When a 24-year-old laborer’s apprentice used a chainsaw without training, they sustained a jagged laceration through their left quadriceps. When I saw them 12 months later in my general practice, their laceration was well healed. However, they remained unemployed because their untreated post-traumatic stress disorder (PTSD) was aggravated on their return to work when their boss put a chainsaw in their hands to help them “toughen up and get over it.”
Clearly, the apprentice’s severe mental injury was contributed to by the failure of his employer to provide adequate training and support. The young man’s surgeons carefully attended to his physical injury, but underestimated his mental illness when they certified him fit for pre-injury duties in an unsafe workplace.
There are striking parallels in this case with the way the medical profession sometimes underestimates acute and repetitive work-related mental injury in doctors who work in psychologically unsafe health care workplaces, particularly in its own apprentices.
In recent times, major global and national issues have plunged our health systems into chaos and resulted in a major mental health crisis in our communities – and health workers, including the medical profession. And yet, in the wake of a pandemic and other multiple disaster exposures (here), there seems to be a tendency in medicine to “just want to put it all behind us.” Have we considered that responses such as “I don’t want to talk about it,” “It’s just part of the job,” or “Toughen up, get over it” may be symptoms of unhealthy avoidance following multiple traumatic experiences?
Work-related mental injury is under-recognized and undertreated
The medical profession must reconsider some fundamental questions if we are to effectively address the current “doctor burnout crisis.”
As a profession, are we recognizing the difference between burnout and more severe forms of mental injury?
According to the International Classification of Diseases, 11th revision (ICD-11), “burnout is a syndrome conceptualized as resulting from chronic workplace stress that has not been successfully managed. It is characterized by three dimensions: 1) feelings of energy depletion or exhaustion; 2) increased mental distance from one’s job, or feelings of negativism or cynicism related to one’s job; and 3) a sense of ineffectiveness and lack of accomplishment”.
Work-related mental injury may include a range of different mental illnesses in addition to PTSD and complex PTSD, such as adjustment disorder, major depression, anxiety disorder, and panic disorder, each with diagnostic criteria requiring a comprehensive mental health assessment and specific evidence-based psychological treatment and/or pharmaceutical management.
When burnout does not respond to rest, self-help strategies, and reduction of work stress, we must consider the possibility this is more likely to be a more serious work-related mental injury, as this hospital medical officer (HMO) described to me.
“I am haunted by traumatic losses of patients, family members, and friends during the pandemic. When I was expected to cover other doctors’ sick leave at short notice and take on enormous patient caseloads, I couldn’t cope, and I still feel like a failure. Although lockdowns are over, I continue to withdraw from people outside of work. I’m exhausted, but can’t sleep due to bad dreams …”
How can the medical profession better support doctors like this young HMO?
It is important to remember that, sometimes, simple actions rather than formal psychiatric interventions are effective. This may include being listened to, receiving informal emotional support from colleagues, confronting and discussing fears, finding a new meaning or purpose in life and work through adversity, and having senior role models who are willing to share their vulnerabilities “having been there and recovered.” Unfortunately, these sorts of supportive interventions are lacking in medicine.
Every doctor can benefit from prioritizing advanced approaches to psychological protection just as we prioritize physical protection. We can also seek professional support from a GP for routine mental health screening as part of an annual comprehensive preventive health check.
Unfortunately, there is a persisting negative stigma and shame surrounding psychological problems in medicine, which prevent doctors from seeking interventions for mental health problems.
Why have we been unable to shift the entrenched attitudinal barriers that deter the access of the doctors to optimal mental health care, including fears about confidentiality and mandatory reporting? Having a trusted, independent GP (who is not a friend or work colleague) for routine health care allows a doctor to take time off work for stress and mental health issues confidentially and also overcomes any risk of an inappropriate report to a regulatory authority.
Do doctors know where to access early specialized psychological therapies and, if needed, pharmaceutical treatment for the specific psychiatric conditions listed above? Or where to access online cognitive behavioral therapy programs, websites and resources, specialized online treatments for insomnia, and regular consultations with an experienced therapist face to face or via telehealth, particularly for isolated rural doctors?
Many of the answers to helping doctors recover from work-related mental injury are documented in evidence-based guidelines for psychiatric conditions. As one example, Phoenix has published specific guidelines for PTSD or complex PTSD, which should be read by every doctor given the extent of trauma exposure in our communities and ourselves.
Work-related mental injury is aggravated by an unsupportive culture in a psychologically unsafe workplace.
The mutual support of colleagues through shared challenges is one of the great joys of a medical career. Through adversity, we develop strong connections and lifelong friendships which sustain us. Unfortunately, during the prolonged isolation imposed by the coronavirus disease 2019 (COVID-19) pandemic, these supportive relationships have been lacking, and many doctors were let down by other colleagues in vulnerable times in the past few years.
In a medical career, when we are routinely confronted with many stressful and traumatic experiences; suffering is a natural human response, not a mental weakness. In this situation, it is unfathomable that doctors continue to report being bullied, ostracized or overlooked by colleagues or employers after temporarily being unable to “pull their weight” due to a work-related mental or physical illness. After years of dedicated service to patient care, the words “toughen up” and “get over it” are deeply painful when a doctor is unwell.
A clarion call for a new approach to work-related mental injury in medicine
The intractable nature of mental health problems in doctors has a long history, which suggests that something must dramatically change in the future.
Unacceptably high levels of mental health problems persist in the medical profession for complex reasons. Notably, many doctors have been subjected to abnormally demanding and unsafe work environments, long hours, high stress, and traumatic situations in the past few years, and are at increased risk of mental health problems.
It’s time for a united medical profession to re-evaluate and scale up its efforts in relation to high levels of work-related burnout and mental injury in doctors who work in psychologically unsafe health care workplaces.
If this opinion piece has triggered any discomfort, please make a long consultation with your independent and trusted general practitioner or other mental health professional to talk about recovery from burnout and work-related mental injury.