Trigger warning – post makes reference to suicide.

Today is #CrazySocks4Docs Day 2019; it’s wonderful.  This movement, started by Geoff Toogood, has spread around the globe.  We have doctors and other health professionals all standing up to speak out and say, “We aren’t going to accept a professional culture that stigmatises those who experience mental illness.”

From where I am, it seems like we’ve reached a major turning point in the culture of medicine.  Those who are standing up, donning their #CrazySocks and saying, “We simply must do better.” are not just the people who have experienced mental illness, but their ‘well’ peers who recognise that it could have been them and may be them in the future. 

We’ve reached a critical mass of voices in unity.

Is it too early to call this a critical mass?  No, I don’t believe so.  According to Wikipedia, “critical mass is the smallest amount of fissile material needed for a sustained nuclear chain reaction.”  For a high school physics nerd like me that feels pretty exciting!  But what does it mean for this issue?  Can we now expect an automatic flow-on out of the critical mass of real-time changes that will support our peers who are impacted by mental illness?  Will the changes we need in order to reduce the incidence and impact of mental illness in our professional simply occur?  The answer to that is, no.  The critical mass of people standing up in unity is the crucial ingredient, the foundational step, and an immeasurable achievement: For a nuclear chain reaction, we need to do certain things with that ‘critical mass’.  It doesn’t stop here.

Those who have advocated along the way and helped bring us to this point should be proud beyond words.  I have no doubts that #CrazySocks4Docs 2020 (and in the years after that will continue to grow exponentially).  I’m certainly on the lookout for some super crazy socks I can add to my collection before then.  But what happens tomorrow?  What am I going to do in this space to ensure stigma around mental illness has no place in the profession I chose?  What action am I going to take to ensure any remaining stigma has no mechanism to survive? What action are you all going to take to ensure the stigma we’re screaming out against is genuinely thwarted and becomes a sad part of the medical profession’s history?

Mental illness doesn’t discriminate.  Doctors, and other health professionals, face situations that place us at an increased risk of depression, anxiety, and trauma.  We can’t afford to keep losing peers from our ranks because they experience these difficulties.  We need to take out critical mass and actively implement strategies that support stigma reduction.  

What does that look like?  

Time travel back 10 years with me to 7 June 2009.  I was about halfway through my internship and had started my third rotation on a busy surgical unit.  Before graduating I had experienced severe depression and made attempts on my life.  However, I had been travelling pretty well for a sustained period and was not unwell… My medical registration was subject to conditions based on the assumption that someone who had experienced mental illness would be a risk to the public without those conditions.  I also had fairly serious physical health challenges that made long hours an impossibility; but I was capable of working the full-time hours for which I was contracted.  On this day, 10 years ago, I was not ‘clinically depressed’; ten days later I was in an intensive care unit, barely alive, after having taken a high-lethality overdose. How did that happen?  

The attempt on my own life, on 17 June 2009, wasn’t rooted in an episode of clinical depression.  That attempt was a very much a reflection of a training system and a medical culture that did not allow for good self-care (mental or physical).  On that day I was isolated, trapped, feeling helpless without any way forward, and utterly exhausted.  To put it frankly, I was so overwhelmed by the situation and could see no way of surviving.  Sounds a bit like ‘depression’, so I’ll explain why it wasn’t.

In the months leading up to the commencement of that surgical rotation I flagged with the internship coordinator that, physically, I wasn’t managing the 16-hour days (sometimes several in a row depending on the roster). I explained I was getting physically sick as a result and requested the hospital assist in organising my roster so that I was still meeting my full-time obligations (80 hours a fortnight), but not rostered on for up to 120 hours (plus non-rostered overtime).  The proposed solution was totally unacceptable to me; it involved simply redistributing my excess hours among a handful of my peers who were already burdened with similar hours.  Needless to say, I told my Director of Intern Training that I could not accept that solution.  I don’t want anyone to see this openness as a criticism of that Director of Intern training; I don’t think there was a solution because we simply didn’t have enough bodies to fill all the hours.  That particular Director of Intern training is one of the kindest, most genuine, surgeons (and people) I’ve come across; he just didn’t have a magic wand and the situation was just as much out of his control as mine.  There was nobody more senior to flag it with because our hospital was temporarily without a Medical Director.  

In the email trail there was ‘administrative gaslighting’; to this day I don’t think the author realises that’s what was it was.  It was suggested that any intern who needed to work any ‘extra hours’ required remedial training in time management:  This wasn’t the case for me, or any of the other interns that I worked with that year.  We were all pretty capable and efficient.  If you added up the hours, we were all rostered on for over the course of that intern year you’d probably find the hospital could have employed 60 interns with full-time hours rather than the 40 interns we had.  The reality was, we had more work to do than hours in the day. The expectation was that we would pretend that wasn’t the case and work the excess rostered hours, plus any additional un-rostered overtime needed to get the jobs done for our patients.  At one stage hospital administration even asked us not to document our un-rostered overtime on timesheets.  It was implied that anyone documenting un-rostered overtime would be ‘pinged’ in their performance assessments for a ‘lack of efficiency or organisational skills’; that was motivation enough for many to simply plough on through.

I was beyond exhausted.  The physical cost of the extra hours was huge.  I barely had time for basic self-care.  I needed every moment of rest I could get.  Grocery shopping, cooking healthy meals, and even cleaning my home or doing laundry, all became ‘luxuries’.  My roster rarely allowed me to attend much needed medical appointments with my GP and specialists.  If I elected to take the weekly ‘afternoon off’ that we were allowed to take, I would inevitably return the next day and face criticism for that absence, even when I had communicated appropriately with my seniors before leaving.  My monthly infusions of immunoglobulins would normally have required one day off a month; interns can only take 20 days off in a year, or you fail on attendance.  I found myself having my infusions via the Baxter-bottle antibiotic infusion pumps, connected to my port-a-cath, while I did my rounds with everyone else. When my port needed replacing, I was back at work on a 16-hour shift the following day because I couldn’t get leave for more than the one-day needed for the procedure.  I’m able to look back now and judge myself far less for having become so broken during that time.  It was a lose-lose situation.  

My mental health issues in medical school were fairly widely discussed and gossiped about.  The majority of students knew ‘stuff’, but few really knew what was going on, the details, the facts, and few asked:  I guess it was easier to simply assume.  Senior staff in the hospitals and medical school participated in the gossip and the message was out there; it was totally acceptable to engage in that kind of behaviour because I had experienced a certain type of illness.  It wasn’t everyone, but there were a large number. Stigma and prejudice were alive and well.  I knew about the back-chatter.  I knew about the breaches in privacy and ongoing inappropriate access to my clinical records where I had been treated for mental health issues.  I knew that many of my intern colleagues, at least those who went to the same medical school as me, viewed me as ‘less worthy of being in the profession’.  

At our graduation ball when the ‘joke awards’ were being handed out people asked, “Who is the least likely to be in medicine in 10-years’ time?”: Someone shouted out my name and the room went silent.  If I had not been sitting at a table located so far from the door that an exit from the building would have been visible to everyone, I would have left within seconds: Instead, I sat there and acted like it didn’t matter.  The majority of my graduating class knew that I had faced a fitness to practice investigation from the Medical Board the previous year.  The actual answer to the question was meant to be the name of a classmate who had diligently completed their medical degree at their families request while wanting to set up a bakery.  That moment was the embodiment of stigma, and it hurt; actually, it still hurts to write about it (publicly) more than 10 years later.  That stigma was isolating.  

Having been unsuccessful in trying to negotiate safer working hours, having been repeatedly berated when I did take time to engage with my health practitioners, I was in a tough spot.  Add to that the extra scrutiny I was under as a doctor with conditions on their registration and facing stigma for a mental health history that was fairly widely discussed; I felt trapped.  How could I possibly ‘win’?  I couldn’t do what I needed to look after my health.  Any criticism of my performance was likely to be attributed to ‘a mental illness’ by the Medical Board and potentially used to further restrict my registration; the reality is, I am a human, and was in my first year as a doctor just like everyone else.  Isolated by the stigma, and absolutely exhausted beyond the point of being able to make good decisions, I broke.

The story above highlights how various factors can bring someone to that breaking point without there even being an underlying clinical depression. I’ve also reflected back over the years and wondered whether I would even have been in a position to recognise if I had been clinically depressed; I don’t think I could have.  

How do you assess a change in your appetite when you’re too busy and tired, to really think about food and just grab whatever you see at the hospital’s cafeteria, or the Hungry Jacks drive thru?  How do you assess a change in your sleep, and weigh up the cause, when you’re barely getting the sleep you need, and your hours require you to frequently deny yourself sleep, or wake up from your sleep, while you’re still tired?  How do you tell if you’re overwhelmed because you’re becoming depressed and coping less well than normal, when the stressors you’re facing are all quite significant and could be overwhelming to someone who isn’t depressed?  How do you tell if your anxiety is above and beyond what is expected of a junior doctor desperately trying to pass, succeed and secure referees so they’ll still have a job the following year?  How do you let your doctor know you’re finding life tough when you can’t even attend an appointment without criticism from your seniors?  Even if you do get an afternoon off each week, how do you book an appointment when you don’t know in advance which afternoon? These are all relevant questions. 

How can we expect doctors to look after the health, mental or otherwise, when we’re putting them into a situation that makes that close to impossible?

It’s my personal belief that while we still have rosters and attitudes that don’t allow for good self-care that we actually still have stigma; or we’re at least leaving the foundation there for stigma to regrow.  By having a situation where we are essentially looking at ‘survival of the fittest’ we create a situation where those facing other issues ‘drop-behind’ or appear less capable when they can’t meet the excessive demands for whatever reason.  Maybe they’re physically sick, maybe they’re experiencing depression, perhaps they have young children and family commitments, maybe their elderly parents need their help:  They’re not less capable, but they may not have the same time resources available to meet the demands of ‘more than full time’ employment expectations.  The likelihood is that they’re just as good a doctor as the person who seems to work their 70-hour week with relative ease.  

I’ve been very open about a very dark moment in my history.  Some may see it as blaming…  I hope most will see past that and realise that any of us could end up facing a moment of being overwhelmed, helpless to change our circumstances and trapped.  We need to be taking action to change our professional environment so that these factors are not there.  We need to take the passion behind wearing our crazy and loud socks today and actively seek out ways we can re-work our medical culture so that the risk factors for mental health problems are minimised, so that our peers can discuss mental health as openly as a broken leg, and so that we can recognise warning signs of serious mental health conditions (because the warning signs aren’t masked by system issues). 

For those who are wearing their craziest socks today (and in all the lead up events this week), Thank you!  My challenge to each of you is to think of 3 things you can action in your own workplace to bring about a change in the circumstances that give stigma its foundation.  Can you change the rostering?  Can you help your staff plan their time off so they can use that effectively for self-care if they need it?  Can you take a team coffee break and let everyone know that its ok to come forward and ask for assistance or understanding?  Can you show your own vulnerabilities to your colleagues to they know they can show theirs when they need to?  

Let’s take this critical mass and drive it towards a sustained change in our medical workforce and culture.  #MH4Docs  #CrazySocks4Docs.