Iris Otto tells a gripping story about why the medical world needs a cultural change.
It was a dark evening in late November and I was doing a night shift in the Emergency Room. It had been quiet so far and the time was creeping towards eight o’clock. My stomach was informing me that it was time for dinner. As I was contemplating whether to concede to my rumbling stomach, the most feared pager of the entire hospital made itself known: the CPR signal. The loud and prominent sound of the alarm had my heart racing within seconds, and without thinking twice I ran after the doctor on call towards the crash room. I found myself in a room full of slightly nervous people, in an ordered chaos, awaiting the patient whose heart had given up. It would be the first cardiac resuscitation I would witness in my life, and, retrospectively, possibly one of the most impressive too. Because the patient wasn’t a man in his sixties as you would expect, but an eleven-year-old boy, and I would see him die. The image of the ambulance bringing him in, his purple extremities, the cardiac pump nearly breaking his ribs, and the despair in the eyes of all those doctors is an image I can recall vividly, and one I will never forget. I remember how I wandered around the ER afterwards: numb, shocked, in disbelief.
People die in hospitals. That’s a fact no one will or can deny. A large group of individuals working in a hospital will one day or another be faced with the death of a patient, and possibly a horrid one. Doctors, nurses, students, assistants, paramedics, nutritionists, secretaries, laboratory staff… For some it is a more common event than for others, but it remains a shocking event nonetheless.
It was an ER nurse who asked me afterwards if I was OK. Only then I realized that I wasn’t, as I had been preoccupied by trying to make this a learning experience, like everything in our internship. But in fact I was shocked: I have seen and experienced lots of bad things, but this was really intense. During the subsequent months, I often thought back to that night. It got me thinking about why this image is set in my mind so vividly, while others ebb away. In psychology, a shocking experience is defined as an event that occurs outside the pattern of usual human experience, causing marked distress in almost anyone. It is a sudden and overwhelming event, where a strong sense of powerlessness can be apparent. In other words, it is an event that is so poignant it is hard to process emotionally. There is a whole slew of symptoms that may arise, either directly or months later. Physical symptoms include fatigue, insomnia, increased muscle tension, heart palpitations and changes in sexual desire. Psychologically, people can experience difficulty concentrating, depression, anger, anxiety, increased vigilance, helplessness, and irritability. In addition, without adequate support, victims can start to use alcohol, drugs and prescription medicine as a mechanism of escaping their situation.
Medical staff is at an especially high risk to witness a shocking event and suffer from psychological trauma or emotional distress. It may or may not come as a surprise that there are high numbers of alcohol abuse, burnout, depression, and even suicide among doctors. A 2004 meta-analysis shows that in the Western world, physicians are at a significantly higher risk of committing suicide compared to the general population. Male doctors had a risk ratio of 1.41, whereas for women the suicide risk was increased even more, to 2.27. This means that female physicians are more than twice as likely to commit suicide as non-physicians. Theories on causal factors include work-related stress, a high level of responsibility, and achievement pressure. For women, add to that the pressure of building a career in a male-dominated profession, potential sexual harassment, and combining a career with a family. However, a causal relation between suicide and all the aforementioned factors has never been proven.
Fact is, however, that suicide attempts are often more successful with doctors than with people who are not medically trained. Resources aplenty, it appears that doctors often resort to self-treatment with alcohol or drugs instead of turning to colleagues for help. This is illustrated by a report that over 50% of physicians admitted to psychiatric hospitals had apparent alcoholism or drug addiction. Exact numbers on medical staff suffering from burnout or depression are not available, as there appears to be a high threshold in coming forward and many consequently suffer in silence.
The competitive and often harsh atmosphere in the medical world may well be the reason why doctors are so hesitant in approaching their medical colleagues for help. Psychological problems are often left unmentioned, as doctors are afraid of stigmatization, loss of prestige, and a less successful career. Medical interns, especially, get to deal with many new and sometimes shocking experiences, without there being adequate support available, apart from their peers going through the same. Showing emotion as a medical student is barely tolerated by their superiors, making the factors mentioned above already evident early in a medical career. Sickness, trauma and death, however horrible, are part of the job, and doctors and students alike just have to deal with it.
To get back to my own experience with the death of a child: none of my superiors has ever asked how I was dealing with that shocking experience. At the time, I also didn’t have the feeling that they would open themselves to my thoughts and emotions. A little research has taught me that there often is no set protocol in hospitals on how to deal with shocking events and the psychological impact it has on their medical staff. In principle, employees can turn to their supervisor for a reference to a company doctor or psychologist. This does apply for nurses and other medical staff employed by the hospital, but not for students and doctors in a partnership (an alliance of a number of specialists, hired as such by the hospital), as the hospital’s collective employment agreement doesn’t apply to them. In reality, many choose not to come forward about their psychological problems as a consequence of hospital events because of the aforementioned reasons.
Psychological suffering, be it as a student or as a doctor, thus seems to be scarcely acknowledged and confidential support is limited. Unhealthy self-treatment, getting lost in isolation, and suicide are some of the serious consequences of the often cold and unforgiving climate of the medical profession. Striving towards an open attitude towards psychological stress attained in medical careers should be a major goal of medical management, in order to facilitate early recognition of psychological suffering and impairment of medical staff.
They say happy doctors make for happy patients, and that might just be true. I plead for a culture change in the medical world to create a healthy open atmosphere where doctors are allowed to have humanly feelings and dealings. In my view, this will improve the quality of healthcare and will likely only increase patients’ respect for their doctor. And the latter should count for colleagues too…
Iris Otto (‘09) went on to study at Selective Utrecht Medical Master (SUMMA) at Utrecht University after taking a year off to get research experience, and is currently finally using her cherished stethoscope at a peripheral teaching hospital.
Van der Heijden, F.M.M.A. et al. (2005) “Burnout in de opleiding tot medisch specialist.” Medisch Contact 47: 1905-1907.
Lagro-Janssen, A.L.M. & Luijks, H.D.P. (2008) “Zelfdoding bij vrouwelijke en mannelijke artsen.” Nederlands Tijdschrift voor Geneeskunde 152: 2177-2181.
Van Schaik, A.M. et al. (2010) “Te veel dokters kiezen de dood.” Medisch Contact 25: 1218-1220.
Schernhammer, E.S. & Colditz, G.A. (2004) “Suicide rates among physicians: a quantitative and gender assessment (meta-analysis).” American Journal of Psychiatry 161: 2295-2302.