Surgeons and mental illness: a hidden problem?BMJ 2014; 348 doi: https://doi.org/10.1136/bmj.g2764 (Published 22 April 2014) Cite this as: BMJ 2014;348:g2764
- Clare Gerada, medical director,
- Richard Jones, cognitive behaviour therapist and specialist nurse
Doctors are not immune to developing mental health problems, but surgeons seem to be less likely than other doctors to seek help for these problems. Clare Gerada and Richard Jones consider why this might be and what might make surgeons different in this way from other doctors
Doctors do not have immunity to mental health problems. In the United Kingdom, between 10% and 20% of doctors become depressed at some point in their career.1 Suicide is a disproportionate cause of death among doctors, and relative to the general population female doctors have a 3.7-fold to 4.5-fold increased risk of death from suicide, and male doctors have a 1.5-fold to 3.8-fold increased risk.23 This is in contrast to suicide rates among the general population, where men account for three quarters of successful suicides.4 It has been suggested that greater access to lethal drugs and knowledge about drugs may be an important reason for these high suicide rates.5
Practitioner Health Programme
The Practitioner Health Programme (PHP) is a confidential London based health service for doctors and dentists. Practitioners presenting to the service have considerable, often severe, mental health problems, similar to patients who present to NHS mental health services.6
Between 2008 and 2013 the service saw 1059 practitioners, 1014 of whom were medical practitioners and the rest dentists. Alongside a specific diagnosis, PHP has four main groups for the problems that affect patients:
Addiction to drugs or alcohol, or both
Common mental illness (such as depression, anxiety, panic disorder, or obsessive-compulsive disorder)
Complex mental illness, not involving addiction (such as bipolar disorder, psychosis, or severe anorexia nervosa)
Other—for example, physical health problems, no diagnosis, organic presentations, or unknown diagnoses.
Over the five years that the service has been running, around 80% of the presenting practitioners have had mental health problems, the most common being depression. In addition, about 20% have had problems with addiction, and around two thirds of these doctors have also had alcohol dependence.
Of the 1014 doctors accessing the service, 44 were surgeons, representing 4.3% of the total cohort. Because PHP is a London based, self referral service, exact comparisons with the General Medical Council’s register are difficult to make, but 11% of those on the council’s register are surgeons, and so it is likely that surgeons are under-represented among doctors seeking treatment at PHP.
As a group, surgeons have differed from the other doctors presenting to the service. For example, 32 male and 12 female surgeons presented, whereas there is a roughly equal split between men and women when all doctors and dentists presenting to PHP are considered. Male surgeons in the service were significantly older than female surgeons—the male surgeons’ average age was 43.8 years and the women’s was 38.1 years.
Surgeons presented to PHP with problems across the mental health spectrum: around half, 24 (55%), had common mental health problems, such as depression and anxiety, 13 (30%) had complex mental health problems, and seven (16%) had problems related to addiction. Compared with the total cohort of doctors and dentists, surgeons had a lower proportion presenting with problems related to addiction; 50% of the total cohort had common mental health problems, 23% had complex problems, 24% had problems with addiction, and 2% were “other.”
Surgeons’ apparently lower rates of presentation could be the result of a number of factors. It may be that there is a true low prevalence rate of mental health among surgeons, perhaps because surgeons tend to have characteristics that protect them against developing mental health problems. Or it may be that surgeons’ training and their “typical” personalities give them the resilience to cope with occupational stress. Another reason may be that surgeons find it harder than other doctors to present for care, fearing stigma, shame, or risk to their career if they disclose mental health problems.
Unfortunately, there is a scarcity of research into the mental health of surgeons compared with other medical practitioners or the general population. The research that does exist points to a pattern similar to the findings among the surgeons presenting to PHP, principally high rates of burnout, anxiety and depression, and low levels of addiction.
In a survey of almost 8000 US surgeons, burnout, anxiety, and depression were reported by between 30% and 50% of respondents.7 Rates of depression increased with rising workload, particularly for night work. The survey also found that surgeons struggle with suicidal thoughts. Around 6% had experienced such thoughts in the previous year, and only a quarter of these surgeons had sought professional help. Older surgeons were especially likely to have suicidal thoughts, and having made a medical error was significantly associated with suicidal ideation.8
Hidden minority of surgeons
In a survey of 549 members of the Society of Surgical Oncology, 28% of respondents met the criteria for burnout.9 About 30% screened positive for depression, and further analysis suggested that around 10% of respondents would have met the criteria for major depressive disorder at the time of the survey if they had undergone a full psychiatric assessment.
In a UK survey of almost 1000 surgeons, respondents scored significantly higher than the general population on a range of occupational health factors, especially with respect to anxiety.10 Other studies find similar high levels of burnout in surgeons working for the NHS.11 These surveys imply that surgeons presenting with mental health problems are a hidden minority within a hidden minority. 12
There may be a set of specific risk factors for surgeons with respect to developing mental health problems. Surgeons have long training and regularly make substantial personal sacrifices to achieve their chosen profession, and perhaps it is not surprising that in a US study of divorce among doctors, surgeons had the highest divorce rate (33% after 30 years).13
There is little information on the number of surgeons with addiction problems. The sample approaching PHP suggests that they have low rates. The literature would also suggest that problematic alcohol use (over six drinks on one occasion in the last year) among surgeons is low and was reported by 6.8% of surgeons; a similar frequency was noted in another study of surgical residents.714 Given that it has been suggested that about 10-12% of physicians in the United States develop a substance use disorder,15 this makes surgeons among the lowest consumers of alcohol in the medical profession
These apparently lower levels of problematic substance use among surgeons may well have face validity. Close working relationships, with every move witnessed, as well as long and unpredictable hours of work, frequent on-call shifts, and out of hours work, would make it difficult to disguise an alcohol or drug problem.
Surgeons are also likely to have a number of protective factors that would help to protect them from developing mental ill health. It could be argued that surgeons have a more deep rooted sense of specialness and professional institutionalisation, described in the literature as important factors in the creation of the “medical self.”
It may also be that surgeons have a stronger medical self than other doctors. Surgery is generally seen as more prestigious than other specialties, and the surgeons’ work may strengthen their sense of medical self. Compared with other specialties, surgery often involves more obvious “victories,” close contact with medical peers, alongside ritualistic language and behaviour, such as washing and changing clothes before operating. This allows doctors to do their job effectively, in so far as dealing with stressful and long hours and providing the veneer of invincibility to live and work in such close proximity with sickness.
This would be in keeping with the experience of those providing treatment at PHP. Surgeons who present to PHP generally struggle more than other doctors to relinquish their professional identity and see themselves as patients. Surgeons often seem to struggle to accept that they might be ill or, when they do, they seek a quick fix.
Almost every surgeon who presents to PHP talks at length about the fear they have of other colleagues finding out about their mental health problems. They report that other surgeons don’t “believe” in mental illness, and they fear that they will be excluded by their peers.
Good prognosis for those seeking help
Surgeons accessing services at PHP often do so following a strong suggestion from an occupational health department, a manager, or a spouse. This would be in keeping with the relatively high rate of major mental health problems compared with other specialties.
When doctors do access the right health services, they have good outcomes. Once in treatment for mental health or addiction problems, doctors have a good prognosis. Over 90% of those with opiate addiction and 88% of those with alcohol addiction are abstinent five years after completing treatment. Improvements are substantial in areas of mental health, social functioning, numbers returning to work or training, and a reduction in the involvement of the regulator. Improvements persist over time and are regardless of gender, diagnostic category, or age of patient.16
Surgeons play a vital part in the complex network of the health service. They frequently deal with death and despair and are not immune from the mental trauma this might bring. It is important therefore that, as with all doctors, surgeons have access to timely, confidential, and specialist mental health services and are not left to suffer in silence. It is also important to look at factors in the work place that might lead to increased levels of mental health problems. For example, long hours will always be a part of surgical training, but working in teams (firms), access to respite when on call (a bed and food), and built-in time for reflection may go some way to offset the stresses of long shifts.
Surgeons who seek help are not failing surgeons. Surgeons who don’t seek help when they need it are exposing both themselves and their patients to greater risks.
Competing interests: We have read and understood the BMJ Group policy of declaration of interests and declare: CG is medical director of the Practitioner Health Programme; RJ is cognitive behaviour therapist and specialist nurse at the Practitioner Health Programme