neurological problem, it was taken more seriously even though transient global amnesia was far less life-threatening compared to my depression.
You do think you’re the only one, because doctors aren’t very open about their mental health issues or about not being able to cope with stress or failure or weakness and so normalising the conversation would help. But you need leaders who’ll tell their story in a genuine way, and make it OK to have a mental health issue.
MIC CAVAZZINI: You say you feel like you’re the only one that’s struggling, and that everyone else is coping. What was the catalyst that finally enabled you to get help, that pushed you to go seek help?
GEOFF TOOGOOD: Look I think one was, you know, a couple of texts from some friends worried about me. A couple of other colleagues as well, some very senior clinicians did ask if I was OK and came and had a little chat with me which was fantastic. It was all those that made me realise that I really, really needed to get some help. Just general chatting with your other staff is enough, you know, even asking them to know which footy team they follow. Simple things like that, you might just have a chat.
We’ve done a lot about patient-centred care, but we also need staff involved as well and considered. Because hospitals, despite all the technology and all the tests, largely run on the people that are in them, so if they’re not well they can’t deliver the care that they need to give.
MARGARET KAY: So a lot of what we do as physicians is we find someone who’s got an infection and we fix them. And we’ve taken that mind-set to try and approach our own health and wellbeing. But I really think that just saying, “Ooh, look at all those people who are burnt out—let’s try and fix them,” almost blaming the person who got burnt out is hardly what burnout is ever intended to be about. It’s actually about an organisation that needs to not burn out individuals and understanding how that then shifts in fact the whole culture of our medical profession to positive physician wellbeing.
I think we have to acknowledge that it was actually in the 1800s when we first realised that we had higher suicide rates than the general community. Now we have taken a long time—we’ve actually almost been mesmerised by the data that’s out there—because it is, you know, basically shocking—but it’s time to move forward as individuals, as smaller teams and as a system as a whole.
MIC CAVAZZINI: GP Hilton Koppe leaves us with an event that challenged his skills and his ego but that inspired him to reframe how he dealt with the daily experiences of practice.
HILTON KOPPE: So I’d been caring for a woman who had pretty significant depression and most of the usual treatments were not effective, so I really thought that that thing about the doctor being the medicine was true in this situation. As she got better she left me some of her poems and in one of the poems she spoke about her experiences of being my patient and it was very unflattering—it ended with the line, “Perhaps I should instead seek a vet.”
MIC CAVAZZINI: “You look abashed or possibly bored, a gentleman of science revealing your ignorance. I should perhaps instead seek a vet.” And what did that reflect back on you about how you saw yourself as a therapist, as a healer?
HILTON KOPPE: Yes, here was me thinking I was the hero, like the knight in shining armour riding along to the rescue. And this is the response. So I was quite devastated, I was really hurt. I read it on my own late one night at home and there was no one to talk to, and so I thought, “Well, maybe I could write a poem in response.” Which is what I did.
And I hadn’t written anything since primary school, but I found the writing experience quite cathartic and quite helpful. Somehow, by some process that I don’t pretend to understand, I feel a little bit easier. And if I then share that piece with other people and it resonates with them, then that also helps me to feel better, in that I feel not alone and at another level it can be used to prompt a conversation or a discussion about other people’s experiences.
And again I would think that the debriefing or the reflective practice would not just be limited to times when something’s gone wrong; they would be used regularly to think a little bit more deeply about the full range of experiences as a result of working as a doctor.
MIC CAVAZZINI: Many thanks to Geoff Toogood, Margaret Kay and Hilton Koppe for sharing their experiences and insights with Pomegranate Health. There are more interview outtakes at our website racp.edu.au/pomcast. The views expressed are those of the speakers, not necessarily those of the Royal Australasian College of Physicians.
Thanks also to the cast of the play Grace Under Pressure and especially director David Williams. It’s a production well worth seeing.
At our website is a list of other great podcasts on self-care and wellbeing resources from Beyond Blue, JMO Health, and the RACP. You’ll also find the number in Australia and New Zealand of the College’s 24-hour counselling service. But if you urgently need to speak to someone, don’t hesitate to call Lifeline on 13 11 14. You can also reach their compassionate staff via webchat.
I’m Mic Cavazzini and I hope this episode has been helpful. Please keep the conversation going in the comments section and sign up via our email alert service or any podcasting app to catch the next episode of Pomegranate Health.