One On One

Q & A – SASOP – Bernard Janse van Rensburg

Recent studies have found that doctors are 2.5 times more likely to commit suicide than the general population due to a host of reasons related to their work and social environment. The Weekly’s Martin Makoni spoke to the South African Society of Psychiatrists (SASOP) past president Prof Bernard Janse van Rensburg to find out some of the reasons for that and what could be done to address the problem. Makoni also asked Van Rensburg why medical practitioners, who are expected to understand health matters better, take long to seek treatment and how that could affect their well being. Excerpts:

You have been quoted as saying medical doctors are 2.5 times more likely to commit suicide than the general population, yet it is the same doctors who are expected to rescue people out of such desperate situations, how is this so?
I think it is important to note that these unfortunately, are not local South African figures. These are figures from overseas, north America where they have much better information on health. But these figures are not very different to what can be experienced in this part of the world because most of the conditions relate. From that information, it is clear that if you compare these types of problems between medical doctors and the general population, that is where we get to this figure of about two times more than the general population in terms of likelihood to commit suicide.

What could be some of the underlying reasons for this?
I think that is very important and that will also take us to the dynamics of how we are being trained,  how we train our students and how we are expected to behave? Are we being hard on each other, because in our hierarchy, we are supervising each other. So, it’s very important to ensure these factors are addressed. The availability of resources is also very important because that allows medical doctors to dispensen of their duties well. Those things may be another layer of problems faced. A third layer of stress, is, if we think in terms of the burnout situation. It takes us to the work environment where we look at interpersonal relationships, the management and perhaps the attention they get. Perhaps it’s strict or harsh management style. Perhaps it’s as if the practitioners are not being listened to and so forth. So, I think there are many layers that make the medical profession a little bit more risky and that’s how we get to the figure of 2.5 times more likely to commit suicide compared to the general population. That will be the bigger problem, but there are also depression and anxiety related problems that may be experienced by medical doctors.

This is striking in the sense that medical doctors, being better informed in health matters should be the first ones to know and seek help when they are not feeling well, why don’t doctors seek help much sooner?
It is true. People in the medical profession are expected to know better and respond much faster to situations concerning their health. But to be honest, it actually leaves us with some kind of a disconnect between what we know and what we feel. So, when we have to deal with somebody else like a patient or their family, it is not coming close to me as a health professional where I have to realise my own personal limitations and my own red flag signs of challenges of stress that may have been building up and may be developing into a burnout situation. It may sometimes just be hard for one to realise this and take appropriate measures to address this. At times one may just feel like they don’t want to go their colleague and seek help because they may feel like they will be opening up a bit too much about their personal circumstances.

That’s certainly a wrong approach to take because the underlying matter remains unresolved. What are some of the risks attached to this approach?
Some of the stories we have been hearing are that this process of isolating oneself when struggling with burnout, for example, also isolates one from their family and other people that really care about them. Generally, it complicates one’s situation because you remain stuck with the challenges.

Society is generally known to stigmatise people with mental health conditions, because of, among other reasons, lack of knowledge. Does the same happen among medical professionals, leading to them not wanting to seek help from colleagues
Absolutely. I agree with that statement. But it’s also important to know that there could be different layers of stigma. There is general stigma that you are referring to from the general population and there is also that other form coming from particular communities, like the medical profession. It is out there. It’s a reality. People are still thinking of mental health problems as madness or as a weakness. And some people would say, ‘I am thankful because, at least, I am not like that. So, by looking at the problem like that, you can call it professional stigma, doesn’t help the situation at all. And then sometimes we just do it to ourselves. You can call it self stigma, that is, I will be considering myself to be having a weakness and I can not really accept that. I can’t be acknowledging that there may be such a challenge in my life without thinking of myself as not good enough or weak.

If we may touch on the issue of training again, does that mean medical practitioners the world over, are not prepared to deal with such situations when they receive their training?
That’s very important. But that question takes us a bit deeper… I can call it the philosophy that we still  have in the teaching and the training of medical doctors. I have heard somebody say that, to an extent, the idea that we must always be very mechanical about how the body works, how organs work and the illnesses, we forget about the human part, the emotional part that is actually connected to everything. It’s actually supposed to be holistic and integrated. I think we could be making mistakes in terms of how we approach our training. We have caused a bit of a split, if i can say so, between the mind and the body. And how we train our students, perhaps we are not paying enough attention to ensure that these integrations can continue to happen. I also believe, because medicine is such a competitive field, for example, students applying for medical training all need to have very good marks, and so I think it starts from that point. There is a lot of pressure just to come through and learn all the stuff. So, with those points in our training, it does make it tricky to say that we have achieved a balance to be able to produce a practitioner who can live with that humanness, and also to be human towards yourself.

What age groups are most affected by these suicidal thoughts?
I think that could be different in different settings but I can imagine that we hear a lot of the information coming from the younger group of doctors. We have, especially in the last couple of months, seen how much easier it almost is for them to come forward for help if we talk about it more openly. We saw that the death of (top cardiologist) Professor Bongani Mayosi last year that it sparked a lot of reactions. As a result, the young groups both career doctors and students have engaged in wellness and outreach programmes. So, I think, if it was easier for them to speak, it may be so that, the older group may be more in the habit of not talking. Perhaps we have isolated ourselves already. I think, it could be across all the ages but perhaps our younger colleagues are leading us in terms of learning how to speak more about these problems.

I want us to talk about the actual working environment in a hospital, what sort of circumstances and or situation can really break medical doctors down to the point of committing suicide?
I think that will take us to the point of staffing within the health facility. Maybe the hospital is facing some kind of pressures and all the key positions have not been filled. Perhaps there are people who have not been retained and they have to leave. It could be the setting of the hospital, whether rural or urban and it could be carrying a high burden of cases. So, I think it could all contribute to the pressures related to the working environment such as case loads, the equipment, the theatres, the supplies in the hospital may be a challenging point. Those things will not help. They will just add to those layers of being stressed and strained. So, yes, the working environment, how well is the staffing, how well is the relationship between the staff and the management of the institution. Those things play really significant roles.

There is a recent video of a Zimbabwean medical doctor addressing the health authorities there on the situation at the country’s biggest referral hospital. She was in tears explaining the difficulties they faced saying they were just coming to certify deaths because they could not assist patients due to lack of supplies and at times, they had to wash bandages in order to reuse them, how much strain can this put on a doctor?
That is a huge challenge because we know also that, part of being a professional is also to advocate for our patients. And so, if you are carrying that burden as well, if you are trying to raise problems that may not be that easy to address and that may not be easily or comfortably accepted by the management… I can totally see the contribution as well… there may even be more tension and you may even get penalised for that yet you are supposed to care for the patient. You will obviously be raising this point because you want to indicate how difficult it is for you to carry out your duties and the impact of your failure to do so on the patients. It can be quite devastating.

South Africa is faced with a continued shortage of medical doctors and specialists, does it therefore mean these professionals are in a particularly delicate situation in the country compared to other regions with better healthcare?
I do think it does affect us quite significantly. I do not have the exact figures on the situation in the country but a possible scenario could be that one would decide to leave the state sector and join a private hospital because they will be saying, it’s too much. They can’t continue working in such an environment. Some might decide to leave for another country, which will be the brain drain effect to the country. And compared to other countries in Africa, I guess we are still well positioned. But overall, I think we are under strain for the numbers and work environment is adding to the other layers of problems.

What do you think should be done to ensure that medical students as well as practicing professionals do not get to that breaking point which may lead into them taking their own lives?
We cannot just talk. We must have something that is beneficial. I think there should be more open talking about the issue so that it’s not a hidden topic, or an ignored problem. I think that is where it can be started so that it is easier to engage with the facts and how life really is. From there, we will have to look from the universities, the faculties that are are training health science students through to the service delivery levels which employ these practitioners so that they have employee assistance programmes, for example. I also think the profession itself must really be taking very active steps to address this. I know the SASOP and the South African Medical Association have partnered to be actively promoting interventions and trying to create benefits for their members in which we can always assist our colleagues and be available for them providing a comfortable and confidential space in which to start discussing and also reach out and give the assistance that may be necessary.