Thank you Jenny Brockie and the Insight team for a fantastic episode of Insight on Tuesday, 20th of June. It was an honest exploration of the struggle we face as medical students and junior doctors and I admire the participants for being brave enough to put their face on television. I could not do it! However, I have some comments to make on the turn towards gender, particularly towards the higher prevalence of burn out and mental illness in females. Dr Charlie Corke’s comments and the discussion that followed left me disconcerted. To be fair, the half hour time slot gave little time for context and nuance. My intensive care colleagues assure me that his comments were based on a recent survey of Intensive Care trainees focusing on bullying, harassment and discrimination and that, based on the data, his conclusions were reasonable. I don’t have access to this data. However, his article in MJA insight is indeed most excellent. Read it here (2).
However, I still insist that a time limited discussion of the female gender bias in mental illness and burnout was not a useful direction for the discussion and was counterproductive. For those that missed it, an excerpt from the transcript is here:
JENNY BROCKIE: Is there a difference in the experience for men and women do you think?
CHARLIE: Can I answer that?
JENNY BROCKIE: Yes, sure.
CHARLIE: I thought that burn out was something that happened to elderly doctors and made them, elderly male doctors and made them grumpy, but the evidence is that young girls are very vulnerable and they’re very vulnerable, we believe, because they’re so highly, have such high internal expectations of their, and drive themselves much harder and are disappointed by themselves.
JENNY BROCKIE: Is this imperial Charlie or is this…
CHARLIE: That’s from research that has been done. The issue is for me that you know, I don’t have to tell them that they’re not doing very well. They are just absolutely fierce on themselves.
JENNY BROCKIE: Reaction to that?
CHARLIE: The ability to be fair to yourself I think is a problem in young high achieving girls.
LIZZY: I’ve certainly noticed that it’s, yeah, three women on the panel tonight. I think we all have our strengths as well as our own self-awareness of our vulnerabilities. Having male colleagues as well I find that they’re much more able to say, you know what, I’m take a day off to go to the dentist or I’m take a day off to do this and they’re able to just kind of go too bad, I’m not going to work today or I need do this. Whereas myself and my other female colleagues do that sense of greater responsibility or I must stay on.
JENNY BROCKIE: What do you think Arghya?
ARGHYA: Yeah, I think there’s definitely some gender bias, it is easier for a guy to take a day or just, you know, sort of get out on time and say okay I’m going now. I’ve found female colleagues do have to justify themselves a bit more.
I don’t contest the fact that women in medicine are more likely to suffer burn out and mental illness (as defined by the DSMV criteria). The Beyond Blue National Mental Health Survey of Doctors and Medical Students indicates that there is a gender disparity in rates of current psychological distress, mental health disorders (particularly anxiety and depression), thoughts of suicide and attempted suicide. However, rates of detection of mental illness and patterns of coping behaviours in medicine reflect similar patterns occurring in society as a whole, where men are more likely to suffer alcohol dependence and antisocial personality disorder and are less likely to seek help for distress. They are also less likely to attempt suicide, but are more likely to be successful (2,6). Any discussion of gender bias in mental illness should embrace all of these facts.
Moreover, efforts to prevent mental illness and suicide have to be generalized. Identified risk factors for suicide are neither sensitive nor specific enough to target prevention efforts. So, if we cannot make changes based on gender-bias in mental illness, how useful is it to point it out on national television? Discussing risk factors can be useful. For instance, we know junior doctors have higher rates of burn out and mental illness than our senior colleagues, so prevention efforts should be particularly targeted at stressful career transition points, earlier in one’s career. However, other than addressing female specific stressors, such as the unjustified career persecution women face for getting pregnant and taking maternity leave, why would we make a gender-targeted burn out and mental illness prevention program? Especially since the data from Beyond Blue suggests that men in medicine are much more susceptible to psychological distress and mental illness than the general population (2).
I also contest that these statistics shouldn’t be considered in isolation from the history of “madness” and “gender” (3,7). Our definitions of mental illness arose from a world where madness was a female malady. Symptoms of madness were defined by female distress. Moreover, feminist critics, including Jane Ussher, argue that centering madness on feminine traits was a method to delegitimise reasonable female distress in response to external factors- read: maybe burn out is a legitimate response to work stressors, not a problem with the high achieving females. In a systematic review by Afifi (2007), he suggests that socialisation influences our responses to stress, with men socialized to express anger and act out, where women express dysphoria (1). This is important for our interpretation of data. With definitions of mental illness skewed towards “female traits”, it is unsurprising that women are overrepresented in diagnoses of depression and anxiety, whilst men are more likely to suffer substance abuse. In 2013, a study by Martin et al showed that alternative depression scales that include masculine coping behaviors (anger attacks, irritability, aggression, substance abuse and risk taking behaviors) eliminated the discrepancy in rates of depression between genders (5).
Thus, Dr Charlie Corke was not wrong. Women are vulnerable to burn out. However, I urge you to consider ALL of the statistics, to consider how definitions of distress and mental illness influence the results of surveys and to consider the importance of historical and social context. Otherwise, we do our male and female colleagues a disservice.
Acknowledgements
Thank you Karen Druce for ensuring I don’t say anything completely ignorant and for adding your expertise.
References
- Afifi, M. (2007). Gender differences in mental health. Singapore Medical Journal. 48 (5): 385.
- Beyond Blue, National Mental Health Survey of Doctors and Medical Students. October 2013.
- Corke, Charlie. Have the Courage to Act on Burnout. MJA Insight, Feb 2017. https://www.doctorportal.com.au/mjainsight/2017/7/have-the-courage-to-act-on-burnout/
- Foucault, M. (1965). Madness and Civilization: A history of insanity in the age of reason. New York: Vintage Books.
- Martin, L.A. Neighbors, H.W. Griffith, D.M. The Experience of Symptoms of Depression in Men Vs Women: An Analysis of the National Comorbidity Survey Replication. JAMA Psychiatry. 2013;70(10):1100-1106. doi:10.1001/jamapsychiatry.2013.1985; http://jamanetwork.com/journals/jamapsychiatry/fullarticle/1733742
- Men’s Health Forum: Statistics on mental health and Men. June 2016. https://www.menshealthforum.org.uk/key-data-mental-health
- SBS Insight: “Why are rates of mental illness so high among junior doctors and nurses?” http://www.sbs.com.au/news/insight/tvepisode/critical-care
- Ussher, Professor Jane. The madness of Women: Myth and Experience. Routledge, 2011. https://books.google.com.au/books?id=WSWpAgAAQBAJ&lpg=PA1&dq=Jane%20M.%20Ussher%3A%20The%20Madness%20of%20Women%3A%20Myth%20and%20Experience%202011&lr&pg=PA1#v=onepage&q=Jane%20M.%20Ussher:%20The%20Madness%20of%20Women:%20Myth%20and%20Experience%202011&f=false
