Sarah Tulk is a family physician in Hamilton, Ontario
Despite earnestly advocating for physician mental health, my own story has remained cloaked in secrecy. As a medical student, I felt far too junior to risk such a revelation. I watched as stigma, perpetuated by the hidden curriculum, kept my peers from seeking mental health care. Still, I kept my head tucked safely in the sand, and swore to break my silence in residency. However, as a resident the fear of jeopardizing job prospects maintained my mutism. I vowed to speak up when I was staff. Unfortunately, early in my staff career my advocacy efforts were smothered by fierce judgment and harsh consequences. I wholeheartedly renewed my vows with the ostrich approach and reconciled to start talking about mental health when I was protected by more seniority. I hated the secrecy and hypocrisy, but at least I was safe. Then I heard of another resident suicide. Then a medical student. Another resident. A staff physician. Tragically, suicides stopped being surprising. There is no perfect time to start the conversation about physician mental illness, but there is a right time, and that time is now.
The mental health advocacy physicians readily afford patients does not extend to the profession itself. There seems to be more talk about the importance of talking about mental illness, than actual talk about and by physicians with mental illness. Where are the stories? If the recent CMA National Physicians’ Health Survey is to be believed, this silence isn’t due to low prevalence. They report that 20% of physicians have contemplated suicide in their lifetime, with just under 10% having contemplated it within the past year. Depression and burnout are also rampant, with 30% reporting high levels of burnout, and 34% screening positive for depression. With numbers like that, you would expect hordes of physicians to be screaming “me too!”. Yet physicians’ stories of ill mental health are scarce.
Physicians are proud, hard-working, resilient professionals. “If you aren’t dead, you show up” is the golden rule of medical training. Unfortunately, mental illness doesn’t come with the casts, scars or impressive laboratory abnormalities that authenticate physical illness. When a physician discloses mental illness, they need to be taken at their word. This opens the door for judgment and discrimination. Is someone experiencing a panic attack, or are they attention seeking? Do they have depression, or are they lazy? Was their suicide a terminal symptom of mental illness, or evidence of a lack of resilience? It is appalling that any physician should ‘show up’ until they are dead, without ever receiving care.
To help our colleagues, our profession, and ourselves, we need to starting talking – really talking – about mental illness. We need to break the silence that fuels stigma and propagates mental illness as something shameful to buried. Silence stifles the growth and evolution of medical culture towards one of openness, understanding and support. If no one speaks about what helped them recover, and what stood in their way, best practices cannot be established. By withholding stories of sickness, others are denied the support found in shared suffering. By withholding stories of recovery, others are denied the inspiration and courage that are found within.
When I was depressed and suicidal, I reached out for help and was overwhelmed by the positive response. The road to remission wasn’t easy, but the kindness and compassion of colleagues and care providers made it bearable. Now, I can share first-hand that recovery from even the darkest of places is possible. I may never lose the label of “major depressive disorder”, but in a way that’s okay. It reminds me that I am strong, resilient, and surrounded by support and care. It reminds me to always consider the patient experience, to which I can now relate on a much deeper level. Finally, it reminds me that I, like all my colleagues, am human, with human vulnerabilities, and that I need to actively manage my mental health in this rewarding, but very demanding, profession.
Talking about my depression has had painful consequences, but also many rewards. I have helped others get the treatment they needed. I have shown them that they were not alone in their suffering in ways a statistic could not. With medical students I have sought to normalize mental health care by modeling good self-care and validating mental pain. I want them to know the importance of holding judgment and offering a helping hand to a struggling colleague. The sound of stigma and stereotypes breaking when colleagues find out about my depression is music to my ears. “Really? You?” Yes, me. Anyone.
I’ve learned that it doesn’t take grand gestures to promote a medical culture that is mental health friendly. “Hi, how are you” should be treated as a genuine question, not a passing greeting. Buy your stressed colleague coffee. Offer to lend an ear. Create awareness about physician mental health. Tweet about it. Bring up an article you read on the topic (like this one!) in conversation. Tell people when they’ve done something well. Own that a case was emotionally challenging. If you feel ready, share just a tiny bit of your own experience. Above all, when someone makes a brave disclosure, react positively.
We owe it to ourselves, our colleagues and our profession to enable open discourse about mental health. Seeing a psychotherapist needs to be as acceptable as seeing a physiotherapist. Taking psychiatric medications must be expunged of stigma. Presenteeism, especially for mental health reasons, needs to stop. Suicidal ideation deserves the same respect and response as a STEMI – if not more. Shamefully, suicide is the only means of death more common in physicians than the general population. Not shameful on those physicians lost, but on our profession for not supporting our own like we do our patients. We know better – now we need to do better. How will you help?
Thanks for your story of pain and resilience. We need to speak more loudly…all the time.
I am in the process of actively supporting a NATIONAL CANADIAN HOTLINE that should offer 24/7 contact for any physician or medical trainee in serious distress. We do have provincial physician health programs but not all of them are available around the clock. My suggestion would be to “man” this line with physicians who have “been there” like yourself and have survived….showed up at work!
We need to truly support each other and SPEAK LOUDLY.
Thank you for opening up your heart and talking about mental illness. I think we need to be even more open but in a very caring, nurturing and private area where we feel safe. We need to be more specific about how we feel. About how we want to be the best, how we feel when patients seem to be disapproving of us, how we are critical of other physicians, how we don’t feel that we can share our feelings for fear of reprisal.We need to talk about anxiety, how could come from our background, our experiences, our childhood and will eat it to the myriad of experiences of physicians. A forum for such discussion is limited. Recently I had the opportunity to be with two other physicians discussing a resiliency program that was offered by the University, Online. That was great. We were honest with each other. We shared some issues that were happening to us and our families. This stuff never comes out in the usual way. We needed a safe boardroom where no one was judging us and where we could be honest. Let’s try to create those safe areas.
As an alcoholic physician with over 30 years of recovery and 4 lifetime episodes of depression I have seldom been asked to share my story of recovery we have so much to share but stigma and ignorance stop folks from asking.
Graeme Cunningham MD,FRCPC
As a recovering alcoholic physician I welcome any resource that moves our profession from the stigma of the disease to the dignity of recovery.In the secrets lies the sickness.
Hi Sarah, great article. Could you send me your contact information, I have someone that needs to talk to you as a fellow medical professional?
Thank you for your bravery and honesty. I hope we as a profession can change our culture, support our community, and also grow as individuals. I offer a Mindful Healing course for my physician colleagues (based on work of Ron Epstein et al in Rochester), as community and mindfulness has helped me immeasurably.
Speaking of sharing individual stories, here is one from a highly accomplished physician in Australia that moved me: https://insightplus.mja.com.au/2018/41/learn-from-me-speak-out-seek-help-get-treatment/
Thank you for the courage to say this.
Thanks for sharing. Very well written.
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