There have been frequent occurrences of suicide among medical professionals in the past, but the rising number in such cases since December 2020 (involving four trainee and junior doctors in Penang and Shah Alam), with the most recent one in August 2024 (involving a specialist in Lahad Datu), is justified cause for worry.
This last suicide had prompted the Ministry of Health (MOH) to form a task force to probe the incident. The MOH then announced in October that it would issue guidelines on how to recognise and tackle this problem, after several members from the Putrajaya Hospital Board of Visitors acknowledged it was not an isolated incident, and reflected problems within our health care system.
Long working hours, decreased levels of resilience, sexual harassment, and workplace bullying have long been known to be sources of stress. A 2023 Malaysian Medical Association (MMA) survey found that 40 per cent of Malaysian doctors have experienced bullying.
Medicine is undoubtedly a stressful profession with extended working hours, ethical dilemmas, and sometimes-difficult patients and families. Medicine also requires high levels of responsibility and care from health care providers, as lives are at stake.
Doctor burnout has been a persistent issue throughout the years, and personality characteristics, a non-conducive work environment, and the constant pressure of having to continuously deliver high standards of care towards patients can produce feelings of persistent anxiety among doctors that can lead to job dissatisfaction.
Depression and suicidal ideation are the dire consequences of doctor burnout, and are well-reflected in the national databases of several countries. It has been reported that suicides among male and female doctors are 41 per cent and 130 per cent higher respectively than the general population.
Doctors are exposed to more work-related stressors than other professional groups, making them more vulnerable to developing depression. These include long hours, extensive workloads, the intensity and complexities of the job, relentless contact with patients, having to deal with emergencies, high levels of responsibility, rapid changes within health care systems, institutional constraints such as discrimination and intimidation, lack of autonomy, low levels of support, loss of job satisfaction, low morale, and the inability to attend to their personal lives.
Workplace bullying has recently been brought to light and appears to be a worrying trend, and the frequent targets of such bullying are junior doctors. The predictors of depression in doctors are difficult relationships with senior doctors, staff and/or patients, lack of sleep, constantly dealing with death, making mistakes, loneliness, 24-hour responsibilities, and self-criticism.
Doctors also have higher suicide rates, and one of the major risk factors appears to be depression. Administrators (and doctors) often forget that a diagnosis of depression does not necessarily mean impaired professional abilities.
However, this might culminate in fears of breaches of confidentiality that may compromise the openness required between management and doctors, which further discourages affected doctors from seeking help. This subsequently creates a barrier, thus making a proper diagnosis even more difficult.
Hence, health care workers need to be more intuitive about the manifestations of mental illness within the medical profession, not only among those under their supervision, but also among their superiors.
The common belief that mental distress may be misattributed to ineptitude or weakness would naturally encourage depressed doctors to conceal their illness from themselves and others. This self-judgmental line of thinking will subsequently compromise access to care.
In order to cope, some medical professionals may start to take illicit substances. Self-medicating with alcohol or recreational drugs may strengthen the illusion that all is well, but on the other hand, this will pose an additional risk factor for delayed care and suicide.
The challenge for all doctors is to learn to recognise depression, not only in their patients, but also among themselves and their colleagues. This should be done to transcend the numerous personal, professional, and institutional barriers to effective treatment.
Physicians need to be cognisant of this and where possible, implement access to proper health care, whether in their roles as administrators, colleagues, or friends.
We have eight free suicide helplines, but doctors rarely call in; they may, however, be more amenable to speaking with a colleague — hence the importance of peers being aware of suicide risks so as to be able to detect and intervene when necessary.
Doctors themselves need to acknowledge the various factors behind the complex phenomenon of suicide and the increasing risk of suicide among doctors worldwide, with females having an increased risk of 2.5 to 4 per cent.
The causes include mental illness, lack of confidantes, a sense of futility, access to drugs, and having to deal with complaints against them. Obviously, a more targeted approach to address this is needed.
A good start would be to introduce peer counselling, which is not regarded as therapy, and is done manly for the support and collegiality that comes from talking to someone who has ‘been there’.
Physician coaches have also been made available in some countries, and they connect with stressed or burnt-out doctors in person or over the phone, dealing with four areas, namely leadership skills, major life decisions, disruptive physicians, and burnout, with many of them conducting additional workshops.
We believe these endeavours will improve decision-making skills and resilience. The College of Physicians has already embarked on leadership training courses over the past few years with much positive feedback from participants. Establishment of peer-support groups is of paramount importance, and we recommend it to be tabled as mandatory in high-risk fields of medicine.
Interventions within a medical organisation can also help reduce job stress and are expected to lead to long-term results by way of task restructuring, work evaluation, supervision aimed at decreasing job demand, increasing job control, or increasing the level of participation in decision-making.
Various medical departments should be mandated to display notices on the process and benefits of seeking help via suicide helplines and available counselling services. It should be emphasised here that these have to be confidential.
Regular awareness training should be implemented by human resource departments on workplace bullying and workload management. This should be made available via e-modules, since there is evidence that some interventions have seen reduced work hours and subsequently, reduced burnout rates.
Finally, employee assistance programmes need to be instituted and reinforced in hospitals to address and resolve conflicts at workplaces through healthy ways.
Some of the suggestions above have probably been taken into consideration by governing bodies, and the addition of those that may have not been considered could provide for a sound protocol for the mental health evaluation and management of medical personnel.
Lastly, information on stern action from the disciplinary board of the Malaysian Medical Council (MMC) with regard to workplace bullying and sexual harassment should be disseminated on a regular basis to reduce the likelihood of such incidences occurring. This is, of course, subject to internal inquiries about any such incident, and when required, an external committee should be formed to analyse the situation.
All doctors are expected to fulfil the criteria of being competent and safe, given their huge responsibility of being tasked to care for the public. This duty of care cannot be compromised nor be left open to abuse.
There cannot be a system where ineffective and disruptive doctors are not penalised or informed of their incompetencies, due to their superiors walking on eggshells when dealing with their subordinates.
In essence, the Hippocratic Oath needs to be strictly adhered to.
Prem Kumar Chandrasekaran, Selvasingam Ratnasingam and Thinesh Rajasingam are from the Psychiatry Chapter of College of Physicians, Academy of Medicine Malaysia.
- This is the personal opinion of the writer or publication and does not necessarily represent the views of CodeBlue.
