Medicine as mental illness

Waving or drowning?

On night duty, some years ago, I took a call via switchboard. It was the police, searching for my colleague. I said I’d ring round to help the hunt.

I spoke to the police again, around dawn, by which time they’d found him. He’d parked on the motorway and walked in front of a lorry; leaving a note in his car, for his wife and infant at home.

We’d trained together for years, during which time he gave no hint of what would happen. A superb surgeon, he was able to do and teach stuff that consultants couldn’t. And he was humane; slow to judge, quick to help. But at the end, he seems to have denied himself that compassion.

There are modifiable risk factors for suicide. But doctors may not address theirs, for fear that candour about mental illness could wreck hard-won careers.

Could we change this, and save lives, by being more candid about the profession as a whole? The days of pretending at superhuman skill and invulnerability are coming to an end. But we’re still slow to address the vulnerability that comes with superhuman failure; those mistakes with grotesque consequence.

Here, I suggest that one approach would be to treat a medical career as a mental illness from the outset. In that way, doctors might receive more support upfront, might feel more able to seek help in crisis, and might take the mental health needs of others more seriously too.

But is there then any real case for labelling medicine as a mental illness?

First, there is flexiblity and opportunity. Philosopher Ian Hacking has pointed out how mental illnesses can be adopted into clinical reality, even if only to fade away decades later. They can serve a useful purpose for society at the time.

Second, we accept that features of nurture can drive mental health problems; from childhood abuse to the societal pressures that could feed eating disorders. So why would we assume that the exceptional and sometime brutal nature of medical training wouldn’t also induce mental health problems?

Consider only the mixed messages that medical students and junior doctors have to contend with. It’s little wonder they suffer moral injury.

We select students who have to claim to be a cross between Mother Theresa and Einstein – just to get in.

We take these multi-talented kids, fritter their youth in study; steadily narrowing them, and their time for recreation – as if this were preparation for meeting the diversity of life.

We tell them to be upright and honest, when all around they see a profession that’s not honest with itself; adverse events and bullying being quietly hushed up; professionals fearful to speak up for their own health, let alone others’.

We ask them to be compassionate while denying themselves sufficient compassion to recuperate and relate to their friends and families.

We require that they’re cool when confronted by lives and traumas that should make any of us scream.

We teach that the patient must be their first concern, when what they see ahead is burnout and disillusionment, or politicking and avarice.

We teach how medicines can be used for pain until they kill, and are then surprised when they kill their own pain that way.

We teach them all of pharmacology but nothing of failure. So they know how to explain the actions of drugs they never see, but not their own actions when they make mistakes.

And foolishly, we teach them that medicine is a privileged existence, without teaching how it is also a long term condition.

We assume that knowing what ails others can insulate from what ails us.

We talk of saving lives, even creating them in test tubes – without the humility; without the simplest insight that for all the medical arts, we’re “suffering limited beings- perennially outmatched by circumstance, inadequately endowed with compensatory graces”.

Taken together, we have a powerful set of delusions; of control; of invulnerability; of perfection; of virtue. For each, the attempts to square them with reality can induce disconnection and searing disaffection. It’s little wonder perhaps that psychopathy and depression are reported so often.

So I propose that entry to medical school becomes a diagnosed long-term condition.

In the same way we have clinics for (pre)diabetics and screen for risks and consequences, we could all be entered into specialist clinics for medics; one that helps us self-manage and which screens for our long term risks; where disclosure of issues (in groups or not) would bring support not censure; where vulnerabilities would be valued in clinical work, rather than getting quietly shamed.

If nothing else, we might learn from what it means to be a patient. And at best we might have more compassion for ourselves and others; valuing our lives, imperfect as they are; rather than ending them amidst the brief melee of medicine.

We might also be reminded that caring for others isn’t some wondrous calling; it’s a staple of life. And medicine can surely improve – by descending the pedestal, to tend its own.

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