When the boot is on the other foot

With 58% of doctors now suffering from some form of anxiety or depression – and 46% saying their condition has worsened since last March – we are serialising sections of a new book edited by Dr Clare Gerada. This month: Doctors as patients.

It is often said that doctors make the worst patients. 

Systemic barriers to accessing care as well as cultural and individual factors play their part in keeping doctors away from the consulting room and relying on self-care or ‘corridor consultations’ instead.

Maybe our reluctance to seek help is that we are all too familiar with what it means to be sick, to have vulnerabilities and relinquish authority and trust to another and we recoil against this. I certainly prefer to manage my own health problems. 

If I seek help, which I have had to, then it is with a feeling of shame and embarrassment that I am taking up the precious time of another. 

I have had mental health problems; no one can go through nearly four decades of caring without some of the emotional impact of our patients sticking to us, and everyone, even the most robust, is not immune from the pain of significant life events. 

But when my depression hit me, when I too became sad, felt worthless, hopeless and even had thoughts of suicide, I found it difficult to seek the help of another doctor, of going to my own GP, someone I knew professionally. 

I worried she might consider me unworthy and incompetent to care for patients or force me to refer myself to ‘the authorities’.

Irrational concerns 

I did seek help, but by-passed all ‘standard’ routes, instead, using a pseudonym, I contacted a psychologist privately. 

The anonymity did not last long. As with the patients in my service who also try to hide behind their mother’s maiden name, my email address gave away my real identity. 

My concerns are shared by many doctors; irrational concerns in the main, but real, nevertheless. Maybe it is because I am older, with my ‘stiff upper lip’ mentality more ingrained than in the younger, more enlightened generation that I have found it so hard to seek care. 

Or maybe, as with most doctors I meet, becoming a patient means relinquishing our identity of the powerful, knowledgeable, invincible professional and this step is difficult.

In 2008, against a growing concern of suicide among doctors, the report Mental Health and Ill Health in Doctors was published. It discussed a range of issues relevant to this professional group, including stigma, secrecy and shame. 

It said these three factors contribute to doctors failing to take on the sick role and instead work when unwell. Doctors average less than three days’ sickness per year, while in the general population the figure is eight days and for nurses it is 15. 

A paper two years later, called Invisible Patients looked at the barriers to doctors seeking help and the subsequent risks to both patients and doctors due to this failure to seek timely care. 

Alternative paths

That doctors are reluctant to present themselves to services for mental health problems is demonstrated by the findings of a number of surveys. 

For example, one study published in 2009, found only 13% of doctors would seek help through professional routes. 

The majority would choose, as I did, alternative paths such as self-medication or informal help from friends or family. 

Most, when asked why, said they feared their career would be jeopardised if they approached a colleague. 

A survey sent to all GPs and psychiatrists in Devon and Cornwall found nearly one-half reported that they had suffered an episode of depression, 14% in the last year. Yet, despite these high levels of mental illness – and a knowledge of mental health services given their specialties – they would not seek care, rather prefer to suffer in silence. 

Reasons given, in order of responses, were: 

 Not wanting to let their colleagues down; 

 Loss of confidentiality; 

 Fear of letting patients down; 

 Worries about their career.

Surprisingly, the group most reluctant to seek care for mental health problems are psychiatrists, with one study reporting nearly 90% would be averse to consulting with another mental health professional.

Terrible crime

Fear is often at the root of why doctors do not seek care. For some of my own patients, this has been so great that it is as if they are trying to conceal a terrible crime. They tell no one, not even those closest to them, how they are feeling. 

Others have consulted doctors in the private sector under the mistaken belief that this will buy them anonymity.

In my experience, what doctors worry about most about falls into two main categories. The first is around loss of confidentiality, with others being told about their mental health problems without their consent. 

Small world

The second is that, by disclosing mental illness, it will mean they will be referred to the regulator or sanctioned. Both of these have some basis in reality. Medicine is a small world and it does not take long for two doctors who have never met each other to find they have mutual friends or colleagues in common. 

Many doctors also live in the same area they work in – as I do. Their local hospital is often the one in which they work or their neighbouring practices are within the same clinical network as their own practice. 

Others have relationships with doctors, are related to them or, as with me, are married to one, making our social networks among the profession even more entangled. This makes it very difficult to consult with someone with no personal or professional ties to you or your family. 

At a pinch, this might be acceptable if the reason for needing a consultation is not sensitive. However, if it is for a mental illness or a personal problem, it can be difficult for medical professionals to discuss it with friends or colleagues. 

Perhaps the most extreme example I can remember of the inability to obtain a confidential space was a psychiatrist who, having attended his own GP for help with depression, found a few weeks later at his referral management multidisciplinary team meeting that he had been referred to his own team.

Breach of confidentiality

The fear of breach of confidentiality also relates to one’s personal issues being relayed beyond the privacy of the consulting room to others in their wider educational, professional or employment circles. To be blunt, doctors do not trust the system to keep their problems confidential. 

This is especially the case once a mental illness has been disclosed in the workplace – for example, to a training supervisor – when it is not uncommon to have other individuals, each claiming ‘a need to know’, also told about the doctor’s illness. These can include appraisers, trainers, medical directors, senior managers and human resources and secretarial staff. 

I once counted 17 individuals being told about a doctor who had recently been diagnosed with attention deficit disorder, all assuming they had a right to know. Even when a doctor is offered confidentiality at their place of work, this rarely happens. 

Each staff member tells another ‘in good faith’ and with the assurance ‘I am only telling you in strict confidence but I think you should know; please don’t pass on… but… Dr XYZ is off sick with…’. This then gets passed onto another member of staff, even those who have no direct involvement, and another, with the message slightly altered each time as in the children’s game Chinese whispers. 

In the end, the doctor’s problem might as well be posted on the world-wide web for all to see. 

Vicarious gratification

Sadly, in my experience, colleagues derive vicarious gratification from the drama that a sick doctor brings to the boredom of their everyday working life, especially if their illness is related to addiction. 

There is also the issue that once disclosed and placed on work records, it is impossible to remove and the diagnosis is carried forward for evermore into any new posts. The doctor then has to face with each move of a job – which can be every six months for doctors in training – having to go over their past illness and be interrogated as whether they are fit to practise. 

This is not, I hasten to add, just for serious mental illnesses, but for problems such as past history of depression, an eating disorder, dyspraxia or indeed any diagnosis that the doctor has placed on their record.

The second major concern for doctors is that of being referred to the regulator. This is a largely unfounded fear, as very few doctors with mental illness are investigated by the GMC and fewer still receive sanctions. However, this does not prevent the anxiety. 

Aside from worries around admitting to mental health problems, there is also the real concern of not being treated with compassion when they are unwell and wanting care. 

Becoming a patient

Given the ‘rules’ of medicine, it should be clearer why we find it so difficult to become patients. Crossing that invisible divide between health professional and patient is a fundamental challenge to our personal and professional identity. 

It is patients, on the other side of the consulting room, who become unwell, not doctors. 

The American neurosurgeon, Paul Kalanithi, has written about his personal experience of being unwell in When Breath Becomes Air, published posthumously. He developed a brain tumour. His narrative illustrates how difficult it is for doctors to take on the patient role.

He wrote: ‘Why was I so authoritative in a surgeon’s coat, but so meek in a patient’s gown?’ The answer to his question is because as the complete object, the ‘doctor’, we create an aura of invincibility around ourselves. 

Becoming unwell is challenging, even in the short term, as, with this, comes the loss of the trappings of power, knowledge, status and authority defined by our group norms. 

The behaviour of ‘working nevertheless’ and giving a façade of coping, not just to colleagues and patients but also to ourselves, is hard wired into the medical culture. Doctors who take time off are not viewed favourably by those who have to pick up the work left by their absence. 

Sympathy fatigue

This creates the norm that illness equates with weakness, and doctors should be strong and healthy and cope themselves with illness and stress. Colleagues who are absent due to illness tend to create ‘sympathy fatigue’ and blame rather than compassion and understanding.

When doctors do get into a consulting room, they tend to act differently, as they visibly try to regain control of their medical identity, by, for example, ‘talking shop’ or underplaying their symptoms. 

Sick doctors are different to other patients. They present late, and then with diagnoses rather than saying what is wrong with them. They minimise their symptoms, such as deliberately scoring lower on alcohol screening questionnaires or masking the true extent of their negative thinking.

But the tide is turning and once services can offer confidentiality, containment and skill in managing their problems, doctors are willing to present to care and, in so doing, reduce their fear of seeking help. 

Still, however, the ‘system’ is predicated on the assumption that a doctor with mental illness is dangerous and needs monitoring and even restrictions placed on their practice. This is as far from the truth and is the same as assuming that any doctor with cancer needs the same restrictions. 

Of course, unwell doctors, just as those who might have an acute physical illness or broken leg, will need time to recover and recuperate and, on return to work, they might need reasonable adjustments to be made. 

But my experience of over 10,000 mentally ill doctors is that the overwhelming majority pose no risk at all to their patients and where they might pose a risk, this can be identified ahead by the medical team and measures put in place to reduce this it. 

Dr Clare Gerada (right) is medical director of the Practitioner Health Programme, London, and a former chairman of the RCGP