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 treating doctors
It is not just unwell doctors who find it hard to accept that they can be sick. Doctors who see and treat other doctors find it difficult as well.
Doctors often find it embarrassing to treat their own profession, and that they – the treating doctor – might be less qualified or knowledgeable than the sick one. Consulting with more senior individuals can be especially difficult given the rigid hierarchical practices that exist in medicine.
We have all been in this position and it is rarely comfortable, for either party. Having a discussion about the side-effects and mode of action of antidepressants might feel awkward with a professor of psychopharmacology.
However, what is important is to try and acknowledge and respect any additional expertise the sick doctor has, but always to allow them at the same time to be the vulnerable, ignorant and frightened patient needing simple explanations, reassurance and compassion.
When a doctor becomes a patient, consultations can be difficult, especially where mental health is concerned. In the first instance, both parties prefer ‘corridor conversations’: snippets of care outside the consulting room.
Sitting outside the normal health system can have detrimental effects for the doctor, as unorthodox routes risks distorting the delivery of care. At the very least, the unwell doctor will not be part of the routine call-recall system and, as such, not followed up in the standard manner.
They might miss out on medication reviews or necessary tests. For others, it can have tragic consequences, as in the case of young psychiatrist Daksha Emson and her daughter. The boundaries with the health services she interacted with were so blurred that she missed out on many of the safety-netting systems designed to manage very sick individuals.
Following the birth of her first child, she developed severe post-natal psychosis and killed herself and her three-month-old baby, Freya. The subsequent inquiry into their deaths highlighted how Daksha’s treatment was different, just because she was a doctor and this was implicated in causing her to kill herself and her baby.
Her previous consultant, who had cared for her for many years, retired just before she became pregnant.
On his retirement, he transferred her back to the care of her GP, but, in his transfer letter, diminished the seriousness of her history, concentrating on her ‘good’ points, creating an unduly optimistic assessment of her health.
This despite Daksha, over the years, having been so unwell as to require long periods of inpatient care, some under compulsory admission. Daksha did not make her condition and previous history of illness known to her new psychiatrist; she hid this through worries that disclosure would negatively impact on her career.
Information was not passed between doctors involved in her care – GP and psychiatrist – in order to ‘respect’ her confidentiality. Information sharing was normal practice for other patients.
Once unwell, her psychiatrist did not place her on the Care Programme Approach, which would have offered enhanced care, nor discuss her case with colleagues in the team meetings, again in the belief that he should maintain her confidentiality.
Finally, only informal arrangements were set up with a community psychiatric nurse, which were not adequate in the circumstances, but made in the belief that, as she was a psychiatrist, she would know what to do.
While singly none of these changes to normal practice contributed to her death, the accumulation of them did. Given the seriousness of her condition, she was excluded from the standard of care that would have been provided to any other, non-medically qualified patient with a similar illness and seriousness.
As Daksha illustrates, even once in the consulting room, the sick doctor is treated differently and often seen more as a colleague than a patient, sometimes even going as far as to suggest the sick doctor should treat or at the very least know how to manage themselves, even organise their own tests.
This has certainly been my experience. The implication being that the only role allowed is that of an ‘expert-patient’. This is a two-way collusion, as both parties have a vested interest in maintaining the status quo: that is, the denial of the wounded healer.
Over the years, there have been a number of personal accounts of doctors becoming patients and most of them illustrate how difficult it is for both sick doctor and treating doctor to deal with.
For example, this individual wrote about their experience of being ‘the unwilling occupant of a psychiatrist’s couch’. This doctor gives advice on how to ‘look after one of us’ (mentally ill doctors), much of which focuses on the importance of treating the sick doctor as a patient and not as someone in full control. I would echo this advice.
All too often, mentally ill doctors are treated by trainers, employers and regulators as naughty schoolchildren or wrongdoers at having crossed the boundary from professional to patient.
Collusion of anonymity
Doctors are trained to care for others, not each other. Even if a team member is seen to be struggling, rarely does someone pick this up or make inquiries. We lack a culture of mutual responsibility for each other, leading to a situation, described by the psychoanalyst Michael Balint, of a collusion of anonymity.
This typically was used to describe the collusion that occurs when ‘the patient is passed from one specialist to another with nobody taking responsibility for the whole person’.
In the case of an unwell doctor at work, while everyone can see that something is wrong, and may even raise concerns with a colleague, no one wants to take any responsibility in the hope that someone else will deal with them or that the problem will disappear.
I am not suggesting that we have a ‘duty of care’ for each other in the sense of needing to provide medical care. Rather that we have a duty of caring for each other as fellow professionals, all working hard towards a common aim of treating patients.
Many years ago, while training in psychiatry at the Maudsley Hospital, one of the psychiatric registrars jumped onto a dining table in the middle of the busy canteen.
At the top of his voice, he began a tirade about the corruption he had exposed in this hospital, how his consultant – an eminent professor – had tried to cover up a scandal involving the secret service and that only he (John) could save the world from the invasion that was around the corner.
It was quite clear he was psychotic, yet no one seemed to know what to do. Here were dozens of psychiatrists with one of their own clearly in a distressed state and we were paralysed.
Eventually, a member of the kitchen staff gently coaxed him down from the table and took him by the hand to the psychiatric emergency clinic a short way down the corridor.
If this doctor, instead of a mental health problem, had had a physical emergency, he would have been overwhelmed with helping hands.
John, as I later learnt, had bipolar disorder. He had sought help from his GP in the previous week, who told him that, as a psychiatrist, he must know the best way to treat his condition or maybe he could ask a colleague for help.
Needless to say, he didn’t know how to access care, instead he became increasingly unwell, surrounded by his peers blind to his odd behaviour. Sadly, in my experience of working with mentally ill doctors, this scenario is not uncommon.
So good are doctors at not seeing distress in their own kind, they often describe the shock when the sick-doctor’s condition is subsequently brought to light.
Colleagues perform retrospective trawls through their memory to clues of the doctor’s problems; clues that they would have picked up on in their non-medical patients or colleagues.
The tell-tale signs of alcohol dependence – no one can fully disguise the stale smell of alcohol on the breath or clothes – or the sudden weight loss of someone not eating through depression, or even the small cuts of someone self-harming. The ‘bare below the elbow’ rule makes these cuts even more obvious.
It was only after the doctor’s condition has come to light that others admit ‘they thought something was up’ and illustrates how, both at the collective and individual level, doctors hold to the notion that they should not be ill.
Patients, the public and their views of sick doctors
Beyond the obvious of not wanting to wait longer for care, patients do not take kindly to doctors being unwell. This is because it breaks their – the public’s – belief that doctors are somehow immune from illness.
The sociologist Talcott Parsons described the ‘sick role’ in terms as having certain roles and responsibilities achieved through maintenance of a paternalistic stance and rigid boundaries between the roles of doctor and patient.
These roles act to maintain the tacit contract between patient and doctor; patients become unwell, not doctors. Both patient and doctors enter unconscious symbiotic processes.
The psychiatrist Thomas Main touched on this when he described the defensive interplay of projections between caregivers and patients and the ‘fantastic’ collusion that occurs between the two: ‘The helpful unconsciously require others to be helpless while the helpless will require others to be helpful. Staff and patients are thus inevitably to some extent creatures of each other.’
In this process, the nasty, frightening and distasteful aspect of illness can be projected into and contained (held) within health professionals, who, given their training and status, accept these projections demanded of them by society. If a doctor becomes unwell, how can they hold this pain?
This theme of the collusion between doctor and patient forms the introduction by John Updike of the book The House of God: ‘We expect the world of doctors. Out of our own need, we revere them; we imagine that their training and expertise and saintly dedication have purged them of all the uncertainty, trepidation and disgust that we would feel in their position, seeing what they see and being asked to cure it.
‘Blood and vomit and pus do not revolt them; senility and dementia have no terror; it does not cause alarm for them to plunge into the slippery tangle of internal organs, or to handle the infected and contacts.’
Of course, it makes sense that patients want their doctors to be well, as unwell physicians can impact on patient care.
A study of patients set out to determine how they, based on their own personal experience, perceived doctors’ health and its link to care. Three overarching themes emerged.
Firstly, patients notice cues in their doctors that they interpret as signs of being well or unwell – the way doctors dressed, whether they looked tired, ran late, looked stressed, engaged in general dialogue with the patient and so on.
Secondly, patients formed views based on what they noticed, and these judgments directly influenced how they felt about their care.
Finally, patients made a direct link between doctor wellness and the care they received.
Unwell doctors were seen in a negative light by the patients in this study. For example, they were seen as less competent and more likely to make errors; less appropriate in their interactions, disorganised; and more likely to place added responsibilities on patients to limit their problem list.
Patients also described feeling less comfortable with and less trusting of unwell doctors, even to the point of seeking care elsewhere.
I have highlighted the difficulties other doctors have when asked to treat their own colleagues. Both the sick doctor and the treating-doctor feel embarrassed and find it difficult to accept the change of role from professional to patient.
Nevertheless, it is important that we all accept when we need help. When doctors do seek help, they have remarkably good outcomes in terms of reduced distress, impairments, abstinence rates and overall improvements in their mental health.
This is why it is so important to encourage doctors to make that giant step – for them –from professional to patient. Maybe next time I am unwell, I will be open and honest enough to practise what I preach.
Dr Clare Gerada (right) is medical director of the Practitioner Health Programme, London, and a former chairman of the RCGP