The moments that lie between medicine are a matter of life and death — a reflection on suicide, self-care and clinical practice

Earlier this year, a colleague and a friend of mine, committed suicide.

It was devastating news.

His death shocked me and many others too.

And in the days that followed his wife’s heartbreaking Facebook post, his warmth and smile were all that I could think about.

I was truly shaken by his death.

And as I reflect on this I realise that it was because, on the surface, our lives were quite similar.

We were both the same age and were both country General Practitioners. We had similar clinical interests but more than that we shared the same Christian values and wanted to make a difference in our regional communities.

It left me reeling too because I wondered how such a seemingly happy, positive and brilliant man could find himself in such a mental state where suicide appeared to be his only reasonable option.

Jono was married to his beautiful wife for over 20 years and they had three intelligent and gorgeous children. They lived on a picturesque property which kept him busy, together with the myriad of other musical, cultural and community interests that he was also involved in.

But how the majority of people knew him was from his passion for rural medicine. His true generalist spirit and his deep desire to help others less fortunate than him, both here in Australia and overseas through his mission work were what drew many to him. There was no doubt that Jono lived to serve his patients and make a difference in their world.

As I watched his funeral online and heard countless stories about how Jono’s life had impacted many in his 41 years on earth, I reflected on how he was the last person whom I’d ever think would ever end his life intentionally. And because of that, we’ve all been left with the beautiful memories that he gave us but also with many painful questions.

In one of the state-wide medical debriefings that occurred after Jono’s death, a close colleague and friend talked about his connection with Jono and his last few months. He said that Jono was the go-to guy in town when anything got tricky at the hospital. He was supremely skilled in General medicine, Obstetrics and Critical care — he was a medical all-rounder. He talked also about Jono’s passion for teaching and inspiring the next generation of doctors and his great love for his family.

But then he reflected on Jono’s struggles. For more than a decade, he had battled with a mental illness that he hid extremely well. Only his family and those closest to him knew about his burdens. And the worse things got, the harder he pushed himself. Mike likened it was like a vortex. The closer Jono got to the middle, the harder it was to pull himself out.

I’ve heard it said that those who struggle with the human condition and with the burdens and complexities of life are the ones most at risk of taking their own. And whilst this may carry some degree of truth, I can say without a doubt that as doctors, we face the extremes of the human condition each day and it certainly does take its toll on every aspect of our being and most importantly on our inner world.

Each patient we encounter, every story of tragedy, pain and devastation, each case of suffering and the loss of hope we bear witness to, impacts our spirit. Every worry and concern about a decision we’ve made or the words that we’ve used in haste or in frustration with a patient or colleague plays on our conscience and reverberates in our minds. And every battle we’ve fought within the bureaucracy of healthcare and every toxic environment we’ve had to navigate through, all leave a lasting effect on a doctor’s wellbeing.

This is the invisible toll of medical life.

It is highly unlikely that you will leave or finish your medical career without experiencing a significant impact upon the executive centre of your life, your heart — where your spirit resides, the essence of who you truly are.

Medicine is a full-contact occupation. The twists and turns and the setbacks and challenges of your medical career will change you as a person and it is squarely up to us, to determine the impact that our medical journey will have on the trajectory and quality of our lives.

How much pain will we endure?
How much will we lose of ourselves before we have the courage to say “stop!”?
And will that realisation arrive too late?

The one thing that I have learnt after walking through dark days in medicine and struggling with the complexities, the disappointments, the tragedies and their impact on my inner life, is that a doctor’s longevity, the fullness of their life outside of medicine is impacted by the precious moments that exist between medicine.

That is, the moments that lie between our clinical practice are the ones that matter the most.

These moments determine the quality of a doctor’s life and work.

As Jono’s wife Caroline bravely and eloquently retold the story of their life together, there was one part of her eulogy that grabbed my attention.

She said, “although Jono lived a life of selfless public service, we saw his struggle privately. His public life was outgoing and full of service to his patients. But at home, we saw the fatigue, the discontent and the despair that he experienced. He was always helping others but found it hard to ask for help for himself”.

Our precious moments between medicine matter.

These moments are ours to replenish and heal. And these moments are ours to reflect on our lives and clinical practice and to engage in self-awareness about our emotions and sometimes, our wayward thoughts. Most importantly, these moments are ours to reach out for help.

I am convinced that our moments between medicine and life are where the real impact of clinical medicine is experienced.

For it is in these moments that we will look to find meaning in the challenges that we’ve faced and find hope for the future or simply choose to block out, disengage or numb the pain that we are experiencing.

I know that for the majority of our career, our work will be rewarding and uplifting. It will provide countless opportunities for us to reflect and take pride in what we’ve accomplished and achieved — this is a given for most. But there too will be times of testing, challenge and suffering, this is inevitable, as this is the nature of life.

See the challenge of medicine is not always clinical. The challenge of medicine is often invisible to the public, our colleagues and to our families.

The real challenge of medicine exists in the moments between our clinical encounters in the hearts, minds and souls of the doctor.

And how each doctor handles these moments in dealing with their thoughts, the setbacks and complaints, the victories and tragedies and finds meaning in them, is what determines the trajectory of their life and practice.

If we’ve learnt resourceful ways of dealing with the setbacks and negative thoughts and have learnt to recognise the symptoms and signs that we may need a break or rest, then our moments between medicine can be healing, replenishing and life-giving.

But more often than not, due to the relentlessness of our work and our desire to be in control, it is much easier to block our pain and store our disappointments away and continue on. I am guilty of this like many of us are. Doctors are masters of compartmentalising their lives.

Our moments between medicine are not simply for us to unplug and disassociate from everything but rather to enquire into what is troubling us and to resourcefully connect to what may help to replenish and heal us. This is the journey of self-care, the wisdom behind longevity and legacy in clinical practice.

I have no doubt that my friend struggled in the moments between, as many of my colleagues and I have at times too. Because as his wife said, we (his colleagues and the public) saw his selflessness and brilliance but in the moments between, at home and in private, his family saw and experienced his despair and discontent.

How a doctor deals with the impact of medicine on their whole being in the moments between, determines the trajectory and course of their career. And sadly, in my friend’s case, it determines whether we live or die.

Practically, it is how we as doctors hold ourselves accountable with respect to our psychological, emotional, spiritual and physical well-being that matters most in the end.

Will we courageously ask for help if we need to or will we continue on?
We will say “enough” or push on through, hoping for space to breathe.
Will we say, “this is my time to ask for help” or will we relent again?

It is whether we acknowledge the impact that our work is having on our whole being which determines whether or not we will have a story to tell or a tragedy for others to determine and work out, what happened?

How we care for ourselves in those moments between medicine, at the interface of our inner life — this is what makes, breaks, and creates our legacy in medicine and life.

The wisdom of medicine is practised in the moments between

Oncologist and Pulitzer Prize winner Dr Sidartha Murkerjee writes, “my medical education had taught me plenty of facts, but little about the spaces that live between the facts”.

The space between the facts and the space between clinical encounters are moments that matter most in medical practice. These are the moments between less-than-ideal patient encounters. These are moments after an adverse event or a traumatic medical experience. The space between our clinical encounters is the key determinant of the quality of our career and legacy in medicine.

This is because it is in these moments that we as doctors are called to practice wisdom.

Wisdom is the skill of living well and making good decisions in the face of challenge, difficulty, and suffering.

The great wisdom of medicine is not about making better clinical decisions but rather about learning and developing the skills of living well as a doctor. And one of the most important skills is developing self-awareness about the impact that this medical life can have on our entire lives.

And as doctors, we must also understand that there is a clear difference between intelligence and wisdom.

Because for many of us, we’ve been blessed with the ability to think and solve complex problems and memorise and apply large amounts of information. Our minds are our biggest asset!

But being clever and wise are two different things. And I think as clever doctors, we often fall into the trap of believing that we can think ourselves out of our pain, setbacks, and challenges.

This is why wisdom and learning the skills of living well in the moments between our clinical life are integral to our success and survival of this medical life.

It is smart to slow down and reflect.

It is courageous to enquire about our hurt and our emotions.

And it is wise to seek help and heal from our pain.

A doctor’s choice — life or death

The mystery of one human being is too immense and profound to be explained by another”
The Wounded Healer — Henri Nouwen

My friend ended his life in a moment between medicine.

We will never know what was going through his mind or how he faced his last moments. And it is ludicrous to even postulate as Henri Nouwen reflected.

But one thing is clear, Jono isn’t here anymore. And what we are left with is his beautiful memory and the pain of losing him.

In her article “Why happy doctors die by suicide”, Dr Pamela Wible MD says that it is baffling to the public why “happy” doctors die by suicide. This is because many doctors who kill themselves appear to be upbeat, confident and optimistic people. However, on deeper examination, we find that this is because doctors are masters of disguise and compartmentalisation — they learn to mask their own despair.

Dr Wibble says too that suicide is an occupational hazard of medicine. This is because, within medical practice, there are many things that take their toll on the inner lives of doctors — patient deaths, traumatic events, complaints, medical errors and the toxicity of the environment that we work in. And if we do make a legitimate mistake, there are investigations, court cases, stories online, rumours and gossip that follow us for the rest of our professional lives. Doctors may choose suicide to end their pain but not necessarily their lives.

My reflection on Dr Wible’s work is that the moments that lie between the practice of medicine are precious and hold the key to our longevity and career trajectory.

When we choose to disguise, numb, and compartmentalise our pain we set a dangerous precedent of not connecting the stresses and strains of medical work with its impact on our inner world. We do this at our own peril.

Doctors learn to segment our medical lives early on, learning this perhaps from senior colleagues and our peers. We learn to “shut our mouths and get the job done”. But the trouble with “leaving work at work” and demarcating our space at home is that medical work has a habit of following us home. This is especially so if there is unfinished business within our subconscious that needs to be processed and find meaning — this is something that I have struggled with too.

We are sense-making beings and our days at work need time to be processed and emotion needs to be expressed, observed, and find meaning.

The suffering that we bear witness to. Our patient’s distress. Our actions or inaction. And our insecurities and deepest fears — these all need to be considered or we will find unresourceful and unhealthy ways to forget.

Drinking, drug abuse, binge-eating, gambling, sexual addictions and the unhealthy pursuit of more possessions and money are all unresourceful, emotionally driven behaviours that all doctors can be susceptible to.

We must find meaning and we must find closure for those less than ideal experiences and for our wayward thoughts. We have to find an appropriate avenue to express our grief, disappointment and pain.

And the most resourceful and secure of us will reflect in love and self-compassion and understand imperfection is universal and that to blame, ridicule and chide ourselves is unhelpful and a slippery slope toward deep insecurity and unrelenting pain.

Help — why some do and some don’t ask 

I’m not sure what made me reach out for help as a young GP registrar over a decade ago. As I stood on the brink of giving up medicine, enveloped in a dark cloud of depression and dark thoughts, I made a few calls that saved my life. I was vulnerable and the conversation was raw, but I managed to say those 3 words in the midst of my pain that changed everything, “I need help”. 

What followed altered my life and practice, but I know that I escaped from falling any further into the darkness by the skin of my teeth, like one escaping from a raging fire.

It was this experience that taught me about the preciousness of our moments between clinical practice and the space between the facts. It forced me to slow down and create space to rest and reflect and replenish myself.

I find comfort that even the great Sir William Osler (1849–1919) struggled with episodes of burnout and periods of listlessness from the challenges and complexities that he faced in medicine. He described seasons of tiredness, a lack of enthusiasm, cynicism and a diminished sense of personal achievement and satisfaction with his work. This eventually led Osler to change the trajectory of his career by taking a position at Oxford which is said to have helped his overall well-being and enthusiasm.

In the long shadow cast by my friend Jono’s death, I’m forced to ask a few challenging questions.

Why do some of my colleagues find it easier to reach out for help and why do some struggle?

Why do some of us engage all the way and why do some of us stop?

I understand these are difficult questions and perhaps they begin with the same set of questions that all of us are trying to answer:

“Am I good enough?” AND
“What will people think about me if I reach out for help? AND
“What does this mean about me as a doctor for my practice and reputation?”

Could it be our insecurity and pride that stops us from seeking help? Or could it be our own false ideas about mental well-being and self-care? Or worse still could it be that we’ve made up our minds that we are too far gone? 

Putting our head down and getting through it, focussing on building resilience, toughening up and having the attitude of “this is the way that it has always been” are dangerous ideas and are the key drivers of insecurity in medicine. These are false truths that have been perpetuated in the medical culture. And these are the very attitudes that feed the idea that we do not measure up when we are hit with the realities and strain of clinical practice.

The one thing I want all doctors and the public to know is that not one doctor has the same emotional, psychological, spiritual and physical distress thermostat as another. 

Each of us by virtue of our background, genetic blessings or curses and formative experiences, and personality, will have a different ability to deal with stresses and strains of medicine differently. And it is unkind, unprofessional, and unwise to think or believe that another doctor doesn’t measure up simply because they’ve asked for help or are struggling.

This is perhaps why some of us do not ask for help — we are afraid of being seen as unfit, weak, emotional, and not having what it takes to be a doctor.

Rather I see a doctor as courageous and secure when they identify their source of pain and seek to resourcefully solve what is distressing them.

Addressing our pain is the most courageous and wisest move that a doctor can make. Addressing our pain is helpful as it identifies an area in which we need insight and most importantly, healing.

Addressing our pain is kindness to ourselves.

It is time that we as doctors understand that perfection is not what our patients and families desire, but rather our perfectly imperfect good-enough selves.

Hope for our moments that lie between

I’ve written this article, not as a doctor who always has it all together but rather as a person who has experienced both the challenges and the wonder of medical practice but also the depth of despair that this doctor’s life can have on the unprepared and unsuspecting.

I’m certain that next to meeting my beautiful wife, getting into medical school was one of the best things that have ever happened to me. I love what I do and it doesn’t feel like work but rather a well-paid extension of medical school. I am privileged that I am invited into my patients’ world and that I am qualified and asked to perform procedures that hold a person’s very consciousness and life in my hands. It never gets old until I forget about caring for myself too in the moments between medicine.

With this in mind, there certainly should be a warning to all would-be doctors and medical students, that a career in medicine, whilst life-changing and full of reward, can also be dangerous. As we know this medical life can expose our weaknesses and exploit our mental and psychological fragility if we are not intentional about our moments.

My encouragement is clear — be intentional about your self-care in moments between your clinical practice.

Develop self-awareness about your unique set of symptoms, the tell-tale signs that you may have unprocessed emotion in your inner world or that may need to slow down. In an act of love, be kind to yourself and attentive to what is troubling you — your pain.

Make the choice not to unplug or to numb your pain with your chosen vice. Engage and enquire. Pain is a signal that something is not right in your world. Pain offers space for growth but only through honest enquiry. It may be difficult but it’s certainly worth it. You are worth it.

Devote your moments between medicine towards intentional caring for yourself. See it as a professional obligation, a foundational practice for your longevity in medicine. Intentional self-care protects and creates your legacy.

We like hardworking doctors, relentless in their pursuit of healing and restoration, but still, we aren’t accustomed even now, to doctors making self-care a priority — building it into our rosters, schedules and training programs.

This is because, in the wake of suicide, significant harm or acute deterioration in mental state, we ask ourselves the same old questions and wonder why medical life can be so bruising.

Unless health professional well-being sits at the bottom line of every health service budget and is taught to all our medical students and trainees, it will always be a tragic and unfortunate outcome when a doctor harms themselves in a moment between medicine because it was too painful to confront and bring into the light and address.

Wise doctors are self-aware because they recognise the impact of medical life.

The wisest decision is always the honest one and in our moments between medicine, honesty with ourselves is the foundation of self-awareness.

And we become wise through one honest decision at a time, self-awareness included.

Self-awareness is thus a skill that can be learnt, one challenging moment and thought at a time. And it is in only self-awareness that you will be guided to those three words that may save your life, “I need help”.

The beginnings of this piece were written a year ago after I made a clinical mistake at work. But now, I dedicate this article to my friend and colleague Dr Jonathan Morling who died earlier this year.

Jono, your death was not in vain brother. Medicine, next to being one of the most rewarding professions, can be a bruising and challenging occupation on a person’s whole being. This needs to be taught to everyone. Because each of us dies a silent or physical death when we fail to acknowledge the importance of our moments that lie between medicine and true life.

Vale my friend.

And thank you to Caroline Morling for reading and approving this article and for allowing me to write about her late husband Dr Jonathan Morling. 

Dr. Jonathan Ramachenderan

Live intentionally.
Love relentlessly.
Enjoy your health.

Additionally— How to access help as a doctor 

In the pit of suffering, it is impossible to see or think clearly. I’ve been there and the numbness can be paralysing. 

But help can be found in a few ways. 

The first is a trusted friend. This may be someone who you may not have called in a little while, but that is okay. The reason you may have chosen this person is that they are safe, unlikely to judge, and even less likely to panic. The tone in your voice, the heaviness of your words and the gravity of the situation prompts them to move and to be your guiding light. “I need help” isn’t theirs to share, gossip or ridicule. It’s a precious human life that needs attention and help now. 

The second is your General Practitioner (GP). Trust me when I say that when that consulting room door closes, the real emotion begins to flow. Your GP knows you (hopefully!). They are the ones with clarity at that moment, a deep concern about your safety and the resources to expedite your care. Real words will be spoken and proper interventions put into place. You would have never thought that you’d ever hear those words spoken nor be in this place, a patient in distress, but that is okay. This IS a matter of life or death. 

The third is placing a call to an organisation, a group with your health in mind. The Doctors Health Advisory Service is the best place to start. Confidentiality is key and your health matters to them. Beyond Blue and Life Line are other places too. But I know it is challenging for a doctor to reach out for help, let alone call. I’m not sure if it is pride or embarrassment, deep insecurity or what I imagine, the cloud of depression and mental illness, that keeps us from asking for help. But these are excellent organisations doing important work.

Before I became a doctor, I knew three people who had committed suicide, all from my high school years. But now that number is nearing twenty, mostly made up of doctors and a few nurses who’ve taken their own lives. Health care, in particular medicine, can be an especially bruising speciality, exposing our underlying psychological frailties. Mental illness and suicide are hazards of this beautiful but sometimes challenging occupation. My selfish desire is for that suicide number of mine to never grow. And it starts with vulnerability about my struggles because, in our weakness, that is where the greatest strength can be born. 

Thank you. 

Dr. Jonathan Ramachenderan