Rehabilitating troubled doctors

Doctors with mental illness have a particular set of problems. Elizabeth Armstrongdescribes the role of the Doctors' Support Network

If someone had told me, as an ambitious young registrar, that 10 years later I would be grateful to be able to do medical examinations for a private company I would have thought they were talking about someone else. Further, if they had told me that this would happen because of mental illness I would have laughed at them. Doctors were by definition physically strong and psychologically intact. Mental health problems were a sign of weakness and happened to other people-that is, patients. I believed my medical state rendered me immune. Time has proved me wrong.

High risk group

It is well known that the medical profession has higher rates of depression, suicide, and drug and alcohol abuse than other professional groups.(1) Furthermore, chronic stress predisposes to depression.(2)Firth-Cozens has shown that high levels of both self criticism and empathy are associated with depression. Among women doctors, particularly, depression is related to conflicts between personal life and a career.(3) Doctors with mental illness face problems in three main areas. They need appropriate psychiatric help. They need to be able to return to work. And they need to make sense of their illness in personal terms as well as understanding its impact on their clinical work.

Confidentiality problems

Many doctors do not have a general practitioner and therefore cannot access psychiatric help. Psychiatric illness cannot be managed with the self diagnosis, self prescribing, and casual consultations with which many doctors manage physical illnesses.

Confidentiality is vital. Many doctors fear that they will be referred locally and will thus be forced to accept treatment alongside their own patients or from clinicians they know personally. There is an unofficial agreement that doctors will be managed outside their own areas. In practice, this rarely happens because health authorities are reluctant to pay for extracontractual referrals. Besides, many doctors do not even know this possibility exists. In 1991 a health care workers' unit was set up in the Bethlem Hospital, which allowed doctors to be cared for well away from their place of work and in a group setting. It was an excellent unit where the staff understood the particular problems of being a doctor with mental illness. Three years later it was closed for lack of funding.(4)

Doctors who are mentally ill are in a vulnerable position and their rights as patients are easily ignored. Recently, during episodes of mental illness, two junior doctors had details of their psychiatric conditions openly discussed in meetings by their senior colleagues. This is clearly unacceptable. Medical reports are properly kept within occupational health departments, referring cases to the health committee of the General Medical Council as needed. Unless sensible occupational mental health guidelines for doctors are devised and adhered to, few doctors will actively seek the care they need.

Getting back to work

Once the doctor is better the next hurdle is returning to work. Most doctors, after recovering from a serious mental illness, find themselves jobless. This is because their contracts expired, were terminated, or they themselves resigned during the course of their illness. Returning to work after mental breakdown is difficult for anyone. For doctors within the NHS there is rarely any opportunity for a graduated return to work. Despite the existence of a consultant led occupational health service, the rehabilitation of mentally ill doctors is still left to the individual. In any case, these hospital based services do not cover general practice. Finally, there is the process of coming to terms with the whole experience and remaining well in the long term. A new organisation, called the Doctors' Support Network has been set up to provide support at this stage. The network began with one doctor who had experienced an overwhelming sense of professional isolation during a mental health crisis. As part of his own healing process, he decided to set up a self help support group. The Doctors' Support Network is coordinated by and composed of doctors who themselves have experienced a breakdown. The network is not a counselling service, a referral agency, a substitute for professional psychiatric care, or a form of group psychotherapy. It does however provide a safe place to share experiences and reduce the profound sense of loneliness, fear, guilt, and shame which undermines the recovery of sick doctors. Simply admitting in a confidential and informal setting that one has been mentally ill can be a tremendous relief. The basic message is that doctors do recover from mental illness and can recreate their identity as competent, caring doctors.

Horror stories

So far there have been five monthly meetings attended by doctors from all over Britain. Their mental health problems have included severe depression, work stress and burnout, manic depression and chronic fatigue. Two prime concerns of recovering doctors are the difficulties associated with returning to work after a breakdown and the stigma associated with mental illness. Doctors also shared various horror stories describing the treatment they had received from psychiatric services. These included the experience of being sectioned, exposed to violent patients, and being treated in locked wards without explanation or concern from any of the nursing or medical staff. One doctor, suffering suicidal depression, was repeatedly asked by ward staff, who knew he was a doctor, to check ward drugs and prescriptions. Furthermore, once fellow patients realised he was a doctor, they also consulted him.

Several doctors attending the meetings are unemployed, working part time or well below capacity. One GP has not been able to work for ten years as a result of chronic fatigue. It is has not been possible for her to find any medical employment that has sufficient flexibility to allow her to vary her workload according to her level of fatigue. She now struggles to retain any of her previous medical identity, with consequent loss of self esteem and clinical confidence.

As one doctor put it: “There is something profoundly wrong with a profession where a third of its general practitioners are showing signs of depression, stress and exhaustion. It costs over a quarter of a million pounds to train a doctor; no sane commercial organisation would tolerate such a situation.”

Senior support critical

For those who have successfully returned to full time work, the critical factor was often the ongoing support of a helpful consultant or senior partner. For one doctor, his recovery from depression began by sitting in with a sympathetic GP colleague during his morning surgery once a week. This was all he could manage for the first three months, but this experience gradually restored his shattered self confidence and helped him regain his clinical judgment.

On the other hand, stories of unsympathetic GP partners reluctant to shoulder the extra workload and uncaring hospital trusts were commonplace. Indeed, one GP was prevailed upon by her partners to resign after she had taken eight weeks' sick leave. Another GP was told by one partner, “pull yourself together, you're a doctor” and by another “I feel just as bad as you but I cope well enough.” Many found it increasingly difficult to explain a curriculum vitae with long gaps, and the disclosure “I have had depression” tends to be a conversation stopper in even the best planned interview.

The Doctors' Support Network already has the voluntary services of an occupational health physician who advises doctors wishing to return to work. It hopes to build up a bank of sympathetic general practitioners and consultants who could provide a ‘shielded' return to work and then support the doctor moving onto to a permanent position.

Describing the relief that he had felt in joining the meetings one doctor explained: “This group has come at the right time for me. I have never had the chance to talk with other doctors who have struggled with health problems whilst trying to carry on working. I realise now that others fear making mistakes and experience the same loss of confidence as I do. It's a tremendous relief to realise I am not alone. The meetings provide an opportunity to share experience as well as to make relationships that can provide support between meetings.” Better doctors now?

Several group members have successfully returned to careers in anaesthetics, public health, psychiatry, and general practice. Although all would have preferred to have lived without their mental illness, almost all agreed that their illness radically changed their view of medicine. Most felt they were more empathetic. Many of them talked about their increased sympathy and sensitivity towards their patients after their own illness. They felt that they were now more appropriate doctors and had more to offer patients and colleagues.

Before my own breakdown, I belonged to the “pull yourself together, what's wrong with you, stop making a fuss” brigade. I am now, I hope, less arrogant and more tolerant. I realise the damaging effect stress can have on colleagues and patients alike; and that we have to learn to be kinder to each other and to ourselves.