Showing posts with label mental health. Show all posts
Showing posts with label mental health. Show all posts

09 December 2018

Part Two: Physician Burn Out and Suicide - The Road She Forged.


by Mary Fernando

Dr. Mamta Gautam developed complications in her pregnancy and, after delivering twins in 1991, she was in a coma for days. She was soon forced to return to work with an open abdominal wound. She realized then and there that, “Medicine doesn't care about the health of their healthcare workers.”

What Dr. Gautam did with this knowledge was to carve out a new way to do medicine. A psychiatrist by training, she became the “Doctor’s Doctor” and, in the 1990’s, began work with individuals and organizations to address burnout and suicide before it was on anyones radar.
A pioneer in the field of Physician Health, Dr. Gautam founded the University Of Ottawa Faculty Of Medicine Wellness Program, the first in the world to deal with physician health issues. She is now an international expert in physician health and leadership. 

So, when I was searching for answers on how to help reduce burnout and suicides in physicians, I reached out to her to find solutions.

Dr. Gautam said, “Before I answer, I want to talk about complexity theory.”

At this point, I had my pen poised. When interviewing people, I always wait for what Virginia Wolfe eloquently asked of them: “…to hand you after an hour’s discourse a nugget of pure truth to wrap up between the pages of your notebooks and keep on the mantelpiece forever.” I was a little disappointed to be sidelined by a theory I hadn't heard of, rather than an actual solution to the serious problem we were discussing.

Luckily, my disappointment was short-lived because that theory, and how it applies not just to medicine but all professions, actually was a nugget of pure truth. So, here it is for you to wrap and put on your mantelpiece. Forever. Whatever your profession.
  • Dr. Gautam explained that some problems are Simple and can be solved by following simple instructions, like baking a cake. There are instructions, and if they are followed, we have a cake.
  • Some problems are Complicated but can be solved by following more detailed instructions and require expertise, like sending a man to the moon. With the right expertise, we can again have a solution that we can replicate.
  • Some problems are so Complex that their solution cannot be boiled down to a list of steps and and expertise doesn't always help, like parenting. If you add people in, we have different outcomes depending on the person (in this case both the child and the parent). So, we are better off with guiding principles, rather than strict recommendations and rules. 

With physician burnout and suicides, prevention is best thought of in terms of guiding principles, at the level of the individual physician, the culture of medicine, and the healthcare system.
One key principle is the need for community. For some this may be implemented by re-creating the doctors’ lounge. This where we can gather and talk about the day; the hard parts, the best parts and the funny parts. It is the ability to break out of the isolation and connect. For all of us, no matter what profession we are in, the trauma of our day can haunt us. For physicians, this might be the patients who died despite our best effort, the metallic smell of the blood that covered the patient, the room and us in surgery as we struggled to save a trauma patient, the young baby who fought valiantly and the breathless sobs of her parents after she died. Those traumas we need to talk about. 

The next part - and the crux of the matter: doctors are human. They should not be so tough that their hearts aren't wrenched when patients suffer. We can and should viscerally feel the often soundless sobs of the families that mourn. That is who we are, and that is the best of us. So, there must be an end to the ‘tough doctor’ and a new opening for the human doctor.

This is a principle for all healthcare workers and for all professions. We have many ideals that we strive towards, never being able to truly fulfil them but always keeping them in mind as we move through life. Many are worthy ideals. However, the ideal of the very strong, very together, never broken and beaten down person is an ideal that many of us hold dear. That person, that ideal, is actually a Trojan horse: if we let it into our lives, it will become stuffed full of all that will defeat us. It will be filled to the brim with the guilt of not living up to this ideal and the feelings of vulnerability that we stuff in it because we are terrified that the feelings are not worthy of the person we should be. It will be filled with the trauma we face, the small and large wounds we suffer but do not speak about. So, it is time to find another ideal and recognize the Trojan horse for what it is. We need to be human, striving to be strong when we need to be and allowing ourselves to be vulnerable, weepy and sad, infuriated and needy too. Because our empathy, our compassion, that makes us vulnerable, is actually the true iron in our spine. Wholly and wonderfully complexly human.

So, how to recreate community where we are allowed to be fully human?

Dr. Gautam said, “There is not one answer. If people accept the need for community and allow each person to be human, how they create that community depends on where they are and what they need.” 

So, Dr. Gautam asks for solutions to this, from each of us. The principle matters, the execution of the solution, like all good answers to difficult problems, is written on water and open to life. 

She sees this article, and others like it, as an opportunity to ask each person what they need and how to carve out this solution. It is a beginning of a conversation we all need to have.

08 April 2018

Hell hath no fury...


by Mary Fernando

Imagine being so ill that you cannot even get out of bed. Or being too sick to spend time with your family and friends. Now imagine being too frightened and ashamed to tell anyone you are ill. Being so humiliated by your disease, that you can’t even tell your own doctor that you are ill.



One out of five people, 20% worldwide, have a mental illness. Many often go through this scenario. Some bravely ask for help. Some hide in the shadows. Some hide in alcohol or drugs.

When I was a young, inexperienced doctor, I was certain that the unfair stigma of mental illness would and should be eradicated in my lifetime. I felt that mental and physical illness were both simply illnesses to be treated. Now, after treating mental illness for decades, I know that I was correct.


The suffering of those with mental illness is real, and as varied, as patients suffering from anything from a broken leg to heart disease. Just as there is nothing shameful in having cancer, there is nothing shameful about having a mental illness.

Where I might have been a tad optimistic was in my hope that all the stigma of mental illness would be eradicated in my lifetime. However, since I am not dead yet there is, indeed, time. I have seen a lifting of the stigma of mental illness, a willingness to talk about it and reach out and get help.

What we still need to do is reach into the dark corners, the places where this stigma grows, and open the curtains and let the light disinfect the place.



The one prevailing myth that needs some attention is that the mentally ill are dangerous. This comes from articles about murders or violent crime, where mental illness is brought up as a possible cause. Also, from the books where murderers are often mentally ill: yes, I mean novels about crime.

If there is a disinfectant for myth, it is fact.

Since the U.S. has one of the highest incarceration rates in the world, with 666 citizens in jail per 100,000 of the population, we can assume that most of the dangerous people do end up in jail. However, if all those who are mentally ill were dangerous, that would mean that 20% of the population, more like 20,000 per 100,000 population, would be in prison.

How about an analysis of those who are in prison? Large scale reviews have shown that, in the prison population, less than 4% have psychotic illnesses.

The myths of mental illness and murder arise most frequently with the worst offenders: mass murderers. Dr. Michael Stone, a forensic psychiatrist at Columbia University who maintains a database of 350 mass killers going back more than a century, has found that only one in five are psychotic or delusional. This means that 4 out of 5 mass murderers are people who are clinically sane. 

Even analyses of those who are mentally ill and commit crimes shows that only 7.5 percent were directly related to symptoms of mental illness.


So, is there NO connection between mental illness and crime, particularly violent crime? The answer is that there is a very small connection, and one that is present largely in those who are not treated and who also abuse alcohol/drugs.

Those who are depressed are three times as likely to commit a violent crime. However, 60% of people who kill themselves have a mood disorder and suicide is the tenth leading cause of death in the US overall, and the second leading cause of death of 15- 34 year olds. Since there are twice as many suicides as homicides, the most likely violence done by depressed people is to themselves, not to others.

With schizophrenia, the risk of committing a violent crime was 3-5 times greater, but this was found largely in those not on medication. This research on violence and mental illness also showed that those who are mentally ill are more likely to be victims of violence than perpetrators.

For a final look at mental illness and murder, I present the full quote from the title of this article: “Hell hath no fury like a woman scorned.” Most of us would say that scorn is a good motivation for murder and that Shakespeare was insightful for writing this. However, Shakespeare didn't write it - it was written by the playwright William Congreve. Further, this isn’t even what was written - the actual line is ‘“Heaven has no rage like love to hatred turned / Nor hell a fury like a woman scorned.”

Common, widespread ideas can be wrong - like the origin of this “Shakespeare” phrase and the idea that those with mental illness are inherently violent. Certainty is meaningless unless it can be backed by facts, and in this case the facts do not support the certainty that most people feel.

Sometimes our first impression is wrong. Even with things we feel that we know, such as Shakespeare or mental illness.



† The US has the highest civilian incarceration in the world. — Ed.