In the early 1980s when Amandip Sidhu was growing up in Harrow, a suburb on the fringe of northwest London, his South Asian family was one of only a handful of non-white households in the area. Having spent some of his childhood in East Africa, where his father was a civil servant, Amandip and his family keenly felt the racist microaggressions that were common across the United Kingdom at the time.

This early experience of prejudice profoundly changed his brother Jagdip, who was five and a half years older than him. Jagdip decided that the best way to beat discrimination was to prove that he was better than his peers. “He was very much the golden boy, and everyone loved him,” Amandip says.

After leaving secondary school with top grades, Jagdip went on to tertiary college, which was at the time a prerequisite for entrance into university. Just to outdo himself, he made a request to the college to be allowed to take four subjects instead of the maximum three for his exams. The request was rejected, but Jagdip refused to be deterred. He bought himself a textbook and taught himself physics, eventually scoring straight As.

Amandip found it tough being continually compared with his accomplished sibling. “I’m not academically gifted, and my dad would have a go at me about it sometimes,” he says. “And my brother would step in and say, ‘Look, just leave him alone.’ He was the only person my dad would listen to.”

Jagdip sailed through medical school, his scholastic record peppered with awards. Then he started work at Ealing Hospital in West London. Amandip recalls how his brother bought a new pair of shoes and, a short time after he started work, showed him his feet. They were bleeding and covered in blisters. Amandip was shocked, but Jagdip was pleased. He was so busy at the hospital that he had been rushing around for 10 miles (16km) a day.

“He felt it was a badge of honour, the fact that his shoes were worn out, that he didn’t have anything to eat or drink or even go to the toilet,” Amandip explains. It was almost as if these were accepted symbols of the dedication needed to be considered a good doctor by the profession and health systems.

Over almost 25 years, Jagdip established a reputation as an excellent doctor. He became the clinical lead for cardiology at a hospital in Kent and was tasked with spearheading several large projects, including one at a teaching hospital in London. “Until today, I still run into people who tell me he was the best they’d ever worked with, that he never got a diagnosis wrong,” Amandip says.

While many other consultants decided to take on private commercial work, Jagdip was committed to serving the majority of his patients under the publicly funded National Health Service (NHS). He felt strongly that he had a responsibility towards those who needed urgent healthcare but couldn’t pay for it. But his clinic lists were far longer than his colleagues, and there simply were not enough resources to support the overwhelming number of patients. Jagdip felt like he had to take every single one of them on.

But the cracks were beginning to show. In mid-November 2018, Jagdip told Amandip that he was scared of what was happening to him. “He was listening to his colleague talk about a case and said his brain couldn’t even function.”
Amandip gave his brother advice he now regrets. “I said he should see the occupational health service at the hospital, which was probably the wrong thing to do,” he says. Deeming Jagdip overworked, the hospital put him on leave for six months. In his severely distressed state, Amandip believes, Jagdip perceived this to be a punitive measure.

The Sunday after Jagdip was signed off sick, Amandip went to visit him. He says his brother was completely broken. It was only the second time he’d seen him cry. The first was at their father’s funeral. “He couldn’t look me in the eye. He felt so ashamed. It was his whole life. Being signed off work was like a draconian punishment to him, to say that you can no longer be the person you are.”

The next day, Amandip sent Jagdip a message to check on him. Jagdip responded and said he was resting. Unbeknownst to Amandip, his brother was actually tidying up his financial affairs.

Then, the following day, November 27, at around 2:30pm, Amandip received an email. True to the perfectionism that had defined him since childhood, Jagdip’s message consisted of a long list of instructions on what to do with his house and his insurance policies. “You’ll find me at Beachy Head with the car,” the note ended. Beachy Head, the highest chalk sea cliff in the UK, has been a well-known location for suicides since the 1600s. Amandip felt a punch to the gut: His brother was saying goodbye.

Amandip drove straight to Beachy Head from London, where he lives. The area was already swarming with search dogs, helicopters and officers from the coastguard. He sat waiting in silence until a policeman told him that they had found Jagdip’s body.

A numbness came over him during the hourlong drive home. “I showered, went to bed and thought I’d process it later,” he says. At 3am, he woke up and started sobbing as his wife held him. “That’s when it really hit me that my brother was dead,” he says.

Dr Jagdip Sidhu was 47 years old.
Alarming statistics
Around the world, doctors are two to five times more likely than the general population to die by suicide with female and junior doctors especially high risk. The most recent data from the Office of National Statistics indicate that in the UK alone, 72 medical professionals (including doctors, nurses, therapy professionals, dentists and midwives) took their own lives in 2020 – that is more than one per week. Suicide is also rife among nurses: More than 360 attempted suicide in 2022. 

Factors contributing to the high suicide rate within the medical community are well established. Among them are immense, high-pressure workloads, bullying and harassment within a rigidly hierarchical work culture, sleep deprivation, poor support structures and limited resources for employees veering towards burnout.
An unprecedented austerity squeeze on the NHS, which began in 2010 after the government said cuts to public expenditures were needed to resolve the UK’s budget deficit, ramped up pressure on healthcare professionals as hospitals were forced to cut back on front-line services. At roughly the same time, from 2009 to 2019, hospital admissions rose by 20 percent every year while the number of people awaiting treatment increased almost twofold from 2.2 million to 4.3 million.

Then came the COVID-19 pandemic, which further exacerbated the stresses on an already overwhelmed and underfunded healthcare system.

While there isn’t a lot of data to prove or disprove a link between government funding cuts and the working conditions of doctors and nurses, Kevin Teoh, an organisational psychologist who worked on a research paper (PDF) about the mental health of UK doctors, says “there are a few proxy measures we can look at” to measure the impact.

“We see higher stress levels among NHS staff at hospitals where there are also high bed-occupancy rates and emergency admissions. When there’s a decrease in funding to social services and to welfare, the NHS ends up picking up the slack,” he explains.

“With cuts, there are more patients who have been waiting longer, and their conditions may be more complex,” says Gail Kinman, also an occupational health psychologist and Kevin’s co-author on the paper. “There are fewer of you [doctors], less equipment and resources, but you still need to do your job under massive pressure at the level that is expected of you. … Healthcare staff end up shouldering the expectation that they should sacrifice themselves, their health and their personal lives for their patients.”

As a result, she says: “Burnout is happening at a much younger age [among doctors] when it used to happen later in their careers.”

And, she adds: “They may not necessarily recognise the symptoms or know how to get support.”

Those left behind
On a February morning last year, Dr Clare Gerada, a psychiatrist by training and president of the Royal College of General Practitioners, greets people over Zoom. “I know we have some new faces joining us today,” she says. “You can just sit and listen. There’s no pressure at all to speak. This is not a group that you would by choice want to belong to.”

Every participant in this online support session has lost somebody to suicide or sudden accidental death. All of the deceased were doctors. The age range of the bereaved is large. One woman is in her mid-20s, and there’s also a couple in their 80s who have been attending the group for about three years. Strikingly, several individuals are medical professionals themselves. The mood is relaxed as people begin to engage in small talk. The older couple has been bird-watching in “a place that our daughter loved very much as well”, the woman explains.

Over the course of the next one and a half hours, the group members speak frankly of their grief and loneliness. There is no real structure to the meeting, but the tears and the jokes flow freely. Many of the participants are angry at how their loved ones were treated within the healthcare system in which they worked.

A middle-aged man has remained silent through most of the call but smiles in encouragement whenever a new participant speaks. He turns on his microphone. It would have been his wife’s birthday today, he says shakily. “It’s a hard time for me,” he adds as his face crumples.

Clare steps in. “I’m putting my arm around you,” she tells him gently. She mentions having heard on a podcast that often when suicide happens, we mark the person’s death as if their whole life is defined by the means of their death rather than everything else that happened before. “But actually, you had a whole life together. You loved each other, had fun together, cried together.”

The session ends on a hopeful note with Clare reflecting on the elderly couple’s comparison of the group to the bird-watching community that they are part of. “This is like a bird sanctuary – people fly away, but sometimes they come back and make everyone else feel supported.”

Suicide at work
A longtime advocate of improving the wellbeing of doctors, Clare served as medical director of the Practitioner Health Programme, the largest publicly funded physician health service in the world, from 2008 until March 2022. The programme has now seen more than 17,000 doctors for mental health or addiction problems, a number that Clare says is “rapidly climbing”. She set up the bereavement group in 2018. “Doctors tend to also have doctors in their family, and they’d come to me and ask to be put in touch with people who have had similar experiences,” she explains.

Clare initially advertised the group via social media, filled with apprehension about the potential reception. “I was very frightened,” she recalls, “because it’s obviously very emotional. But I knew I had to do it.” Now she calls it the most rewarding thing she’s done in her career. During the first in-person meeting, she recalls, nobody spoke. Attendees just cried, but all of them were able to find solace in the knowledge that they had shared similar experiences of grief. At the time of the interview, the group was 80-strong, representing about 60 doctors who died by suicide. There’s never any obligation to stay, and some leave after one session while others have stayed since the beginning.

Listening to their stories over the years has helped Clare make a few observations about doctor suicides. One of those is that they often take place at work. “People tend to kill themselves in the place they feel has harmed them,” she says. “So it’d be their medical school or the hospital, in the car park or the lavatories.”
Clare worries that the increasingly alienating nature of healthcare jobs will drive even more doctors towards depression. Over the past 30 years as a general practitioner, she feels that her relationship with her patients has become much less personal. While she used to know patients, their families and the community where her surgery was based, she is now increasingly being sent out on call to areas that are farther away, where every patient is a stranger she won’t meet again. This has primarily been due to the transition towards hospital-based care rather than a more community-centric model. The rise in digital consultations, especially during the pandemic, has only exacerbated Clare’s sense of detachment from the people she is serving.

“I feel like a gig economy worker,” she says wryly. “We’re being treated as commodities, and patients are like the customers. I’m watching my profession disintegrate, and it’s no wonder that we’re collectively getting quite depressed. It wouldn’t take much to tip somebody over the edge.”

Doctors needing care
Soon after the death of his brother, Amandip set up Doctors in Distress, a charity (previously chaired by Clare and where she officially became a patron this month) that aims to protect mental health and prevent suicide by running support groups for health practitioners before they reach the point of psychological distress. “These are built like therapy groups, but they’re not therapy. They’re run by trained facilitators and group analysts,” says Amandip, who isn’t a trained healthcare worker but works in logistics for clinical trials.

A report into Jagdip’s suicide was commissioned by Dartford and Gravesham NHS Trust, which runs the hospital where he worked. It concluded that “the question of where responsibility lies for his unsustainable workload is difficult” and called out “the failure of the wider NHS to devote time and attention to the development of clinicians in non-technical professional skills – sometimes called soft skills – such as resilience, self-awareness, situational-awareness, and the capacity for self-care”.

Through Doctors in Distress, Amandip wants to give other doctors something that he feels would have saved his brother: a safe, non-judgemental space where they can speak about the emotional impact of their work.

During the pandemic, the charity organised several group sessions for doctors who had caught long COVID and were in isolation. Bringing them together helped to alleviate the loneliness and make them feel better, he says. In addition, the charity runs a group for Black doctors, where they can share their experiences of racism at work. Nurses and other health workers have also contacted them to seek help. At the time of writing, the charity has helped more than 2,500 healthcare professionals, most of them doctors.

Doctors in Distress operates independently of the NHS, which Amandip says is crucial. “If the cause of your distress is your employer, the last place you want to go to solve that is with your employer,” he explains. He knows that fear of regulatory action is very real among doctors because they worry they will not be allowed to practise.

Anthony Omo, the director of fitness to practise at the General Medical Council, which maintains the register of medical practitioners in the UK, told Al Jazeera in a statement: “A mental health illness is not, in itself, a GMC matter. There’s no need for us to get involved or even know about a doctor’s health condition if they’re getting appropriate medical treatment and support, managing their practice safely and maintaining a good level of care for patients. It is important doctors are encouraged and empowered to seek and follow treatment, as they would want for their own patients.”

Yet doctors who spoke to Al Jazeera revealed that anxiety over possible punitive measures for those seeking help for mental health issues continues to prevail.

Amandip hopes his organisation can help tackle what he considers endemic problems in medical culture. “The medical profession and healthcare system put a lot of emphasis on doctors giving care to others,” he says. “But there are no systems or attitudes that allow them to care for themselves or each other. They’ve been put on a pedestal their whole lives, and they’re instilled with this sense that they can never fail.”

‘You never think it’s going to happen to you’
Grief and a desire to improve support for healthcare workers also spurred Liam Barnes to set up a charity for members of the UK’s medical and emergency services after losing his cousin Laura Hyde to suicide in August 2016. She was 27.

The two had been close growing up. Liam, who works in marketing, smiles when he talks about her most distinctive trait: “She had a laugh like Janice from [the sitcom] Friends. You always knew where she was in the building.”

Laura had been a nurse with the navy. “She could have done any corporate job, but she chose to be a military nurse because she had a burning desire to help others,” Liam says. Years on, he’s come to the conclusion that a combination of factors drove Laura to suicide. She worked on average 60 to 70 hours a week and was affected by her observations of bullying in the workplace. Then there was a difficult breakup.

Liam is still haunted by regret over his last interactions with Laura. The month before her death, he had planned to visit her. But work got in the way, and he decided to postpone his trip. “So I never got the chance to see her,” he says. “You never think it’s going to happen to you. The Christmases come round and the birthdays and the anniversaries, and they’re not there. And that’s only when it becomes real.”

Along with his mother, who trained as a mental health nurse, Liam built a website where he uploaded information on self-help strategies for healthcare professionals suffering from emotional distress. The response was staggering: About 11,000 people visited the page in the first week. Realising that there was a lot more they could do, they set up the Laura Hyde Foundation.

Today, their organisation has helped provide access to mental health support for more than 8,000 medical personnel – including nurses, doctors, paramedics and care workers. But the steadily burgeoning need for its services is cause for concern, Liam says. Requests for advice and assistance are pouring in from one demographic in particular: student nurses and student midwives. Many found themselves unable to continue with their education during the COVID-19 pandemic but were not covered by their employers for mental health support until they had qualified.

As he speaks over Zoom, he receives another email from a student nurse asking for help. “Our data for 2020 shows that 17 medical students who came to us had tried to take their own lives before,” he says.

From doctor to patient
One medical student – a man in his mid-20s who did not want to be named in this article – started blogging during his first year at the medical faculty of one of London’s top universities when he found himself so burned-out that he stopped eating or drinking and rarely left his accommodation.

Diagnosed with depression and psychosis, he spent a week in a psychiatric ward. That was in 2016. His blog, initially started as an attempt to air his frustrations, became a channel through which other medical students and healthcare professionals who were struggling could speak to one another and share advice and anecdotes.

“I was in a dark place because I couldn’t find any other doctors who were willing to talk about their experience of poor mental health,” he says. While on the psychiatric unit, he ran into a classmate who mistakenly assumed he was there on placement. “And they said to me, ‘Isn’t everyone here really mad?’ I snapped and went, ‘Actually, I’m here as a patient.”

The callousness of his classmate’s comment was for him an indicator of how doctors are expected to be physically and spiritually indestructible. “We’re meant to be doing the healing, not be the ones succumbing to illness. You’re just expected to deal with it, and if you can’t, it’s a sign of weakness,” he says.

He says switching roles from doctor to patient made him more empathetic. “As a psych patient, you’re cut off from the outside world. Nobody wants anything to do with you,” he says.

For several years, he ran a website called The Depressed Med Student, which chronicled the ostracisation he faced from fellow students he had considered friends. He has taken a break from running the website since October to focus on other things in life. He graduated and became a junior doctor in 2020.

Life as a junior doctor hasn’t gotten easier. The hours are gruelling – shifts begin at 7.30am, and he usually works until 8.30pm – and his typical workweek is six days long. As a junior doctor, he is expected to do “absolutely everything” on the wards he is assigned to, he says, and when he cannot finish those tasks because of an emergency, he describes being shouted at by his superiors as par for the course. “It’s really tiring,” he adds.

He also describes the bullying and racism he encountered in medical school as a British Pakistani and recounts one incident in particular. While working in the oncology department of a London hospital, he incorrectly answered a question posed by someone he calls “a really big name [in the field]”. He says the consultant turned around and asked: “Which backward, sand-worshipping country are you from?” The other students laughed nervously, he says. “They knew that if they said anything else, it would damage their careers completely. And if I tried to raise it, no one would take my side.”

The top-down toxicity of medical culture, he believes, is due to the fact that the doctors on the highest rungs of the ladder know they can say and do anything in the workplace with impunity as long as they continue to perform their high-risk, life-saving work well. “They’re untouchable,” he reflects, “because they’re the only people in the world who can perform that specific procedure.”

But there have been bright spots. He is appreciative of the kindness he’s received from some senior doctors, and his eyes light up when he talks about his placement in gynaecology, where he delivered a baby for the first time. He’s also developed ways of dealing with the deaths of patients, something he struggled with as a student. “Every time a patient dies, there’s a huge feeling of guilt. You keep wondering if there’s anything else you could have done. Now when that happens, I just go away from everyone else for a bit and sit down and think. And this sounds bad, but now I just have to put it at the back of my mind and move on. You have to do that in order to do this job.”

Psychologist Gail Kinman believes that being surrounded by death is not in itself a particular risk factor for poor mental health among medical professionals because “often doctors can do what we might consider to be the most stressful parts of the job because that’s what they’re trained to do and what they expect”.
What makes it much harder for them, she says, “are the organisational constraints such as short staffing and the sort of culture doctors need to work within”.

For people like Amandip, the focus remains on intervening before doctors are pushed to the brink. “It does get very emotional and very hard,” he says. “But what keeps me motivated is the memory of my brother and how he died. It’d be wrong if I didn’t persevere with this.”

By Amandas Ong
Source Al Jazeera

BDST: 1918 HRS, JULY 21, 2023
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