John Bradford always prided himself on being psychologically tough. After all, he needed to be. As one of Canada’s top forensic psychiatrists, he analyzed some of the country’s most high-profile murderers including Paul Bernardo, Karla Homolka and Robert Pickton. In order to keep healthy and reduce stress, Bradford exercised regularly and played competitive squash and tennis. “I was very sensitive to my physical health,” he recalls “I was probably less sensitive to my psychological health.”
So when his mental breakdown hit, Bradford was totally unprepared. He unraveled after analyzing the videotapes of ex-Canadian Air Force colonel Russell Williams sexually assaulting two young women.
“I really had an acute event where I sort of broke down completely within half an hour of viewing the tapes,” he recalls. “I was crying uncontrollably, I felt like a complete failure.”
Bradford did not seek help immediately. “I was sort of thinking I’ll get over it,” he remembers, “I had about two months of this where I was struggling.” Then things came to a critical point when he came just short of an angry outburst while testifying in a dangerous offender’s case.
“Immediately after that I sought help, I got in contact with the Physician Health Program at the Ontario Medical Association.”
Bradford realized he was suffering from post-traumatic stress disorder or PTSD, an anxiety disorder characterized by reliving a psychologically traumatic situation through flashbacks and nightmares.
But even after being connected with a Canadian psychiatric expert in PTSD, Bradford had further delays in receiving treatment. The PTSD expert was someone Bradford knew professionally, creating a potential conflict in the doctor-patient relationship.
“He didn’t want to treat me so he referred me to someone else,” says Bradford. “I was also resistant to treatment because I felt it would go away.”
Bradfords’ health continued to deteriorate. “Things got bad,” he remembers. “I became very depressed to the point that I was actually suicidal.” He then became serious about seeking out treatment – starting medication and undergoing specialized psychological therapy for his PTSD.
“Delay in treatment was my own resistance,” he recalls. “Part of the reason that I talk about it is to help others. Not only educating people about vulnerability in medicine, but about resistance to treatment.” Bradford says that he believes “physicians are resistant to treatment, particularly for psychiatric issues. As much as we try to de-stigmatize it, it’s not an easy thing to come out and say- I suffer.”
Doctors get sick too
Bradford’s story might sound exceptional given the often-disturbing nature of his work as a forensic psychiatrist. However, his struggle with mental illness, and his challenges seeking and accepting care are common to physicians across Canada.
Much of the data on this comes from the The Canadian Physician Health Study, which surveyed nearly 8000 of Canada’s 75,000 licensed physicians in 2007. The study reported that Canadian physician physical health is comparable if not better than that of the general population. Indeed, more than 90% reported being in good to excellent health, and leading healthy lifestyles.
While Canadian physicians have satisfactory physical health, there is substantial concern about their mental health. The study revealed that nearly half of all practicing physicians are in the advanced stages of burnout. About one quarter of physicians reported having a 2-week period of depressed mood, having mental health concerns that made it difficult to handle their workload, and a poor work-life balance.
One area of concern is the risk of suicide among physicians. This area is not well studied in Canada, and there is little recent information in the research literature. A study which reviewed causes of death for a sample of American physicians over a 50 year period from 1948 to 1998 found that physicians are at substantially lower risk of dying compared to the general population for all causes of death – except suicide.
In addition, a 1997 study on the causes of death for over 20,000 physicians in the United Kingdom revealed that physicians, in particular women, face higher risks of suicide compared to the general population. A 1999 United States study, however did not find a higher suicide risk among women physicians.
With the Canadian Physician Health Study data nearly a decade old; there are many gaps in data and knowledge around physician health.
Struggling in silence
Michael Kaufmann, medical director of the Physician and Professionals Health Program of the Ontario Medical Association points out that there are important issues beyond studying the prevalence of physician mental health issues.
“From my perspective, the issue is not how prevalent these problems are, it’s how easy it is for us to get help and how quickly we can get that help,” says Kaufmann. The Canadian Physician Health Study suggests most physicians were not aware of available resources when they were in need of help.
The problem starts with primary care. An American study found that almost one third of physicians have no regular source of medical care, resulting in a whole host of problems including self-diagnosis, self-referral and self-treatment.
Indeed, The Canadian Physician Health Study found that over 50% of physicians agree that if it’s possible to take care of their own medical needs – they will.
A 2011 systematic review found that more than half of physicians self-prescribe medications. More specifically, a 2005 Norwegian study reported that more than half of physicians had self-prescribed medication at least once during the previous year. The most frequently self-prescribed medications were antibiotics, contraceptives, painkillers, and sleep aids.
But perhaps of greater concern are the multiple barriers to physicians seeking help. Michael Kaufmann suggests that the culture of medicine itself discourages physicians from seeking help when they need it.
“Traditionally it’s a culture that does not allow us to become unwell, it’s a culture that champions putting the needs of others before our own; self-denial in all kinds of ways is modeled,” he says.
Indeed, the heavy workload of physicians and the associated time and scheduling difficulties influence the ability to obtain care. Additionally, many physicians struggle with moving from a position of authority as a practicing physician to a vulnerable position as a patient. Moreover, fears about the potential for breach of privacy may lead physicians to delay seeking care or to minimize symptoms or aspects of their medical history. Finally, some doctors fear damaging their careers or putting their medical license in jeopardy if they seek treatment.
But most disturbing is the profound stigma towards physicians who are mentally ill. While this stigma is certainly endemic to society as a whole, physician health experts remain baffled by its pervasiveness within the profession of medicine itself.
“It’s a culture that stigmatizes its members when they have mental health problems or substance use disorders,” says Kaufmann. “It’s a culture that teaches us to act as if we’re fine no matter what we feel inside as part of professionalism, and it’s a culture that until recently hasn’t had a wide array of easily accessible support services,” he says.
Michael Myers, Professor of Clinical Psychiatry at SUNY-Downstate Medical Center is a leading expert in physician health who practiced medicine in British Columbia for decades. He points to this culture and attitudes as adding to higher suicide risk among physicians.
“Unfortunately in the medical world there are too many doctors who totally fall through the cracks who we know kill themselves without ever receiving a diagnosis or treatment,” he says. “They may self-treat, they have no primary care provider or psychiatrist, and they have no file.”
Healthy doctors for a healthy system
Physician wellness is undoubtedly critical for the overall functioning of the health system. In fact, some experts have suggested that physician wellness is a missing quality indicator of health system performance.
Derek Puddester is an associate professor of psychiatry at University of Ottawa and director of the Canadian Physician Health Institute.
Puddester says unwell physicians impact patient care, and health care costs. For each physician who leaves practice, thousands of Canadians are left without care. In addition, he highlights the public costs associated with medical education – estimated at $285,000 for a family physician, and $760,000 for a specialist.
“Until we make a rock solid commitment to the health of our professionals, the health of our system is at risk of lurching from crisis to crisis,” remarks Puddester.
With over half of Canadian physicians in advanced stages of burnout, Puddester also worries about the impact on the doctor-patient relationship. These concerns are validated by several recent studies, including a large American study, which reported that physician burnout was associated with unprofessional conduct and less altruistic professional values. Another study reported that depressed physicians made significantly more medical errors than their non-depressed peers. Finally, a survey of resident physicians reported that burned-out residents were significantly more likely to provide suboptimal patient care including the failure to fully discuss treatment options and answer patient questions.
Canadians are helping lead the way in physician health
Despite the unique struggles and challenges faced by unwell physicians, there is hope for improvement.
Myers has dedicated his career to physician health and has witnessed tremendous progress. He recalls the suicide of a classmate while he was a medical student at the University of Western Ontario in the 1960’s. “Back in those days we just buried ourselves in our work and textbooks. Losing him was really awful, but that’s how we dealt with things.”
Today Myers points to the presence of physician health programs in every province. These programs provide dedicated personal assistance to physicians, medical students, residents and their families.
Myers also highlights the 2012 launch of the Canadian Physician Health Institute through the Canadian Medical Association, a pan-Canadian and multi-stakeholder program aimed at supporting physician health and wellness.
The institute is actively working to support physician access to health care, improve awareness about the importance of well-being, and combat stigma associated with mental health issues. Additionally, the institute is developing promotional activities for physician mental health.
But above all, experts in physician health are sensing a cultural shift in medicine’s approach to the health of its professionals. “Overall a lot of younger physicians say they have much more balance in their lives,” says Myers. “I think there’s finally recognition that we physicians are human.”
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What physicians might fear more than the stigma of mental illness, is fear of the unknown: what will happen once a diagnosis is made? Is a history of mental illness compatible with a career in medicine? Will I ever get better? By definition, clinically significant depression, burn-out and other forms of mental illness are going to affect people’s ability to think rationally, whether they are physicians or members of the general public. As such, our ability to recognize the need for help is going to suffer the sicker we get. We need to be educated as to the early signs, how to approach a colleague in difficulty and that it is NOT the end of the world to be diagnosed with a mental health problem. Yes, there is life in medicine after depression or burn-out…as long as you get help before it is too late.
I know from personal experience how severely impaired one can be while still presenting a facade of normalcy. Despite many people asking “are you all right?”, it was not until I recognized my inability to make even the simplest clinical decisions that I realized I needed help. I am lucky that my fear of hurting someone because of impaired cognitive function, was greater than my fear of discovery. I am even more lucky that I found help quickly. I have recovered from a severe impairment and througfhout this experience, have found my colleagues to be compassionate and supportive. After a 6 month disability leave, I returned to work gradually, following my doctor’s orders to the letter. Eight years have passed since my brush with insanity. I don’t take mental health for granted (mine or anyone else’s for that matter) and I know I am a better person and a better doctor because of that experience.
You bring up some great points, and I applaud you for having the courage to share your personal story. Thank you.
The best thing for younger physicians to do is to never do a mental health assessment and never see psychiatrists. They are dangerous. They can take away your rights, your child, your elderly parent -all without any recourse. Psychiatrists are up to the same things they have been up to for the last 83 years – the inducing of psychosis and suicide with their dangerous drugs and “treatments” all the while crying wolf to profit from it. I doubt that physicians are so gullible as to fall for this PR. Who wants a doctor who is on anti-psychotic drugs or suicidal from antidepressants? Too bad the doctors in this article don’t realize what the public realizes – post-traumatic stress is not a disorder. It is a natural reaction to trauma. It is only called a disorder for a medical insurance code. Take mental health out of the hands of the medical profession.
There is so much misinformation in this post I don’t even know where to begin. Do you happen to practice scientology? Your libelous comments regarding psychiatry seem to match with their own peculiar world view.
I am not a psychiatrist, but respect the challenges of their craft. There is nothing quite so unnerving as trying to heal and comprehend an unhealthy mind.
They are making the best use of the tools they have, warts and all. If we had simpler, safer treatments that worked, they wouldn’t be using the agents with poor side effect profiles that they are.
Statements such as “PTSD is not a disorder” is insulting to anyone whom was has survived trauma and is forced to live with those horrors everyday,
Well said Dr. Pooks.
Misinformation, Dr. Pooks? Personal experience, more like. Yes, I know. I have learned from experience that truth is “libel” to psychiatrists. Serving up ketamine and LSD to soldiers recovering from the trauma of war is not what I consider humanitarian. Pat Menna’s son, a returned vet, died in his sleep after psychiatrists dosed him with 35 psychotropic pills a day. We all know the “D” is PTSD serves up the pharmaceutical and medical profession.
My Mom went to the hospital with pneumonia in Orangeville. The powers that be saw a good opportunity to make a life long mental patient and addict and someone who had extended health care and could pay for “preferred accommodation” at the nearest psychiatric hospital. They admitted her to the local hospital and dosed her with hallucinogens, sleeping pills, antidepressants and antipsychotics and while she was drugged to the gills did a 15 page mental health assessment and then involuntarily committed her with the threat of being arrested by the OPP. I am in the process of putting together a charge of assault and trafficking in persons.
Your comment about a religion shows you don’t even know that a basic human right is freedom of religion.
Excellent article. The earlier treatment can start, the better prognosis for doctors and their patients. I believe learning and healing from errors is essential to our health. The earlier a mistake can be caught and corrected, the better. A non-adversarial process for patients’ concerns to be addressed could be the remedy. Our healthcare system must permit and promote patient engagement – especially when the health status of a doctor is a concern. If the actions of the doctor and the College lead to disengagement of the patient, the lessons can be very costly to the doctor, the patient and the healthcare system. The only winners are the lawyers.