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RESEARCH: Karin E Isaksson Rø, Tore Gude, Reidar Tyssen, and Olaf G Aasland Counselling for burnout in Norwegian doctors: one year cohort study BMJ 2008; 337: a2004 [Abstract] [Full text]

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BURNOUT AND SUICIDE OF DOCTORS: THE FRENCH “COMPAGNONNAGE” AS A SOLUTION

gaëtan thiéry, Nicolas Lari, Saliou Adam, Louis Cador, Jean Baptiste Meynard   (30 November 2008)

BURNOUT AND SUICIDE OF DOCTORS: THE FRENCH “COMPAGNONNAGE” AS A SOLUTION 30 November 2008
gaëtan thiéry, Master II in ethic medicine, chief of the Department of Oro-maxillo-facial surgery Marseille France, Nicolas Lari, Saliou Adam, Louis Cador, Jean Baptiste Meynard Send response to journal: Re: BURNOUT AND SUICIDE OF DOCTORS: THE FRENCH “COMPAGNONNAGE” AS A SOLUTION	Dear sir, We agree with your findings indicating that seeking a counselling intervention could be conducive to reduction of burnout among doctors and so suicide. But why doctor’s reluctance to seek help increases? Do these interventions must take place earlier during the medical studies? We propose another solution based on a singular education system: the “compagnonnage”. Studies over the past 4 decades have shown that physicians die by suicide more frequently than non physicians [1]. The risk of dying by suicide is 70% higher for male physicians than for men in the general population. For female physicians this risk is 325% higher than other women. Although the suicide rates for male and female physicians are about equal. In the general population the suicide rate for men is higher than for women [2]. In 1999, in France, the rate of suicide was 14 % within physicians and 5,6% for the general population [3]. The two main suicide risk factors are represented by depression and substance abuse disorder. Alcohol is the most abused drug [4]. Both biological and psychosocial factors may play a role in physician suicide [5]. A higher prevalence of psychiatric disorders exists among physicians than in the general population. Physician suicide has also been correlated with personal, professional and financial stresses: conflicts between work and personal life, career dissatisfaction, little vacation time, excessive professional demand, long working hours. More recent studies found that physicians experienced stress with a changing set of problems; in particular paperwork and administrative hassles, loss of autonomy [6]. The culture of medicine accords low priority to physician mental health despite evidence of untreated mood disorders and an increased burden of suicide. Barriers to physicians in seeking help are often punitive, including discrimination in medical licensing, hospital privileges, and professional advancement [7]. In 2003, the American Foundation for Suicide Prevention emphasized the need to change physician attitudes and institutional policies to encourage physician to seek help when needed [8]. Though, the principal factors of physician suicide have been well described. Is this phenomenon linked with a crisis of the medical formation? “It’s easier to change people’s habits while they’re still learning”. Medical formation is nowadays more and more scientific. We are no more philosophical physicians but « engeneers of life ». However man remains our « material of work ». Medical teaching provides knowledge by the means of studies, exercises and control help. But what about ethical and philosophical education of the future physicians? Their current material of work, men and women, live, suffer and die. They are not well prepared to deal with all the aspects of the human nature. And without references given by their medical training, they can find a way in drug dependence and suicide. It’s therefore in the heart of the medical education that we have to find some solutions. Does “compagnonnage”, this particular mean of teaching by companionship can be adapted for medical studies? “Compagnonnage” is not only an educational method but also a complete organization of work and life for construction workers and craft people. It was born in the fifteenth century in France. After an important development, industrialisation stopped the spread of this movement. However, today “compagnonnage” is still persisting, underlining the pre- eminence of its education method (9). “Compagnons” (people who take part in the movement) are recognized and searched for their skills and tact. “Compagnonnage” represents specific education and knowledge transmission, but also mutual aid, taking care and giving protection (10). Apprenticeship is different of normal education. The objectives are to develop the knowing but also the being (11). The knowing is to obtain practice, knowledge and skills. The being is the acquisition of attitudes, behaviours and values. The time sequence of apprenticeship is represented by several steps: observation, imitation, probation, repetition and at last presentation. During that sequence, the people have three academic ranks: apprentice, companion and finally master. This apprenticeship comes from behaviourism (12). An exterior stimulation creates a reaction of the subject, which is commented by the teacher who can accept or improve it. This change of comportment is persistent, measurable and specific. The teaching gives an answer for each problem (ie. in front of that clinical case a therapeutic answer). Apprenticeship develops autonomy of management in face of the problems. In front of an abnormal problem, the novice will be competent to react in an efficient way (14). The anxiety face to the problem will be therefore diminished. The apprentice, the companion or the master will be less dedicated to addiction and suicide. During of each day the apprenticeship, the teacher gives ethical references: no maleficence, charity, independence and justice. The “compagnonnage” is based on mutual aid, and fellowship. A “compagnon” is never alone. It is permanently possible for him to ask for counsel or financial help. In the medical world, brotherliness has deviated since Hippocrate’s time. The physician is nowadays often alone. Even if it is possible to find some help within erudite societies or universities, the culture of fellowship has evolved since old times and the physician has not received the education to ask for help. As he is alone, it is easier to fail in addiction, to develop nervous breakdown and at last to be attracted by suicide. The use of the “compagnonnage” method in medical area could be a return to a Hellenic Hippocratic teaching. In latin, “compagnonnage” means “who eat his bred with someone else”. Is it possible to imagine using this specific method of formation for the medical studies? How to adapt it, to estimate its efficacy? Medicine is a profession full of risks. The reduction of addictions, depressions and suicides of physicians has become an emergency. “compagnonnage” could be a solution. It is currently used in France in specific areas like surgery or public health, but its use could be more generalized. REFERENCES 1 Frank E,Biola H, Bunrett CA. Mortality rates and causes among US physicians. Am J Prev Med 2000; 19:155-59 2 Schernhammer ES, Colditz GA. Suicide Rates Physicians : A quantitative and Gender Assesment( Méta-Analysis). Am J Psychiatry 2004 ;161 :2295-2302 3 Le Coz P. Petit traité de la décision médicale. Ed Seuil 2007 ; 95- 7 4 Hampton T. Experts Adress Risk of Physician Suicide. JAMA 2005; 294, 10 5 Man JJ. A current perspective of suicide and attemped suicide. A,, Int Med 2002; 136:302-11 6 Center C, Davis M, Detre T, Ford DE, Hansbrough W, Hendin H and al. Confronting Depression and Suicide in Physicians, a Consensus Statement. JAMA 2003; 289:23 7 Givens JL, Tija J. Depressed medical students’ use of mental health services and barriers to use. Acad Med 2002; 77:918-21 8 Levine RE, Bryant SG. The depression physician: a different kind of impairment. Hosp Phys 2000; 36:67-71 9 Icher F. La France des compagnons. Ed La Martinière 1994 ; 29-37 10 Coornaert E. Les compagnonnages en France, du Moyen Âge à nos jours. Les Editions Ouvrières 1966 ; 63-70 11 Guédez A. Compagnonnage et apprentissage. PUF 1994 ; 23 12 Watson JB. Psychology as the behaviourist views it. Psychological Review 1913; 20:158-177 13 Cador L. Etudiant ou apprenti. PUF 1982; 184-5 14 Tavris C, Wade C. Inroduction à la psycholgie- Les grandes perspectives. Erpi Saint Laurent 1999 ; 186 Competing interests: None declared