Trigger warning:  Blog-post raises ‘suicide’ and ‘physician mental health’.  It’s also brutally honest about physician mental health and the impacts of medical regulation on that.

Yesterday the status of my personal medical registration changed.  It took 2 years, 7 months and 9 days from when I posted my application for registration to the point where I received registration that allows me to practice clinically as a doctor.  I knew what I was getting myself into when I sent the application off in an express post envelope.  Truthfully, I wasn’t sure if I was ready for it, or if I could handle it.  I wasn’t totally unprepared, but I also didn’t know exactly where the journey would take me:  It didn’t take me where I thought it would.  

Where I’ve landed is a better place than I could have imagined, and I need to explain why.  I have a very ‘black-and-white’ thinking style; comes with being autistic.  When I started this journey, I thought the only outcome I would be happy with, or find acceptable, would be ‘unconditional medical registration’.  I wasn’t delusional; I knew that would be the “Disney movie” ending to the story.  Life’s not a Disney movie and the story didn’t end with yesterday’s decision:  We’re just at the next point in a much longer journey.  I’m 36 years old.  I’m glad I’ve learnt the things I did on this journey this young.

The decision and outcome relating to my medical registration very much have the potential to be viewed by doctors (and other health practitioners) as evidence that their careers may suffer if they are identified as having experienced mental illness (or another disability); obviously that concerns me (I’ve blogged about it before).  Fear impacts on people’s decision-making process when they are faced with deciding whether or not to seek help.  That fear has impacted my decisions when trying to decide how I deal with episodes of depression and any suicidal tendencies associated with that:  The impact fear had on those decisions has been to my personal detriment every single time.  The fear of what may happen to my prospects as a medical practitioner has driven me to:

• Plan suicide attempts far more carefully than I otherwise would have (increasing the likelihood of a poor outcome);
• Engage in higher lethality suicide attempts than I otherwise would have (having a special interest in toxicology is already quite unhelpful when entertaining suggestions from the Black-Dog);
• Run from people who may have had the potential to help me recover, when I otherwise would not have (it doesn’t matter whether they would have been ‘effective’ or not, I made the decision to ‘run’ before I knew); and
• Judge the performance or actions of those involved in my care (including any delays in recovery or iatrogenic harm that resulted) based on the overall impact of my illness, and how that has played into my journey as a medical practitioner.

My fears were not unjustified (for the most part), but, I hope that in sharing why I feel the outcome relating to my own registration status has left me in a better place overall, that I can provide a foundation for others which may help alleviate the fear of seeking help when they need it.  

I can’t tell people reading this that stopping, asking for help, and engaging in treatment, definitely won’t impact negatively on your career progression and professional reputation; it may (and that could be very distressing).  If you experience illness in a particular way, or with a certain level of severity, the evidence is that regardless of your conduct and performance as a practitioner, you may still end up with some kind of restriction.  Even three days ago, I hoped I would never have to write that; for fear that someone who thinks the way I previously did, sees it and makes a decision that places them at risk.  

Based on prior experience, I was fairly certain of a few things I’d face on the registration application, and appeal, journey.  Those things included that:

• Questions about my entire mental illness history would be raised and discussed (potentially very publicly);
• I’d probably be on my own regarding legal support (by way of the wording of my professional indemnity policy, and personal financial situation);
• There was a very real potential for personal and family relationships to suffer (because of how sensitive and intense the subject matter is);
• Any outcome regarding my registration would have the impact of potentially influencing how other doctors feel about seeking help (particularly for mental illnesses); 
• The privacy (that I hadn’t already lost) with respect to my mental illness history, diagnosis of autism, and related matters would probably be lost for good; and
• My worth, credibility, and safety (in some people’s eyes) as a medical practitioner would be assessed, primarily, on my health history and disabilities rather than my performance or conduct.

With those things in mind I made a decision that I should apply, and I should allow the progression of the story to be open and public.  At the very least, I knew that being open and transparent would open the doors for others to do the same, and hopefully provide some clarity about what can happen to a practitioner who is flagged as potentially impaired.  

I was right with respect to most of those points above:

• My mental illness history has been publicly discussed.  I am not ashamed of having experienced mental illness (and being a highly challenging patient).  Not being ashamed doesn’t mean that the exposure and those discussions doesn’t have an impact.  Sometimes, the individuals participating have put forward claims of ‘knowing’ ‘more details’ when the truth has been that they’ve never treated me, and they have based their very hurtful, defamatory and speculative comments on second-hand gossip.
• Legally, I was on my own.  It was suggested to me that a ‘free lawyer’ could be provided (somewhat late in the process), however the voluminous nature of my history made it easier to handle the matter as a self-represented litigant.  More importantly, being self-represented gave me the opportunity to actually put me, and my story, before the very people responsible for the ultimate decision in an honest, frank, and detailed way that I haven’t experienced in the past:  I didn’t want to be a name on many pieces of paper.
• The process was not only taxing on me, but it contributed to family tensions and distress.  Those closest to me suffered through the most challenging and traumatic parts of the ordeal with me.  Difficult conversations that may not have been had, needed to be had.  Disclosures about things I may have wanted to keep private occurred just in case I was asked about them while giving evidence (because there are some things you want the people you love the most to find out in a private environment and not a court-room).  The night before the final day of the appeal hearing I thought I’d single-handedly brought my parents’ 46+ year marriage to an end (I didn’t):  But, that’s what went through my mind the majority of the time I delivered my own summations in the case.
• The outcome of my application is so fresh that I won’t know for some time the real impact of the decision, I can only hope that when people read it that they also read this, and that they realise the fear of career damage/delay holds too much power over people in our profession.  Your life, your health and your mental wellbeing is worth so much more than being viewed as that perfect doctor who has it all together:  You are worth more than any career, and, you are enough without your career.
• My personal privacy was further shattered.  That was through my own doing, but also through the approach of the medical board.  One of the reasons I was slightly more accepting of the inevitable loss of privacy was that I already had publicly available decisions about my mental health.  People have breached my privacy repeatedly since medical school.  From my perspective, I had less ‘privacy’ to lose during an ordeal like this than a doctor whose peers know nothing of their personal illness, someone not already exposed.  Knowing the profound impact that the loss of my privacy with respect to highly personal events and information has had on me over the years, I completely agree that no practitioner (no person) should ever be subject to the invasions to privacy that I have experienced repeatedly, intensively, and without repercussion for the individuals involved. 

I was wrong about my final assumption about what the journey would mean:  My worth, credibility, and safety (in some people’s eyes) as a medical practitioner were not assessed, primarily, on my health history and disabilities rather than my performance or conduct.  Where I have practiced and performed well, and safely, that has been acknowledged.  My clean record, with respect to conduct and performance as a practitioner was also acknowledged.  There are some limitations on registration that are in place, they (in my reading) are not reflective of any decision that without these limitations I will be a dangerous doctor, nor pose a risk.  

The limitations on my practice are clearly there to provide a safety-net and reassurance that allowing me to return to clinical practice, in the context of having a pre-disposition to illness and a 5-year absence from clinical work, will not result in a situation where I am inadequately supported and guided as a medical practitioner.  It also protects me from returning to practice in any setting where there is no opportunity for those who have more experience than I do (in medicine) to identify whether I may need any extra help or training (either because of my disabilities or duration away from clinical work).  

Nobody said I’m not highly capable, or that I’m not worth having in the profession.  Nobody said I won’t be able to succeed.  It seems to me that those making the decision have said the opposite; with the right supports, opportunities and guidance, I will be an asset to the profession in the future, as I have been in the past (albeit while dealing with some challenges that other practitioners may not have to consider).  

While my conditions don’t give me licence to walk off and do whatever I want (in terms of freedom to engage in clinical practice), they’re entirely reasonable giving full consideration to the circumstances (training level, experience, past practice settings, absence).  For that, I am incredibly grateful to the four people who made the final decision regarding my registration:  Between them, they have far more insight and experience into the journey, training and support needs of young medical practitioners than I do.  Their decision facilitates for me a return to practice, if I choose to go through that door, that will ensure I have support at the ground level if, and when, I need it; it’s not punitive, it’s more logical and healthy than the outcome I practically begged them for.  

While I am very talented in a highly specialised area of medicine, I’m not ready to immediately dive into being a sole practitioner offering specialised medical advice in that area (pharmacogenomics).  I know the technical and medical knowledge side of it well enough to provide sound clinical advice to anyone with respect to that field, but practicing as a solo practitioner involves far more than simply ‘knowing the subject matter’:  This is something I have learnt relatively recently since electing to establish myself in a more professional setting with respect to the disability consultancy work that I do.  The skills I have in pharmacogenomics are not going to disappear if I am not immediately providing specialist advice in that area.  While it took me an hour to process why I wasn’t just not upset with the outcome that I received yesterday, but was relieved, I realised how glad I am that there is absolutely no pressure for me to fly solo in that capacity in the immediate future (I can’t, it’s not even an option – thank you).  

The unexpected, highly welcomed, realisation that means I can honestly say to anyone who asks that I am genuinely pleased with my current registration status, and the outcome of the appeal that brought me there, is this:

“I am enough.  I am good enough.  I am finally, for the first time in my life, in a place where I accept that I have worth and value even while appreciating that I am not perfect and have faults.”  

I have self-esteem (that’s new), where historically I have only had self-confidence.  They’re quite different.  Actually, today I realise that I now have self-esteem, but I have less self-confidence than when I previously had no self-esteem:  Probably because a reliance on self-confidence was about all that kept me going at some points and it was a little overinflated to compensate for the complete absence of any self-esteem.  You can’t buy self-esteem.  You can’t give it to someone as a gift.  Ultimately, this registration application journey took me through stages, events, and processes, that all acted in combination to help me develop self-esteem.  On reflection, it happened gradually, but the realisation of what has happened only occurred yesterday.  It started a few hours before I knew what my registration status would be, and it concluded when I pin-pointed why I wasn’t the crying, sobbing, mess that I thought I would be regardless of the outcome.  I was prepared for the ‘mess’, and I expected it in response to all possible outcomes, including unconditional registration:  Without self-esteem, I would have still been a crying mess with unconditional registration because of the relief that particular outcome would have provided me if I was still in any way basing my worth as a person or medical practitioner on my registration status or the wording of the decision that told me the outcome.

I can laugh today:  I was genuinely confused when I didn’t find myself sitting at my computer in a flood of tears.  I was calm, and I found myself sitting there feeling reasonably pleased and satisfied (but I didn’t understand why).  My poor father, who was in the near vicinity and allowing me the space to discover the outcome in my own time, was probably similarly confused when I emerged in a rather relaxed fashion to scavenge for food in the fridge:  I think I left him confused for a few hours when I left the house for a while (Sorry, Dad).  The big moment of understanding didn’t happen until some 9 hours after I read the decision.

Plenty of people in my life have told me “I am enough”.  There is a very big difference between being told it and knowing that to be true in your own heart.  I took on the cognitive truth of that concept well over two years ago; I couldn’t have posted my application for re-registration without knowing that cognitively.  The acceptance of that beyond mere cognitive understanding was what made it real and what gives it power in my life.  If I had to pinpoint the moment ‘being enough’ moved from being a fact of cognitive acceptance to something my heart knows to be true, I am not 100% sure I could give you the date and time.  I can assure you that it was after the final day of the appeal hearing and before 10am on 18 October 2019.  

Maybe it was the day I turned down two offers for roles in clinical medicine (for 2020) that I could actually do given my new registration status.  Maybe it was the day I decided I didn’t need to dive back into clinical practice immediately even if I was suddenly able.  Perhaps it was my 36^th birthday when the lease on my consulting suites started, allowing me to more effectively provide services to those I try to assist in my capacity as a disability consultant.  Maybe it was the day I decided to take action on another matter that required a firmer approach than I had been taking.  Maybe it was the day I accepted my own limitation and allowed myself to use assistive technology in a setting where I previously would have felt ashamed. It could have been the day that I decided I wasn’t ready to move interstate again for next year.  I don’t know.  I just know that the reality of self-acceptance and the acquisition of self-esteem has happened for me.  It was the last thing I thought would ever come out of this type of process, and it’s the thing that means I can sit here and tell you that I got the best possible outcome.  

For those who read about the change in my registration status, and the associated decision, I’d like you to remember these points:

• Don’t let fear stop you from getting help if you need it;
• You may end up somewhere unexpected on your journey, that doesn’t make you a failure, it doesn’t make your journey ‘tragic’, and it doesn’t mean you won’t be satisfied;
• Risk is not a reason to avoid challenge, it’s the reason you push harder when you’re in the midst of the challenge;
• You are not defined by your job, career, financial status or where you live:  You’re defined by who you choose to be, your intentions, and how you choose to engage with the world.  Please don’t sacrifice your life and who you are for a career;
• Perfect is not what it takes to ‘get there’.  “Being enough” is what you really need to aim for.  We are only human.

Today, I sign off knowing that “I am enough”; my talents, faults, quirks and all.  I sign-off knowing that I do my best and that is enough.

Kindest Regards,

Dr “Do Your Best”