“I volunteer! I volunteer…” (Katnis Everdeen, Hunger Games)

“I volunteer!  I volunteer…” 

If you can picture Katnis Everdeen saying that as she volunteers to participate in the Hunger Games then you will have some idea of the emotion(s) I felt on 9 March 2017:  But, that’s not where this story really begins.

Everyone has seen the articles about doctors ending their lives, the impact of mandatory reporting, and the desperate need for a complete overhaul of our regulatory system.  So, this is the point where I bring into the discussion a frank account of the lived experience of a doctor with a history of mental health issues, and what happens when AHPRA get involved.

I strongly contest the validity of the following statement made by Professor Anne Tonkin, current Chair of the Medical Board of Australia, in a recent interview. 

“I’m very concerned about people saying that they don’t think they can get help, because the Medical Board is not the slightest bit interested in hearing about anybody who has any kind of health issue that they are dealing with appropriately, and that doesn’t affect their practice. We don’t even want to know.” 

My own experience of AHPRA and the Board, including how my current appeal against imposed conditions that prevent me from practicing clinically is being handled, provides a wealth of evidence against there being any truth in what Prof. Tonkin has said.  It is my intention to progressively address why Prof. Tonkin’s words resonate so far from the truth in a series of posts.  

I surrendered my medical registration in 2015.  At that time, I was completely broken and continuing to fight would have, without doubt, cost me my life.  In the weeks leading up to my decision to surrender my registration one of my closest friends from high school told me that she was afraid that she would lose me in a battle against prejudice.  She told me “I would rather have you alive and working in some crappy, boring, desk job; than live having lost my friend to suicide because you kept fighting an in-just system.”  That message came with a link for a job advertisement in the Public Service. 

At that moment, I wanted nothing more than to be dead.  I didn’t want to wake up and face another day. I was, most certainly, clinical depressed; but, more importantly, I was traumatised.  Traumatised by the impact my mental health had on my career, traumatised by the actions of AHPRA and the Medical Board, and traumatised that I had found out over and over that as a doctor-patient I had no rights to privacy, no rights to treatment, no rights to have a health condition.  I couldn’t bear the idea of waking up one more morning to face the memories of those traumas.  

Less than a month earlier my family had ‘extracted’ me from a toxic situation in Tasmania and relocated me back to our family home, just outside Canberra.  I had just tried to end my life and gone to extensive length to ensure the attempt was successful.  I never expected to wake up and was disappointed, anguished and distraught when I did.  My final thoughts before at that time were not of loved ones and aspirations.  My final thoughts were focused on pure dread that if I woke up AHPRA, the Board and their lawyers would subject me to further torture; nobody should have to think that way.  When I returned to NSW, you could have described me as the walking dead: I was depressed to the point that I didn’t care about anything and, despite still breathing, was destroyed inside.

Like a robot, I applied for the job in the Public Service (APS) that my friend had sent me.  The chances of succeeding in your first application for a role in the APS are slim; particularly when you have a diverse work experience background.  I had no expectation that my application would be successful and applied to appease my friends and family.  What nobody knew was that I had also planned my disappearance and suicide, including a letter with final instructions, and that I was waiting for the confirmation that my application was rejected before I carried out my final plan.  In my mind, while depressed, I believed that if I could say I had at least tried that perhaps the impact of my death on loved ones would be less.  

The conditions imposed on my medical registration at that time were publicly viewable and I worried that if the people assessing my application for a role in the APS saw those conditions that it would jeopardise my prospects of success.  AHPRA had failed to process my registration renewal and my legal support advised me that it was unlikely they would allow me to remain registered; so, I signed a form surrendering my registration.

I will never forget the first appointment I had with my psychiatrist after surrendering my medical registration:  I had no intentions of even reapplying to be a registered health practitioner.  Choked up and struggling to breath, due to the flood of emotion associated with this particular realisation, I burst into tears and said.  

“I don’t know what to say to you:  This is the first time in my life where I’ve been able to attend a psychiatrist and ask for help knowing that I have privacy.  They (AHPRA) can’t go through my files anymore.  They can’t scrutinise everything that is private about my mental health conditions and treatment and throw it at me in my career. I have doctor-patient confidentiality… I don’t have to be scared when I see you now.”

My psychiatrist gave me the time I needed to digest that realisation and then prepared a plan to move forward and get me through the depression and trauma.

Each evening I dutifully took my antidepressant with no expectation of benefit or a positive outcome.  Friends and family continued to cheer me on from the sidelines totally unaware that I had already made my decision and was waiting for the right moment.  Then, I received an invitation to attend a job interview. My emotions were mixed; I was annoyed, but also saw the first glimmer of hope for any kind of future life/career in many, many months.  Consistent with my perfectionist personality style, I decided that it would be wrong for me to attend the interview and give it anything but my best effort.  

January 2016 was when I found out that I was successful in that application.  A number of weeks had passed where I was consistently able to take my antidepressant while also being safe from attacks, hostility and further trauma.  My depression had already begun to lift and suddenly there was a tangible piece of hope that I may have a ‘life’.  By the date I was due to commence my new career, I was safely out of the grips of depression.  Of course, I still had to face the memories and live with the trauma, but I was well and had a way forward.  

My first supervisor in the APS was supportive and a God-send; he made integrating into a new work environment easy and we remain friends even though we are no longer in the same team.  

That brings us to 2017.  By January of 2017 I had well and truly moved on from the traumas of the past. Living back in the region where I had grown up allowed me to rekindle old friendships.  Working in a job role that allowed for healthy working hours allowed me to manage my own health effectively.  I can honestly say that at some point between January 2016 and January 2017 I started to feel and experience genuine happiness again.  

Then it hit me.  The first article I read about the spate of doctor suicides in NSW and the impacts of mandatory reporting hit me like a freight train:  I actually threw up and sat curled up in a shaking, crying, mess on my bathroom floor for a number of hours.  There was a sudden realisation that the pain, trauma and fear that I had experienced at the hands of AHPRA and the Board wasn’t limited to my case.  Until that point, in an unintentionally self-absorbed way, I had assumed that the traumas I had experienced relating to my own medical registration were limited to me.  Certainly, in all my interactions with AHPRA I was left feeling like I was the ‘worst case’, ‘most terrible person’ etc and, that there could not possibly others they invested similar energies into.  

Suddenly my own resignation from medical practice became unacceptable.  I could live with feeling as though my own career was ‘stolen’ by those with prejudices. What I can’t live with is knowing that others are being subjected to the same processes, the same traumas, the same fears; and, that it is costing lives.  

“I volunteer.”  

On 9 March 2017 I mailed my application for (re)registration as a medical practitioner to AHPRA.  

I volunteer to stand up and fight against a serious flaw of our registration system and regulatory body.  I volunteer to stand up and speak out about how doctors (and other health practitioners) with mental health histories are treated and handled.  I volunteer to have my own history and story laid out publicly for the world to see in the interest of having a real discussion about what does and does not make a health practitioner a ‘risk’, or ‘impaired’.  

I am the perfect ‘test-case’ for a discussion about how we should assess if a practitioner poses a risk because of their mental health.  I have an extensive history of depressive episodes, suicide attempts and hospital admissions:  The details of how misdiagnosis, incorrect treatment, prejudice, and inability to access care without the focus being first on you as a doctor, and my own genetic susceptibility to certain medications played a role in this will most certainly come out in the near future.  Importantly, what I do not have, is any record of complaint by patient, family member, or colleague about my ability to perform well and behave appropriately in a clinical setting.  There are no complaints to AHPRA (or the previous state based Medical Boards) about my performance or conduct in practice.  I have taken time off from practice when unwell. Yet, despite a ‘clean record’ in my actual work as a practicing medical practitioner, I am blocked from working clinically.  

A De Novo hearing of my case goes before a tribunal panel of four members at the NSW Civil and Administrative Tribunal (Sydney) on 15-17 April 2019.  I am appealing the conditions on my registration.  If successful, there will be case law that other practitioners can rely on in their own struggles with AHPRA (that’s the goal, my own return to practice would be a bonus).  If unsuccessful, then we will be able to clearly state that how we assess whether or not a practitioner is a risk is not based on their performance or practice history, but merely on a presence of illness (past, or present); and we will have stayed in a place where stigma and prejudice prevail.  

I am all too aware that a statement like I have written here today opens the door for people to say all manner of things about me, my past, my future etc.  It opens the door for a discussion that may not always be pleasant.  Many people have their own views, and I accept that.  It may have taken me until age 35 to be able to say the following with any degree of integrity, but here it is:  

“I know who I am.  I know my past.  I know my history.  I am a doctor who has experienced mental health problems and made attempts on my own life.  I am autistic, and don’t quite ‘fit the mould’.  Many people think they know my story, or something about me; many people also don’t have the full story or context.  I will not be shamed, and I am not ashamed, for having experienced mental illness, nor for having been a less than perfect patient.  I am a good doctor and a safe doctor, regardless of what the Board’s imposed conditions may imply.  Most importantly, I will not be defined by the words of others, past, present or future.” 

With this in mind.  I start this series of posts about the lived experience(s) of a doctor with a mental health history faced with AHPRA and the Medical Board.  

The Weight of the World…

I thought long and hard about whether or not I published this blog post.  I decided to, out of integrity and honesty, with regards to a situation.

You only have to read my opening post on this blog to find out that I have a battle going with the Medical Board of Australia.  

I’m a doctor who has experience severe depression, made attempts on my life and taken time off when impacted by the black dog.  I’m a challenging patient (I won’t deny it).  But, despite the severity of my episodes of illness, my ability to practice has never been impacted.  I’ve matched, or bettered, the performance of my peers.  I’ve never had a complaint from a patient and never had any notifications about my conduct or performance.  

Next year I’ll be a PGY12 (my 12^thyear out of medical school).  Right now, I am applying for PGY2 roles; yes, you read that right.  I’ve had interruptions to my clinical career to the extent that if I ever want to achieve my career goals, I’m faced with returning to practice as a PGY2.  Most people I graduated with are now fully-fledged consultants…  But, that isn’t what this post is about. 

I’m fighting in NCAT to have conditions that are currently on my medical registration removed.  The conditions completely block me from clinical practice, despite a clean record. I made a decision to fight the case publicly; that wasn’t easy.  It means being willing to have anyone, from anywhere, listen into the sordid details of my state when I have been impacted by mental illness.  It means allowing people to discuss my mental health history and speculate whether or not they think I should be allowed to practice. That’s not easy.  That has to be the most vulnerable situation I’ve ever been in, and I am, in some respects at the mercy of the Responding party (the Medical Board of Australia) when it comes to how they choose to deal with my mental health information.  

The decision to fight this publicly was easy.  There hasn’t been transparency, historically, regarding assessments of doctors with ‘fitness to practice’ concerns raised about them. AHPRA and the Board are very good at ‘encouraging’ those impacted by these investigations to stay ‘hushed’, for ‘their own benefit’; really it is for the benefit of the regulator and their lack of accountability in the process.  But, shaming people, and putting the fear of being publicly stigmatised if the alleged ‘dirty laundry’ of their mental health history is aired publicly works well; it’s a very effective way to keep people quiet. Unfortunately, silence and hiding leaves people who choose to in a position of relative power; it means they’ve succeeded in stigmatising an illness, and the impacts of that illness.

Fighting this appeal publicly means we can finally have an open and transparent look at how AHPRA and the Board handle these issues.  With someone willing to have their own case openly examined, we can look at the processes.  So, I’m not hiding any of it.  Anyone who wants to can ask me about my mental health history.  I’m not ashamed of it.  I’m willing to discuss it.  I know I am not a lesser person, or a riskier candidate to provide clinical care, than any other person without that history.  

I’ve become pretty vocal on social media over the past year.  I genuinely believe that it is necessary for us, as a profession, to keep being open and talking about these issues; well, if we want things to change.  

I lodged my application for registration on 9 March 2017. I knew how AHPRA and the Board would approach it; they proved me right.  I knew an appeal was likely.  I also knew how they’d approach the appeal (and, unfortunately, to date I have been proven right).  I lodged my application after hearing about the run of junior doctor suicides in NSW. I was physically ill when I realised that I wasn’t the only one subjected to the horrendous and inhumane processes of AHPRA and the Medical Board, when they’re ‘concerned’ about a doctor’s mental health.  The realisation that it wasn’t ‘just me’ came with the realisation I had a responsibility to stand up and do something about it.   So, I prepared to fight.

In 15 days’, the NCAT appeal Hearing will be over.  We’re returning, the Board, me, the Tribunal Panel, and my faithful four-legged assistant, for four more days between 16 and 19 July.  At this time, in 15 days, the Hearing itself will be complete and the Panel will be left to decide whether or not I pose a risk to the public.  

Although the law doesn’t stipulate the next part as what the Panel will be making a decision about, by the very nature of the case and the appeal, they will also be making a decision as to whether or not we have case law in Australia that says “Even if you’ve had shocking illness (mental or otherwise), if it hasn’t impacted on your practice and isn’t likely to, then we won’t take your career away.”  That is a far more significant decision than just the career of one 35-year-old doctor, who if allowed to practice will be joining the ranks again at the equivalent level of someone who is one year out of medical school and has just completed their internship.  

Right now, I’m still preparing my evidence (it’s a constant process) and I’m still thinking through what I may or may not have to address, how I will address it etc.  As someone who wasn’t fond of English in school, I’ve had a good ‘literacy intensive’ this year while self-representing in this case.  I take my hat off to those studying and practicing law.  

Right now, I also have the weight of the world on my shoulders. 

In the lead up to this final instalment of my NCAT appeal, that’s how I feel.  Having publicly stated that this is an ideal test case as to whether a doctor can lose their career for seeking mental health care, I have taken a big risk.  A positive outcome for me, in the final determination, is clearly going to be a change-maker for the situation doctors currently face; it would be case-law that others can rely on to say ‘it doesn’t affect my practice, therefore, you can’t destroy my career’.  But, the other side of the coin is that if the Tribunal for some reason follow the current ‘pattern’ that AHPRA, the Board and other Tribunals have followed (in imposing conditions based on speculation because mental illness is seemingly scarier than physical illness) then the message that gets sent to the medical fraternity is ‘Yes.  You can lose your career over a mental illness that doesn’t impair you in practice.’  No doubts that kind of outcome would increase the fear doctors already have in seeking mental health care and potentially lead more to believe that suicide is a better option than engaging in care.  

Imagine not knowing the outcome of your own case.  Imagine knowing it would have been easier to get your conditions removed by simply waiting a couple of years and quietly approaching AHPRA.  Imagine knowing that you’re out-gunned in terms of legal representation and resources.  Imagine knowing that your efforts to ‘create positive change’ in a particular space could backfire horribly and that you have no control over that outcome; the decision sits with four panel members.  

That feeling is one of having the weight of the world on your shoulders.  The intensity of that burden is greatly heightened having heard about more recent doctor suicides in the very State (NSW) where you’re fighting the battle.  

I felt ill, and I fell to pieces inside when I read the recent Sydney Morning Herald article about the recent doctor suicides.  I didn’t know them.  I don’t know their families.  I do know the fear and sense of trepidation and debate that they may have faced when considering suicide versus seeking help.  To the families and friend of those doctors, my heart breaks with yours and I am so deeply sorry for your loss.  

For me, seeing that we’ve lost more of our profession in the context of a regulatory system that could have been changed before now to ensure those individuals felt safe seeking care, and recovering, then going on to live health and happy lives, felt like I’d lost the ‘appeal’ already.  

I’m being totally open here, wisely or not, about just how terrifying it is considering what the implications of various decisions in my case will mean for others.  I don’t think it is a reason to make it any less public.  But I do want to openly say I know I’m taking a risk here…

It’s not a Disney movie.  I don’t know what the outcome is going to be.

It’s a tough gig being that person that says ‘go ahead’ look at anything, look at everything, I’m not ashamed.  Even if I am not ashamed, there is still stigma and prejudice out there. I dare say, we wouldn’t be seeing this appeal if there wasn’t.  So, my own lack of shame is not in itself ‘protection’; people can still choose to target me with that knowledge once its public.  To the Panel engaged in my Hearing, I say this:  I know that people can try and use this against me and I’ve made a decision that I am ok with that, just please don’t let this become another case with no transparency and no accountability.  It’s my story, and if I am willing to have it told, please respect that and let me. 

If there is something, I have learnt from the amazing army of advocates screaming out on social media for some much-needed cultural change in medicine, that it is to ask for support when you need it.  The case is lonely, it’s tough, it’s daunting, and it is so highly and deeply personal.  The support I need in that Tribunal room, particularly coming towards the end of the case, is to know that I’m not the only one who’s willing to stand up and fight for change in this space.  It’s not overly interesting listening to evidence being presented to a Tribunal Panel; even I ‘nodded off’ briefly during one of the sessions in April.  I don’t need people to agree with me on everything, or even to have decided in their own minds what the outcome of my case should be.  I do need people to be willing to stand with me (or in this case ‘sit’) and say through their presence “we know this needs to change”.  Even if you’re just there for a few hours, I’d be grateful.  Personally, I’d suggest the 19^thof July, because that’s the final day and the ending is always the best bit, right?  

Who? Anyone who is available, even briefly, and believes we need change in the way health practitioners with mental health issues are handled and treated.  Anyone who believes that doctors should have the same rights to accessing health care as those we care for.  

When? 16-19 July 2019

Where?  NSW Civil and Administrative Tribunal (NCAT), John Madison Tower, 86-90 Goulburn Street, Sydney.

What? If you do come, consider wearing #CrazySocks4Docs, at least then we’ll have some colour in the room and I’ll know who wants to see change.   

Finally, asking for support is hard.  Whether you’re asking people to publicly support something, or you’re asking someone to help you in private (like a GP or psychiatrist).  It’s hard because asking for help and support makes you vulnerable; people don’t have to respond, and you can’t control their response.  Today, I’m choosing to be that vulnerable.  

No more time-share between Plan-A and Plan-B!

I think I just blew my own mind. Sitting and mulling. Considering. Pondering…

For the past 15 years, since I entered the mental health system, I’ve been telling myself “I always have to have a Plan-B”… Not just that I need to have that Plan-B, but be actively preparing for it. Why? So that if anything happens, and someone or something attacks or sabotages Plan-A, I will be ok.

I am unable to measure the amount of energy I have put in to ensuring my Plan-B will be adequate and survivable over the years… I know when it started. It started when people told me over and over “you can’t be a doctor and have mental health problems”, “you don’t belong in medicine”, “you’re different and you’re not one of us”, “you’re not worthy of a career in medicine”, “you’ll never be a safe doctor because you’ve had mental illness”. Those were not quiet messages, they have been the prevailing messages I received throughout medical school and my career thus far. Some people are still trying to send those messages.

“We should scrutinise you more harshly because you’ve experienced something we are not willing to entertain we may also be vulnerable to experiencing…”

I’ve done myself an injustice in my ignorance and naivety. Sometime in the past 3 years, I realised those things were bullshit. I realised I didn’t have to let people who know less about me than I do, and who haven’t walked my path, dictate to me what my future is limited to. The problem was, until today, my brain was still operating in defence, in preparation for attack and failure. I’ve kept pouring effort into Plan-B preparation and engagement.

Wrong approach.  

Recently I started, without realising, pouring all that energy into Plan-A again… Signing up for the extra study courses I will need to succeed in Plan-A… Applying, against the odds, for jobs that will let me progress through Plan-A… Asking for opportunities that will help make Plan-A possible (not just opportunities that are visible, but seeking to create ones). But, most importantly, I am now allowing myself to believe in my own mind, and visualise, the actuation off Plan-A: Seeing Plan-A as reality sometime in my future.  

For fear of pain, suffering, heartache and disappointment, I haven’t let myself believe in Plan-A enough to fight for it. Yes, I have to fight harder than some others for the same thing (in this setting). But, I am fighting for it. I am appealing in NCAT. I am owning my story. I’m standing up and calling out the people who are so very wrong about who/what I am.

I am planning to make it possible. I’m relearning some things that were forgotten and strengthening new skills I have learnt on this pathway.

Today, I realised I’ve let people put me in a position where it wasn’t just them stealing from my future; it was me too. By giving power to their judgements and their words (most often made with no evidence) I let them convince me that Plan-A could never happen. I let them motivate me to invest more heavily into preparing for Plan-B than into fighting for Plan-A.  

Now, I am not. No more! I’ve already learnt that others do not get to define who or what I am, or where my story goes. 

I am actively investing in Plan-A and will make it happen. I am going to stop wasting my resources preparing for Plan-B, just so that it hurts less if I face a set-back. And, I’m going to see set-backs for what they are; set-backs. They’re not final endings or conclusions, not final chances…  

Screw Plan-B! I’m resilient and capable.

Plan-A deserves my efforts and Plan-B is simply the acceptance of other people’s attempts to put me in a box and dictate who I am, what I’ll be, and where I’ll go.

From Critical Mass to A Nuclear Chain Reaction

Trigger warning – post makes reference to suicide.

Today is #CrazySocks4Docs Day 2019; it’s wonderful.  This movement, started by Geoff Toogood, has spread around the globe.  We have doctors and other health professionals all standing up to speak out and say, “We aren’t going to accept a professional culture that stigmatises those who experience mental illness.”

From where I am, it seems like we’ve reached a major turning point in the culture of medicine.  Those who are standing up, donning their #CrazySocks and saying, “We simply must do better.” are not just the people who have experienced mental illness, but their ‘well’ peers who recognise that it could have been them and may be them in the future. 

We’ve reached a critical mass of voices in unity.

Is it too early to call this a critical mass?  No, I don’t believe so.  According to Wikipedia, “critical mass is the smallest amount of fissile material needed for a sustained nuclear chain reaction.”  For a high school physics nerd like me that feels pretty exciting!  But what does it mean for this issue?  Can we now expect an automatic flow-on out of the critical mass of real-time changes that will support our peers who are impacted by mental illness?  Will the changes we need in order to reduce the incidence and impact of mental illness in our professional simply occur?  The answer to that is, no.  The critical mass of people standing up in unity is the crucial ingredient, the foundational step, and an immeasurable achievement: For a nuclear chain reaction, we need to do certain things with that ‘critical mass’.  It doesn’t stop here.

Those who have advocated along the way and helped bring us to this point should be proud beyond words.  I have no doubts that #CrazySocks4Docs 2020 (and in the years after that will continue to grow exponentially).  I’m certainly on the lookout for some super crazy socks I can add to my collection before then.  But what happens tomorrow?  What am I going to do in this space to ensure stigma around mental illness has no place in the profession I chose?  What action am I going to take to ensure any remaining stigma has no mechanism to survive? What action are you all going to take to ensure the stigma we’re screaming out against is genuinely thwarted and becomes a sad part of the medical profession’s history?

Mental illness doesn’t discriminate.  Doctors, and other health professionals, face situations that place us at an increased risk of depression, anxiety, and trauma.  We can’t afford to keep losing peers from our ranks because they experience these difficulties.  We need to take out critical mass and actively implement strategies that support stigma reduction.  

What does that look like?  

Time travel back 10 years with me to 7 June 2009.  I was about halfway through my internship and had started my third rotation on a busy surgical unit.  Before graduating I had experienced severe depression and made attempts on my life.  However, I had been travelling pretty well for a sustained period and was not unwell… My medical registration was subject to conditions based on the assumption that someone who had experienced mental illness would be a risk to the public without those conditions.  I also had fairly serious physical health challenges that made long hours an impossibility; but I was capable of working the full-time hours for which I was contracted.  On this day, 10 years ago, I was not ‘clinically depressed’; ten days later I was in an intensive care unit, barely alive, after having taken a high-lethality overdose. How did that happen?  

The attempt on my own life, on 17 June 2009, wasn’t rooted in an episode of clinical depression.  That attempt was a very much a reflection of a training system and a medical culture that did not allow for good self-care (mental or physical).  On that day I was isolated, trapped, feeling helpless without any way forward, and utterly exhausted.  To put it frankly, I was so overwhelmed by the situation and could see no way of surviving.  Sounds a bit like ‘depression’, so I’ll explain why it wasn’t.

In the months leading up to the commencement of that surgical rotation I flagged with the internship coordinator that, physically, I wasn’t managing the 16-hour days (sometimes several in a row depending on the roster). I explained I was getting physically sick as a result and requested the hospital assist in organising my roster so that I was still meeting my full-time obligations (80 hours a fortnight), but not rostered on for up to 120 hours (plus non-rostered overtime).  The proposed solution was totally unacceptable to me; it involved simply redistributing my excess hours among a handful of my peers who were already burdened with similar hours.  Needless to say, I told my Director of Intern Training that I could not accept that solution.  I don’t want anyone to see this openness as a criticism of that Director of Intern training; I don’t think there was a solution because we simply didn’t have enough bodies to fill all the hours.  That particular Director of Intern training is one of the kindest, most genuine, surgeons (and people) I’ve come across; he just didn’t have a magic wand and the situation was just as much out of his control as mine.  There was nobody more senior to flag it with because our hospital was temporarily without a Medical Director.  

In the email trail there was ‘administrative gaslighting’; to this day I don’t think the author realises that’s what was it was.  It was suggested that any intern who needed to work any ‘extra hours’ required remedial training in time management:  This wasn’t the case for me, or any of the other interns that I worked with that year.  We were all pretty capable and efficient.  If you added up the hours, we were all rostered on for over the course of that intern year you’d probably find the hospital could have employed 60 interns with full-time hours rather than the 40 interns we had.  The reality was, we had more work to do than hours in the day. The expectation was that we would pretend that wasn’t the case and work the excess rostered hours, plus any additional un-rostered overtime needed to get the jobs done for our patients.  At one stage hospital administration even asked us not to document our un-rostered overtime on timesheets.  It was implied that anyone documenting un-rostered overtime would be ‘pinged’ in their performance assessments for a ‘lack of efficiency or organisational skills’; that was motivation enough for many to simply plough on through.

I was beyond exhausted.  The physical cost of the extra hours was huge.  I barely had time for basic self-care.  I needed every moment of rest I could get.  Grocery shopping, cooking healthy meals, and even cleaning my home or doing laundry, all became ‘luxuries’.  My roster rarely allowed me to attend much needed medical appointments with my GP and specialists.  If I elected to take the weekly ‘afternoon off’ that we were allowed to take, I would inevitably return the next day and face criticism for that absence, even when I had communicated appropriately with my seniors before leaving.  My monthly infusions of immunoglobulins would normally have required one day off a month; interns can only take 20 days off in a year, or you fail on attendance.  I found myself having my infusions via the Baxter-bottle antibiotic infusion pumps, connected to my port-a-cath, while I did my rounds with everyone else. When my port needed replacing, I was back at work on a 16-hour shift the following day because I couldn’t get leave for more than the one-day needed for the procedure.  I’m able to look back now and judge myself far less for having become so broken during that time.  It was a lose-lose situation.  

My mental health issues in medical school were fairly widely discussed and gossiped about.  The majority of students knew ‘stuff’, but few really knew what was going on, the details, the facts, and few asked:  I guess it was easier to simply assume.  Senior staff in the hospitals and medical school participated in the gossip and the message was out there; it was totally acceptable to engage in that kind of behaviour because I had experienced a certain type of illness.  It wasn’t everyone, but there were a large number. Stigma and prejudice were alive and well.  I knew about the back-chatter.  I knew about the breaches in privacy and ongoing inappropriate access to my clinical records where I had been treated for mental health issues.  I knew that many of my intern colleagues, at least those who went to the same medical school as me, viewed me as ‘less worthy of being in the profession’.  

At our graduation ball when the ‘joke awards’ were being handed out people asked, “Who is the least likely to be in medicine in 10-years’ time?”: Someone shouted out my name and the room went silent.  If I had not been sitting at a table located so far from the door that an exit from the building would have been visible to everyone, I would have left within seconds: Instead, I sat there and acted like it didn’t matter.  The majority of my graduating class knew that I had faced a fitness to practice investigation from the Medical Board the previous year.  The actual answer to the question was meant to be the name of a classmate who had diligently completed their medical degree at their families request while wanting to set up a bakery.  That moment was the embodiment of stigma, and it hurt; actually, it still hurts to write about it (publicly) more than 10 years later.  That stigma was isolating.  

Having been unsuccessful in trying to negotiate safer working hours, having been repeatedly berated when I did take time to engage with my health practitioners, I was in a tough spot.  Add to that the extra scrutiny I was under as a doctor with conditions on their registration and facing stigma for a mental health history that was fairly widely discussed; I felt trapped.  How could I possibly ‘win’?  I couldn’t do what I needed to look after my health.  Any criticism of my performance was likely to be attributed to ‘a mental illness’ by the Medical Board and potentially used to further restrict my registration; the reality is, I am a human, and was in my first year as a doctor just like everyone else.  Isolated by the stigma, and absolutely exhausted beyond the point of being able to make good decisions, I broke.

The story above highlights how various factors can bring someone to that breaking point without there even being an underlying clinical depression. I’ve also reflected back over the years and wondered whether I would even have been in a position to recognise if I had been clinically depressed; I don’t think I could have.  

How do you assess a change in your appetite when you’re too busy and tired, to really think about food and just grab whatever you see at the hospital’s cafeteria, or the Hungry Jacks drive thru?  How do you assess a change in your sleep, and weigh up the cause, when you’re barely getting the sleep you need, and your hours require you to frequently deny yourself sleep, or wake up from your sleep, while you’re still tired?  How do you tell if you’re overwhelmed because you’re becoming depressed and coping less well than normal, when the stressors you’re facing are all quite significant and could be overwhelming to someone who isn’t depressed?  How do you tell if your anxiety is above and beyond what is expected of a junior doctor desperately trying to pass, succeed and secure referees so they’ll still have a job the following year?  How do you let your doctor know you’re finding life tough when you can’t even attend an appointment without criticism from your seniors?  Even if you do get an afternoon off each week, how do you book an appointment when you don’t know in advance which afternoon? These are all relevant questions. 

How can we expect doctors to look after the health, mental or otherwise, when we’re putting them into a situation that makes that close to impossible?

It’s my personal belief that while we still have rosters and attitudes that don’t allow for good self-care that we actually still have stigma; or we’re at least leaving the foundation there for stigma to regrow.  By having a situation where we are essentially looking at ‘survival of the fittest’ we create a situation where those facing other issues ‘drop-behind’ or appear less capable when they can’t meet the excessive demands for whatever reason.  Maybe they’re physically sick, maybe they’re experiencing depression, perhaps they have young children and family commitments, maybe their elderly parents need their help:  They’re not less capable, but they may not have the same time resources available to meet the demands of ‘more than full time’ employment expectations.  The likelihood is that they’re just as good a doctor as the person who seems to work their 70-hour week with relative ease.  

I’ve been very open about a very dark moment in my history.  Some may see it as blaming…  I hope most will see past that and realise that any of us could end up facing a moment of being overwhelmed, helpless to change our circumstances and trapped.  We need to be taking action to change our professional environment so that these factors are not there.  We need to take the passion behind wearing our crazy and loud socks today and actively seek out ways we can re-work our medical culture so that the risk factors for mental health problems are minimised, so that our peers can discuss mental health as openly as a broken leg, and so that we can recognise warning signs of serious mental health conditions (because the warning signs aren’t masked by system issues). 

For those who are wearing their craziest socks today (and in all the lead up events this week), Thank you!  My challenge to each of you is to think of 3 things you can action in your own workplace to bring about a change in the circumstances that give stigma its foundation.  Can you change the rostering?  Can you help your staff plan their time off so they can use that effectively for self-care if they need it?  Can you take a team coffee break and let everyone know that its ok to come forward and ask for assistance or understanding?  Can you show your own vulnerabilities to your colleagues to they know they can show theirs when they need to?  

Let’s take this critical mass and drive it towards a sustained change in our medical workforce and culture.  #MH4Docs  #CrazySocks4Docs.

Doctors, Broken Systems and Stockholm Syndrome

Over the past few years we’ve seen a dramatic increase in public discussion and media coverage of issues impacting the ability of doctors to provide safe medical care.  You’d only have to spend a few minutes on Twitter scrolling hashtags like #MH4Docs and #MandatoryReporting to see the loud acknowledgment from the profession that the issues are there and need to be addressed. 

Doctors are scared to seek care for health issues, particularly mental health concerns, because of mandatory reporting laws and the risk of career damage.  Not only is seeking care problematic, the exposure to risk factors for mental health issues are significant; long hours, bullying cultures, victim blaming and endless competition for training and job opportunities are rife in medical workplaces.

Despite the profound levels of discussion and advocacy around effecting positive change in these areas, you’ll still find comments that are seemingly negative and critical of attempts to improve the system(s).  

Why is that?  These individuals are frequently health professionals also facing these issues.  Why wouldn’t they want to see change implemented?  I have not found one negative comment or criticism of advocacy in these areas that actually denies the issues exit:  There is a resounding agreement that they most certainly do. The criticisms and negativity appear to be focused on the hurdles and challenges that will need to be overcome to successfully overcome these endemic system problems.

There’s the group that are advocating for changes and striving to take steps towards better systems, that will be safer for doctors and patients.  There’s the group that are too drained and thwarted by the very systems that need changing to do anything more than watch the advocacy and efforts of others, hoping that change will occur.  Then, there’s the group that seem to discourage the advocates, loudly proclaiming the awful realities of the hurdles that have to be overcome before change can occur; and, at times, implying that those hurdles are impossible to get over.

The final group are sometimes assumed to be trolls on social media platforms.  However, after some serious consideration I’ve decided that as frustrating as their defeatist attitudes may be, they aren’t trolling. These individuals are evidence of just how damaging the systems we are seeking to change are.  They’ve moved past being overwhelmed by the traumas/dangers of working in these systems, while still holding onto threads of hope that the issues will eventually be addressed, and they’ve moved into a place where they believe the situation can’t be addressed because it’s just too hard. It is the final group who are sometimes identifiable through comments like “That’s how it was when I went through” and “It worked for my generation”.

The advocates aren’t blind to the immense challenges associated with pushing for change; but choosing to give those challenges too much power steals away the chance of taking even small steps towards system(s) improvement.  

In a way, the defeatist group, have developed a form of Stockholm Syndrome to the very systems that have stolen their own health, relationships and hope.  Accepting system problems as facts and realities that are unable to be addressed for one reason or another provides a level of self-protection: If you accept that the problems can’t be changed then there is no inner turmoil associated with not addressing them.  Agreeing, and sympathising, with the administrators and organisational power holders who say “we can’t fix that because…”, they’re almost defending the perpetuation of these issues which are affecting each new generation of health professionals who graduate into these systems.

When I consider the defeatist group with this perspective, they become less like ‘thorns in my side’ as I join with others in doing everything I can to bring about change, and more like ‘fragile, broken reminders’ of what the outcome for for many more doctors will be if we don’t succeed in changing these systems.  And, I realise, that for several years I was one of them…

With that perspective, the urgency and importance of fixing our broken systems becomes even greater. Those of us who are able must push hard, and with strategy, to ensure that we do not become the next cohort of defeated and accepting broken professionals.  We must fight for those who are not yet broken, but currently swimming upstream against such powerful system issues that all they have capacity for is their own survival (I dare say, that is probably the majority of junior doctors – it was definitely me).  And, we must fight for change and hope that even small steps forward will bring those who have been defeated back from complete brokenness (and acceptance of the systems that broke them), to a place where their wounds can heal and allow them to nurture future generations.

In no way should this post be taken to be a criticism of those who have suffered through the current systems to the point of being broken; I am only sad that the changes we are pushing for now were not there before they, and I, became so damaged.  

History isn’t my strong point, but I can’t identify any moment in history where great change began with someone saying “This is too hard” or “It isn’t possible”.  Change is rarely easy and rarely cheap.  It doesn’t happen overnight, and it takes unity and alliance to truly implement.  

Knowing that, I’m committed to continuing to try and effect change in our broken medical systems for the safety of doctors and our patients (two cohorts with equal importance).  If I see a hurdle, I’ll acknowledge it, but only so that I can try and identify a way to overcome it.  

Staying on Your Feet

I have a very strong focus on advocating for improved mental health, particularly for doctors.  Aside from trying to do my part to reduce stigma and prejudice against those who experience mental illness, I am always looking for strategies that I, and others, can use to not just improve mental health, but to maintain it.  After all, why climb a mountain only to fall off a cliff as you reach the summit. 

Last weekend I had one of those moments of realisation that we sometimes have in life.

For those who don’t know me that well a bit of background will help.  Last year I became a part-time wheelchair user, not long before turning 35 (which I still think is young).  I have Ehlers-Danlos syndrome which, for me, means my joints are quite hypermobile. After losing 75kg of excess weight during an 18-month period, I developed a significant amount of muscle weakness. Given the stability of my joints is heavily reliant on good muscle strength and coordination, this became a big problem; my joints started dislocating more frequently and recurrent hip dislocations took a toll on my mobility.  The introduction of a wheelchair came after careful consideration and we hoped it would reduce falls.

To an extent, using a wheelchair does help; clearly, I can’t fall over when I am not walking.  But, as they say, “If you don’t use it, you lose it.”  It became a choice whether I became more reliant on my wheels or worked harder to ‘stay on my feet’.  It’s a love-hate relationship I have with my wheelchair:  It is a blessing on days when I am in considerable pain or extremely tired, however, I am naturally inclined to run around, and it cramps my style. I’ve chosen to focus on option number two – ‘staying on my feet’.  

Towards the end of last year, I was working very hard on improving strength and coordination to minimise dislocations and falls; but I wasn’t really getting anywhere.  I was definitely more tired, and my joints and muscles felt well used:  Despite doing everything I could with the exercise physiologist and a personal trainer, I kept on falling.  For a few months I resigned myself to a permanent decline in mobility and was, to a degree, grieving that loss.  My treating team (now changed) appeared comfortable with a lowered expectation of what my mobility status would be in the future. My own resignation to using my wheelchair most of the time didn’t last long; I am simply too stubborn.  If there is anything I’ve learnt from growing up autistic with parents who always focused on my abilities, not my difficulties, it is that other people’s expectations of what you can or will achieve don’t have to limit you; and the limitation is often more related to how much you believe those assessments of your capacity vs the actual impact of any disability.

My wheelchair is named “Franklin” after the former American president Franklin D. Roosevelt who stood up out of his wheelchair and said, “Don’t tell me it can’t be done.”  Matthew Wilder’s song “Break My Stride” crept up towards the top on my regular play list and I found myself humming “Ain’t nothing gonna break my stride… Oh no …I’ve got to keep on moving.” as an hourly mantra.  And yes, I felt the need to put it on repeat while writing this blog post.

I booked in with a new physiotherapist who had some great reviews on google and whose practice offers tailored Pilates rehabilitation programs. I always thought Pilates was glorified pseudo-exercise where you play with those awesome giant exercise balls (I standcorrected).  My new physiotherapist did something entirely logical, but unexpected.  During her assessment she pulled out an ultrasound machine and scanned over each muscle that should activate and contract during each movement to assess whether or not it was pulling its weight.  The logic behind this had me questioning my own competence for not asking someone to do this sooner.  We have multiple muscles around each joint, and each muscle has a purpose; it makes sense to check they’re all working…

From all muscles we observed, only my gluteus maximus was doing any work on the left side, and the right-hand side wasn’t far behind.  Those gluts were working very hard; compensating for all the others, to whatever extent is possible.  No wonder when my unstable joints were facing possible dislocation I just kept falling.  There was a single ‘safety net’ stopping dislocations, and if that safety net ‘failed’ down I went.  There started a program that looks easy to an observer but is mentally and physically hard; it is focused on reactivating and retraining all those weak and atrophied muscles around my joints to start working again and do their job (that and training the muscles that have been doing all the work to ease up and let others have a chance).  The program takes effort and concentration; Pilates with the physio, hydrotherapy with the exercise physio, personal training at the gym, daily exercises for at home…  I’ve got sore muscles where I didn’t even know I had muscles (anatomy was definitely not my strong point in medical school).  

The moment of realisation came while attend one of my favourite conferences.  I stood up quickly while turning (high risk for me) and there was a notable wobble; the horrendous feeling right before I usually feel my hip pop out and fall to the ground. But I didn’t fall.  I was stunned.  Right at the moment when I would usually feel a complete loss of control in the joint, I felt something tighten and hold things in place and I was able to regain my balance without a dislocation or subsequent fall; the gluteus medius muscle kicked in and I saw the first tangible improvement from my new exercise program.  A colleague noticed the wobble and said, “You nearly fell”.  I paused while the reality of the situation sank in and then responded “Yes, I did nearly fall.  But, I didn’t.” – that statement was as much for my benefit as theirs.

A subsequent review with my physiotherapist indicated that those muscles are starting to activate more when I try certain movements.  I felt an enormous sense of achievement and pride based on a solid investment of time and effort into changing my mobility status.  Now she is faced with being the ‘fun police’ at times while I enthusiastically eye off the more entertaining looking pieces of equipment in the Pilates gym; who wouldn’t want to play on a giant wobbly surf-board! (I’m told the surf-board may be in my ‘future’ dependent on further improvement). 

Not falling over with a hip dislocation is a pretty objective measure of an improvement in functioning.  But how to we measure things like this when it comes to mental health.  How can I apply what I’m learning with my visible disability to the less visible entity of mental health improvement and maintenance?

The key things I can identify from my loss and partial (ongoing) regain in physical mobility is:

• Sometimes things happen that damage or weaken our safety nets; those things are not always in our control (muscles supporting already vulnerable joints became weak with rapid weight loss)
• If you don’t use it, you lose it (sitting in my wheelchair all the time was never going to improve the muscle strength and coordination around my joints)
• You absolutely do nothave to settle for other people’s expectations of what you are capable of; the older I get, the more I realise nobody else has the right to define the limits of what I can or cannot achieve based on their perception of my disabilities.
• Staying ‘on your feet’ requires multiple muscles to work; you need more than one safety-net, you need a team of muscles to keep those joints stable.
• Strengthening and retraining weak and atrophied muscles takes time, effort, strategy, concentration and commitment; you can’t just keep doing things the same way, you need to try new movements and learn new skills.
• Developing and training muscles might hurt a bit, especially at first.
• You have a right to feel proud of yourself for small gains, achievements and even minor progress.  Use it to motivate yourself to go further and as encouraging evidence that you can improve.

Now let’s consider how all of this applies to mental health.  My “uh huh” moment last night was while lying in bed, struggling to sleep.  I was thinking about the sense of achievement and pride I felt when I realised that I had succeeded in beginning to improve certain muscle functions, and my physiotherapist confirmed the progress.  Then, I felt confusion and guilt.  Over the years I have invested countless hours into self-development, into strengthen my resilience, coping skills, mental health, communication skills, and emotional intelligence.  I lay there wondering why I hadn’t ever felt that sense of achievement and pride when attending an appointment with a psychologist or psychiatrist (or someone else helping me work on improving my mental health).  

In contrast to the sense of self-pride and achievement I felt with my physio this week, on many occasions my feelings when working on improving my mental health have been better described as shame and failure (even when I’ve made positive progress).  Those negative feelings have certainly not been attributable to projection of negativity from the treating specialist (at least not in the context of my own private long-term treaters, in the public system I can’t say that’s always true).  I pondered whether those negative feelings and the absence of a sense of pride and achievement were a possible indication that I have some unconscious prejudice towards mental health problems; I decided I do not.  After careful consideration I recognise that perhaps my own feelings of shame and failure when faced with working on the improvement or maintenance of my mental health is a reflection of the rampant stigma that we still have in society towards individuals with mental health problems.  

Somewhere along the road, to some degree, I have bought into that stigma and prejudice:  I have allowed myself to feel shame and failure for even needing to ask for help for depression, anxiety and trauma.  I have not allowed myself to celebrate small or big gains in mental health improvement and maintenance despite having invested significant efforts into those gains; I haven’t mentally allowed that because somewhere along the road I started believing the projected stigma that says “you are a failure if you needed to work on those things in the first place”.  

This morning I can sit here and say that it is not true. Needing to actively work on strategies to improve and maintain your mental health in no way makes someone a failure.  Having mental health problems does not make someone a failure.  Small and big improvements in skill sets, coping strategies and independence should be celebrated with the same enthusiasm and gumption as gains in mobility.  Now I am determined to approach my own mental health from that same perspective.  

I do see a psychiatrist regularly, sometimes just to check in and update him, and other times to seek extra assistance in managing anxiety or depression.  In the past, I have also spent many hours with psychologists working on coping skills, emotional intelligence, self-awareness and communication skills. In my private time I regularly seek out resources for self-development to improve resilience and ensure I can maintain my mental health.  Doing those things, and gaining benefit from them, does not mean I was weak or defective in the first place.  

Here’s how my checklist is going to translate into mental health improvement and maintenance:

1. Certain events and factors in life can cause insult/damage to our mental health.  I’m going to acknowledge those things when they pop up and understand that if something has acted to damage my mental health that I may need to invest extra time into it to improve my mental health and bring it back to a point where it is being maintained.  I am also not going to view myself as a failure from now on when something external impacts on me negatively; requiring that extra effort.
2. The skills and tools I develop to improve and manage my mental health I am going to deliberately choose to practice even during times when I seem to be travelling along just fine; because if I don’t, they won’t be there when I need them to stop me from ‘falling’.  That means having a support network in place, knowing myself well, maintaining a healthy life balance (including exercise, good diet and sleep hygiene).
3. I will not accept other people’s projections and assumptions as to what I can or cannot do based on their knowledge of my mental health history:  Other people do not get to define my limitations and capacity (especially not based on stigma/prejudice).
4. Identification of a variety of skills that I can use to improve and maintain my mental health is going to remain a priority.  I won’t be focusing on just one avenue to protect this important part of who I am; I’m going to deliberately explore options that may seem less appealing but will give me extra safety-nets when those insults to mental health occur.
5. The time I invest into developing these skills, and applying them in my daily life, is going to be something I view as important as my ‘daily 30’ (of exercise); it cannot be viewed as a waste of time, or an optional extra.  In order to maintain health you have to invest into it.  Perhaps I will call it my ‘daily 30 for mental wellbeing’.
6. Finally, I will call myself out on any occasion in the future where I am self-critical for needing to take time to manage or improve my mental health, or for needing to ask for someone else’s assistance or advice in managing it.  That commitment is about actively living out my belief that mental health issues should not be treated any differently to physical health issues; I am going to celebrate the gains and improvements the same way I celebrated not falling over.

For me, realising that I had let other people’s prejudices towards mental health impact on my own perceptions of personal attempts to self-care seems like a critical step in moving forward in the future.  I hope that in the future fewer people buy in to these negative views on mental health improvement and maintenance so that as a society we can be mentally healthier and happier.

#WAModelNow – It’s Constitutional!

The past few years has seen article after article reporting doctors’ fears associated with the Mandatory Reporting system (administrated by AHPRA).  We’ve all read about the concerns registrants face when considering the impact of seeking health care for certain types of health issues, particularly mental health concerns.  

Advocates have been pushing for all States and Territories to adopt the Western Australian model; and with good reason.  There is no evidence that WA has a higher incidence of medical practitioners causing harm/risk to the public when practicing; but doctors in WA can access health care without the same concerns as their peers in the rest of Australia.

While taking a mental break from the intense task I face in preparing for my own appeal against conditions imposed on my medical registration (as the result of having a mental health history) I sat down last night to watch “The Castle”.  

“It’s the vibe of it.”  

At some stage, late in high school, I did read the Australian Constitution; that was a while ago.  I read it again.  We don’t have a Bill of Rights in Australia (which is quite unfortunate), but we do have two clauses in our Constitution that provide some degree of ‘protection’.

Section 117 is of particular interest to me, and perhaps to others interested in changing our Mandatory Reporting laws.  

Section 117:

A subject of the Queen, resident in any State, shall not be subject in any other State to any disability or discrimination which would not be equally applicable to him if he were a subject of the Queen resident in such other state.

It’s a little wordy, like so many things in law.  Let’s break it down:

Subject of the Queen = Australian citizen and/or resident

Resident in any State = Broad/Temporary

Disability or Discrimination = A less positive circumstance/situation

The essence of Street v Queensland Bar Association was that a State cannot impose limits on professional practice qualifications on the grounds that a person is not permanently residing in that State. While it can be said that this requirement impacts equally on residents of any particular State, it has a more significant impact on those not residing in a particular State.

All Australian States and territories have Mandatory Reporting laws; WA’s being the safest for doctors and the public.  The National Law, as worded in all other States and Territories does apply equally (within each State) to residents of all States:  A Western Australian doctor seeking certain types of ‘health care’ in NSW/VIC could well expect to be subjected to the Mandatory Reporting system of that State.  The issue here isn’t whether the Law applies equally to people from any particular State, it is that residents from any State/Territory other than WA are subjected to far more significant and serious consequences than a resident of WA would be subjected to under Western Australian Law.

Section 117 of our Constitution has been discussed amongst lawyers over the years without any finite conclusion about its ability, as a clause, to allow for equal treatment between residents of different States.  Perhaps it is time for a revival of those discussions.

#WAModelNow is a Constitutional proposal.  I’ll go further to say that any State/Territory applying Mandatory Reporting Laws that are more stringent and onerous to registrants are behaving in a manner that is unconstitutional!  

It isn’t just ‘the vibe of it’; it is a Constitutional right that health practitioners across Australia be afforded the same protections as their peers receiving health care in Western Australia.

Empathy – An Autistic Doctor’s Thoughts.

April is now referred to by many as Autism Awareness Month. Many of us in the Autistic Community would prefer it was called Autism Acceptance Month; people seem adequately aware of autism these days, but acceptance is often lacking.  

I want to address something that is both an issue around awareness and acceptance.  Having recently been the subject of a number of media articles that highlighted the fact that I am a doctor and also autistic, I was faced with certain comments and assumptions.  The one below is worthy of discussion.

“Am I alone in thinking that autism is not compatible with seeing patients? Surely empathy is essential in a medical practitioner but this is by definition lacking in someone with autism?”

My immediate response to this comment was an internal monologue along the lines of “No, sadly, you are not alone in that thinking…  But, you are wrong.”

Let’s talk about empathy, and then let’s talk about that in someone who is autistic. 

Autistic people do not lack empathy:  This is an age-old myth that is harmful and quite lacking in insight! Empathy is the ability to understand and share the feelings of another; it relates to how good we are at sensing another person’s emotions and understanding what they are thinking or feeling.  Breaking it down, there are multiple parts to empathy:

• Sensing what someone else is feeling (distress, happiness, anger)
• Understanding what another person is thinking or feeling (being able to put yourself in their shoes, having theory of mind)
• How a person visibly responds to emotions expressed by those around them (perhaps you reach out and hug someone who looks sad).

Other forums might describe the two different types of empathy; Affective empathy and Cognitive empathy.  The first, affective empathy, refers to the sensations and feelings we get in response to others’ emotions.  The second, cognitive empathy, refers to that ability to identify and understand another person’s emotions by taking their perspective.

There is good evidence that autistic individuals do have a strong sense and awareness of the emotions expressed by others.  Often a heightened sensitivity to the emotions of others is something that overwhelms autistic individuals.  Now consider the role of affective empathy in medical practice; it is the feelings we get in response to others’ emotions:  We see someone sad, so we feel a bit sad.  We may see someone is fearful and become fearful too.  Often the role of affective empathy isn’t to ‘fix’ something driving another person’s negative emotion (if it is negative), but to ‘convey’ to that person a degree of understanding so that they feel heard and understood.  Consider that in the context of a doctor treating a patient.  If my patient is highly distressed about their illness, I would prefer that I not mirror that high level of distress, automatically. It is important that I understand they are distressed, and why that is likely (cognitive empathy, which we will come to), but there is little benefit in me mirroring their distress beyond communicating that I do have an appreciation of their predicament.  To be honest, the ability to not become enveloped by the emotions of those around, when faced with highly distressing scenarios can be an advantage; perhaps it allows you to step back and focus on finding a solution to the distressing situation, perhaps you can calmly handle a pressing medical emergency.  

Please don’t assume I’ve never cried with a patient or family member: I have.  When it has been appropriate, I have sat with patients or their loved ones and cried, laughed, and celebrated.  

Cognitive empathy is something we learn.  It is a developed social skill.  It is true that autism is a developmental disorder and that many individuals who are autistic need some extra assistance in developing certain skills, including theory of mind and cognitive empathy.  The point is, cognitive empathy is something you can be taught, and you can choose to develop in yourself.  Perhaps more than many of my neurotypical peers, I have specifically worked on my own skills in cognitive empathy (from quite a young age) after realising it didn’t come naturally.  

Here is an example of how age, and experience can impact on an autistic individual’s cognitive empathy.  

At the end of 5^thgrade, in primary school, I recognised that my teacher had clearly struggled having me in her class for an entire year.  I was pretty advanced in mathematics but struggled with the nuances of language. My teacher was amazing with language, but not quite so strong with basic maths.  I had affective empathy; I realised she felt stressed whenever she needed to teach what she considered ‘difficult mathematics’.  What was lacking was my cognitive empathy.  By nature, I am extremely caring, and I thought I should try and help my teacher so she wouldn’t feel so stressed the following year.  While we hadn’t managed to get along for most of the school year, I decided I would offer her a solution to her woes on the second last day of the year.  During recess I approached her and said the following:

“Ms Brown (name changed).  I’ve been thinking about how you could have a better year next year. I know you’ve found the maths quite hard while teaching grade 5.  Maybe next year you could teach Grade 2; then the maths and the English will be at your level and you won’t have to feel stressed.”

As an adult, with developed cognitive empathy, I both cringe and laugh at that statement.  It was said with the best of intentions and I was quite shocked at the absolutely volcanic response it received at the time.  Now, I understand how offended a grown adult would have been having an eleven-year-old suggest they were only capable of Grade 2 maths.  I only attended that school for one more day and then my parents moved me.  

Life experience, social stories and lots of practice mean that I have a reasonably strong cognitive empathy capacity now.  No, it isn’t always natural.  It doesn’t matter that it isn’t.  It is a bit like having to have learnt another language to communicate in.  I simply have to make the decision to think through a situation and actively consider what the other person’s perspective may be in any situation.  As with any other learnt, unnatural skill, it is more likely to ‘fail’ when tired or sick.  For many people with a second language, they prefer to use their native language when tired; that doesn’t mean they can’t be extremely proficient in the use of their non-native tongue. 

The development of cognitive empathy is foundational to responding in a socially acceptable manner.  A socially acceptable response can also differ depending on who you are responding to. Having invested into my own cognitive empathy abilities I am relatively confident that, in the majority of situations I can display an appropriately empathetic response to a patient or family member in a clinical setting.  After all, I never saw medicine as simply knowing a bunch of facts about physiology/pathology/anatomy; medicine is about helping people.  When I am with a patient, I see making an assessment of how they are feeling and responding as much a part of my job as interpreting their blood work or chest x-ray.  Because it is, to me, part of my role as a doctor, the cognitive empathy side of an interaction is something I actively consider and plan for.  

I have never had a patient complain about my level of empathy.  I have had a multitude of patients convey to me their gratitude to have been treated by someone that clearly stopped and considered their emotions and perspective; this is a far cry from the inference that an autistic doctor lacks empathy.

Being autistic, I often watch the same movies over and over again. In high school I watched the movie “Patch Adams” so many times that I can literally watch the movie in my own head with all the scenes and script lines perfectly recorded by my own memory. In my first year of medical school the walls of my college bedroom were plastered with quotes from the movie “Patch Adams”.

“If you treat a disease, you win, you lose.  You treat a person, I guarantee you, you’ll win every time; no matter what the outcome.”

“What’s the difference between a scientist and a doctor?… … People!”

“If you focus on the problem you can’t see the solution.”

Simply having that obsession with “Patch Adams” before I even commenced medical school was a strong foundation in ensuring I developed cognitive empathy alongside all the other requisite skills taught in medical school.  

Finally, we need to think about the response we exhibit once we’ve identified emotions in another person and considered their perspective. Every person is different (and that’s a good thing).  Some people will show they care by reaching out and hugging someone who is distressed. Another person may walk away to go hunting for a solution to whichever problem has caused that distress.  We need both of those kinds of people! There is nothing wrong with being the hugger.  There is nothing wrong than being the person who takes on board that someone is distressed and then walks away to try and find a solution.  Hopefully, the ‘hugger’ and the ‘solution hunter’ are paired together within a team, giving a distressed patient the best of both styles. They are also not mutually exclusive. With enough time available, a single individual can offer both responses.  

Personally, I am the ‘solution hunter’.  When I see a problem that is causing distress, I want to get to the root cause of that issue.  I’m that person that will be trawling through countless books and journal articles trying to come up with a creative and effective solution if there isn’t one that is immediately obvious.  I am the one whose mind won’t shut down while they’re eating dinner at home until I’ve solved that problem.  That’s my strength.  I can be the one to sit there, listen and be a shoulder to cry on; but I am much better at being the invisible solution finder.  Heading off to the library to try and find a solution to your patient’s problem is no less empathetic than sitting there and holding their hand while they process their own emotions. 

The ultimate positive of being an autistic doctor is that I have had to learn cognitive empathy and practice taking the perspective of a lot of people who think quite differently to me.  But there have been times when I have been the only doctor able to take the perspective of certain patients; my autistic patients.  

I have had autistic patients who have struggled with the same things I struggle with when I am in that patient role.  Sensory issues.  Food preferences.  Difficulties in a different environment.  All of these things impact on patients, and particularly autistic patients.  It amazed me while working on one unit that my entire team were quick to criticise how challenging one of our adult autistic patients was.  To me, it was completely logical.  The young man was in a 6-bed bay, in a state of sensory overload, and being denied access to his usual coping mechanisms.  The need for a ‘psychiatric consult’ vanished overnight when I implored the nursing team leader to implement some minor changes to his location and how nursing staff were approaching him.  With this patient, my own natural ability to understand what was causing him difficulty was superior to that of my neurotypical colleagues.  While they are more able to naturally relate to the perspectives of other patients, they struggled with their own cognitive empathy skills when faced with a neurodiverse patient.  

In concluding I’d ask the following.  If you are a doctor, or health professional, consider what I’ve written before you criticise yourself or a colleague on their ‘empathy’ skills. We are all different and we have patients who are all different.  Your way of expressing empathy may differ to the doctor sitting next to you; neither one of you is better.  You may be ‘better’ for Patient X in Bed 1 and your colleague may be ‘better’ for Patient Y in Bed 2.  Instead of criticising when someone responds differently to how you would, consider it a blessing that we have peers who are able to think differently to us and who have different strengths to our own; because when we team up, we are able to offer a broader level of support to the patients we come across.