Medicine is a profession that attracts a certain type of person. To get into medical school you have to be a driven, high achiever. That often correlates with perfectionism and a competitive streak, not explicitly for competing with others, but often with ourselves1. This need to achieve can make us profoundly sensitive to failure, and indeed to see what some would consider a good grade, as simply not good enough. Many of those that go on to attend medical school were used to being the top of the class but are now surrounded with hundreds of top-class students.
I was no different. I expected above 80% in all academic endeavours before my first year of medical school, to find despite my best efforts I was averaging 60%. This was still a pass and compared to my cohort a respectably average one. Still this fall from exceptional to average was a hard pill to swallow and caused a visceral shame at first. With hindsight I wasn’t the only one to feel this way, but out of feeling shame also came an uncanny ability to mask that struggle; something I now realise a vast number of my peers were also doing.
There is now a wealth of evidence that medical students suffer a great impact from the stress of their demanding education. Multiple systematic reviews have concluded more than 1 in 4 students in medical schools around the globe have clinically defined levels of anxiety and depression1,2; a higher rate than found in age matched peers, and this has become something that medical education need to address. I was one of those 1 in 4; contributed to by my own chronic health issues and a string of close bereavements I fell into a vicious depression. Once again, I felt compelled to hide this, feeling ashamed that I couldn’t somehow fix myself.
One night I found myself crawling out of bed, pulling on discarded joggers and a hoodie and walking to a nearby bridge over a busy road, with the intention of jumping. I didn’t want to feel ashamed of myself anymore. The guilt that I couldn’t just ‘pull myself together’ was too heavy. It was halfway there that I realised I needed help. I turned around, crawled back into bed and called a friend, who urged me to go to the doctor.
The antidepressants were trial and error, which felt more like trial by fire. Before finding the right one I seemed to either get worse or turn into a zombie. It gave me a better appreciation of what a long road mental health recovery can be. At this point I still hadn’t disclosed my situation to the medical school. Admitting I wasn’t coping was still a mental block. It felt like weakness, it felt like failure; but by now I had fallen behind my peers and decided that I could cope with the ‘failure’ of postponing my studies far better than actually failing my exams. When I look back now it was the smartest decision I made during medical school. I concentrated on my physical and mental health and was able to return ready to cross that finish line.
However, my medical school career was given one final hurdle when in my final year I was sexually assaulted. Needless to say, my mental health took a dive and a whole new spiral of shame began. Yet, regardless of everything I was going through, my primary fear was disclosing this to the medical school. A second mental health episode in as many years… I was certain they would tell me that I was too damaged to graduate. The dreaded phrase ‘fitness to practice’ as a student seems synonymous with ‘bad, irresponsible doctor’. In reality, assessing someone’s fitness to practice is much more an exercise in how your medical school or workplace can support you. Still, I was caught up in negative thoughts; how could someone like me be a good doctor when their own health, especially mental health was so fragile. I went into counselling instead, and this helped, yet I was still heartbroken when a concern was raised. As I slowly let the medical school support me and showed them that I was doing everything I could to be capable despite what I’d been through, we navigated the last stretch together. I graduated and was given protected time in my rota for counselling to continue.
It still took me years though to not feel shame over my mental health battles. In fact, in my foundation training having a single afternoon off a week for my counselling was something seen by some of my colleagues as something to feel ashamed of, not so much that it was for counselling, but because it left them short on those afternoons. I have heard many comments about colleagues over the years, especially those working part-time in their junior years of training, that have reflected this sort of attitude. As if those having to take a slower route or take a break from the relentless training are somehow less committed.
This is a message I had clearly internalised and made me feel that by being ill myself I could not be an effective clinician. Something I now know to be profoundly untrue. Perhaps my biggest breakthrough was in realising that I would never suggest to a patient they were weak for having mental health struggles, or fragile for having physical ones. While in my career I am a doctor, in my personal life I am just a person who has just as much potential to get sick and to go through adversity. It isn’t a failing, it is just a part of being human. The problem is I am far from being the only one who has felt like this. In the research it is common to find a fear of disclosing mental health issues to the medical school, despite research that suggests such disclosure is widely met with implementing support4. Paradoxically it is hiding the struggle and continuing to practice despite deteriorating health that would really raise concern.
So, if it’s not from their medical training, where are our doctors receiving this message? From my experience, this attitude is embedded in the remnants of a hierarchical system. Not just within medicine but health systems generally. Modern health care is under extreme and increasing pressure due to structurally imposed scarcity (including both resources and staffing), while patient expectations and needs are increasing. This drives a feeling that in such times you are ‘letting the team down’, and that even necessary time off for illness is something to be ashamed of.
Add to this that care-givers at every level are burning out at a higher rate and increasingly earlier in their careers than ever before. When experiencing burnout, it is well documented that our capacity to empathise is decreased, not only with our patients but with each other. Social shaming of colleagues for sick leave, (especially for mental health issues), then further drives the internalisation of the message in favour of relentless productiveness, with anything less being synonymous with personal failure. This leaves many of us feeling they must continue, regardless of struggling, to meet the weight of colleagues’ expectations. In the process, risking further burnout and turning to maladaptive coping mechanisms. It is a vicious cycle, that directly feeds into short staffing.
In my second year of foundation training, I was involved in a road traffic accident that rendered me paraplegic. I use a wheelchair full-time; I have a catheter and I need help around the house. I have chronic medical needs and have also struggled in the 5 years since the accident to overcome PTSD. However, I am still a practicing doctor, currently working in a busy emergency department. Even despite these extreme circumstances, I still struggle with shame when I need sick leave to attend to my own, now complex needs.
At first, I was desperate to prove that I was still a valid member of the medical community, that my contribution wasn’t worth less because I can only manage a 2 day a week rota. It has taken time to internalise a different narrative. To see that, if anything, all these experiences have made me a better clinician. I understand how it feels to be a patient, I consider things that would not perhaps occur to fellow juniors, and while I only work 2 days a week, I am now involved in tackling the feelings of inadequacy and anxiety in medical students. Firstly, by talking to them about my experiences and advocating for awareness via social media, but also in a new role as a research assistant in a currently active randomised-controlled trial looking at mindfulness training for medical student wellbeing. It’s so important to me to address this issue. However, while this study (led by Professor Grant, Professor Kemp and Dr Dave of Swansea University) is a step in the right direction in giving young doctors tools for self-management, we cannot afford to ignore the structural changes and cultural shift that is needed in medicine.
We are all simply human and are united in our vulnerability by our capacity to empathise and support each other when adversity arises. A feeling of shame leads only to hiding something profoundly natural and deprives us and those around us of genuine connection and the creation of communities for positive change. I now see that none of these incidences of personal struggle were failures. In fact, each one, while difficult, has added something to how I practice medicine. They have taught me and led me to new opportunities. They have given me a story to tell that I sincerely hope makes others realise there is no shame in needing help when times get tough.
Dr Georgina Budd @mymindonwheels