Wednesday, February 26, 2014

Burnout and depression in the veterinary profession

Everyone needs to curl up in a ball now and then, as demonstrated by Bosca.

Burnout, depression, and - unfortunately - suicide are all too common in the veterinary profession, although the profession doesn't have a monopoly on these problems. They seem increasingly prevalent, but we're reflecting on these issues lately due to the loss of several very special people in recent weeks. Whilst I was merely an acquaintance to each of these people, the feeling of sadness is pervasive. It can be very difficult, impossible even, for those left behind to get their heads around why someone made a final decision and it is challenging not to obsess over the details. All I know is that each of them felt somehow trapped.

Two years ago I wrote the story below which featured in The Veterinarian Magazine

It is well established that veterinarians suffer a higher suicide rate than the general adult population. In fact, research by former Australian Veterinary Association President Helen Jones found that veterinarians were four times more likely to take their lives when compared to non-veterinarians.

In absolute numbers, the number of veterinarians who commit suicide is not high however compared with the average suicide rate for the general population it is high. Suicide in our profession is the tip of an iceberg that none of us can afford to ignore. It is likely that far greater numbers of veterinarians suffer from burnout - physical and psychological fatigue brought about by chronic stress and anxiety.

In a study of Finnish veterinarians, 40 per cent reported moderate symptoms of burnout and just under 2 per cent reported severe symptoms. In a Belgian study, almost 16 per cent of veterinarians suffered from high burnout. Studies are underway to determine the prevalence of burnout in Australian veterinarians, but there can be little doubt that burnout is a cause of significant morbidity in veterinarians in this country.

What is it about our profession that predisposes us to burnout?

According to Jones, veterinarians become stressed because of the volume and nature of their work.

“Vets do work so hard, especially rural vets,” she says. “Some have real problems coping when the phone constantly rings, especially in one-person practices. People are dependent on veterinarians – particularly rural veterinarians – and the vets feel responsible, so I think they take the world’s problems on their shoulders.”

Jones also believes that some veterinary degree admission procedures only favour high achievers - some of whom cannot cope with failure.  

“I think that some of these bright young things simply don’t know how to fail. I think in the past veterinary graduates have had some unrealistic expectations so that when they could not perform perfectly in practice or when something died unexpectedly, they couldn’t cope.”

Counsellor and veterinarian David Foote, best known for his bereavement counselling service for pet owners, has been working in the field of stress, burnout and suicide in veterinarians for 12 years in addition to offering a bereavement counselling service for pet owners.

“Burnout is the result of a long period, typically years, of chronic stress so sufferers are usually exhausted physically, emotionally and psychologically. Some people recover, albeit slowly, while others never fully recover and are often forced to make difficult decisions including leaving the profession.”

Signs of burnout are many and varied but include fatigue, a broad range of medical problems which are initiated or exacerbated by stress, chronic musculoskeletal problems, insomnia, depression, anxiety, cognitive impairment (such as memory loss), hypervigilance,  work errors, absenteeism and, in some cases, substance abuse.

"Having recently attended the funeral of a colleague who took his own life I have been painfully reminded that perhaps the greatest danger in burnout is that it can be potentially part of a continuum that leads to suicide,” Foote says. 

“To hear his family struggle to speak as they paid tribute to a much loved father, husband and brother was overwhelmingly sad and gut wrenching.”

“I see a lot of people with autoimmune disease,” Foote says. “While there is no proven link between burnout and autoimmune disease it is something I’ve observed anecdotally. Many people also feel an inappropriate sense of embarrassment or shame at being somehow ’weak’ which, in reality, is far from the truth.”

“Put simplistically people become burned out because of choices they have made and not made. Typically in our profession these are people who are overworking, heavily invested emotionally in work, and who feel that if they pull back or leave the work situation they have somehow failed.”

“Burnout has profound effects on the brain so people in burnout often have cognitive distortions which lead to them closing off options and choices especially if they are carrying the sense of shame previously mentioned. A big part of what I do is help clients question these beliefs, open out choices again and understand that taking care of themselves is just as important as taking care of their clients, patients and loved ones. If they aren’t addressed then an individual, once feeling better and more energised again, is likely to repeat the same patterns again.”

Foote provides a safe, confidential environment to talk about those issues and facilitates the process whereby those suffering burnout can turn their lives around.

“It’s about helping them to bring their life back into balance. This includes reducing workload, learning stress management techniques (especially mental and physical calming techniques like mindfulness), prioritising all aspects of self-care including sleep, diet and down time and seeking appropriate medical support. Finding a sense of joy and fun again is also very important.”

Foote also helps people unpick the deeper issues.

“The personal traits, attitudes and behaviours that lead to burnout are formed in our developmental years. We can end up with strong beliefs that, to be worthy or of value, we must strive relentlessly to achieve, be perfect in every way and always put others needs before our own.

Veterinary education can reinforce these beliefs.

“We attract a high number of people who are high achievers and ‘caretakers’, highly invested in meeting the needs of others through kindness and compassion but not so good at identifying and meeting their own.” Foote says.
“In combination with this our profession is set up with some powerful potential stressors including long hours, a high level of responsibility, client expectations and exposure to patient death and client grief. Clients’ high emotional investment in their animals increases our sense of responsibility again.”

That makes it challenging at times to distinguish a healthy work ethic, care and professionalism (normal professional functioning) from potentially unhealthy professional functioning.

“We have to keep clients happy, we have to foster good relationships and work to the highest standard we can. The catch is when our self esteem becomes too strongly attached to these things or when work takes up too much of our life.”
According to Foote, basic self care and stress management, including how to have boundaries around work, should be taught at an undergraduate level.

“It’s about educating people in how to keep balance in a profession that has a lot of demands that can pull them off balance. Fostering the development of life skills and adaptive coping strategies in undergraduates can be a powerful preventative measure.” he says.

To this end, Foote regularly lectures undergraduates at the University of Sydney. He is also director of the Intern Mentoring Program for final year students.

“Mentoring plays a very important role in that it creates a culture of giving and receiving support, encouraging people to seek support early and understand that asking for it is not a sign of failure.”

“It really is about creating a culture of giving and receiving support, encouraging people to seek support early and understand that asking for it is not a sign of failure.”

Veterinarian Paul Davey, President of the AVA’s WA division and previous coordinator of the AVA’s Graduate Support Scheme for eleven years, is also a strong believer in the value of mentors.

His involvement began with the loss of a fellow veterinarian in 1996.

“He was a classmate of my brother, due to start work with me on the Monday,” Davey says. “Unfortunately on the Sunday before he chose to end his life. There are various theories as to what resulted in him making that final decision, we can only assume it was a combination of disappointment in where he found himself and the stresses of career choice.”

Davey feels mentors can help prevent such tragedies.

“They act basically as a sounding board, a trampoline if you like, a protective net that a new graduate can use in that first critical year or so of practice.”

But Davey advocates mentors for veterinarians at all career stages.

“Over the years it has become obvious that it is not just new graduates at risk of stress and burnout, but there seems to be a peak at two years [after graduation], again at around seven years and again at retirement age or thereabouts.”

“If you can improve resilience and give people skills to make the right choices about career paths and lifestyles early then you may be able to prevent some of this.”

According to Davey, one of the biggest factors contributing to stress and burnout in veterinarians is euthanasia.

“It’s said that we deal with death seventeen times more often than a GP. That obviously has to take its toll. Personally speaking I think it takes a little bit of us each time.”

Another common cause of stress is poor clinical outcomes.

Davey says that poor clinical outcomes are second only to employment issues as a topic discussed between mentees and mentors.

“I wonder whether it should be compulsory to have a lecture stream at every conference called ‘when good cases go bad’ – it is important for veterinarians to understand that even in the best hands things don’t always go according to plan.”

Mentors and colleagues can be a valuable sounding board when things go wrong.

“I believe fairly strongly about talking about these things and expressing our feelings,” Davey says. “Perhaps not always with workmates. I’ve got a group of close friends I can talk to. Just knowing that someone has experienced similar feelings, particularly things like compassion fatigue, makes a big difference.”

Davey argues that work/life balance is key in preventing burnout.

“Being a vet makes it challenging to maintain work/life balance but it isn’t impossible – it just makes our decisions even more important. Our resolve about things such as keeping our sporting interests or hobbies going is going to be tested.”

Like dogs and cats with chronic renal failure or mitral valve insufficiency, veterinarians may suffer from subclinical burnout for years before symptoms become unmanageable. But there is always a danger that severe stress will trigger decompensation.

“A lot of vets are dealing with subclinical mental illness. I think it is important that we get the message out there, get people talking about it, and disseminate information to the rest of the profession.”

Former West Australian Turf Club veterinarian Peter Symons survived three  brain haemorrhages, two brain surgeries and two cardiac arrests – but claims that his experience of burnout or depression was worse than all of those experiences put together.

“It was particularly demoralising because I could not understand what was wrong with me,” he says. “After suffering for six months I saw a doctor and was told I had major depression. Despite never feeling sad or depressed.”

Anti-depressant medication helped, but was only part of the solution.

Symons, together with Dr Clyde Jumeaux developed what is now known as the Brain Fuel Depletion model for explaining the condition currently called depression (and previously called names such as ‘nervous break-down’ and ‘melancholia’.).

“Brain Fuel Depletion has many disguises,” he says. “It goes by a variety of names including ‘burn-out’”.

The central tenet of this model is that when we are stressed, the brain suffers a depletion of neurotransmitters (or ‘brain fuels’), and a concurrent increase in adrenaline.

“The increased level of adrenaline explains common symptoms such as anxiety, panic attacks, insomnia, and "fight or flight" symptoms like irritability, frustration, remoteness or withdrawal,” he says.

“The depletion of neurotransmitters explains the forgetfulness, phobias, sadness - depletion of neurotransmitters in the limbic system - , and some of the physical symptoms such as Irritable Bowel Syndrome - depletion of neurotransmitters in the hypothalamus.”

“Vets, amongst many other professionals, are predisposed to Brain Fuel Depletion because they are big brain fuel users.”

As Symons explains, vets are often doers (working to get through many jobs in a busy day), perfectionists ( a trait required to get good marks to enter the course, and to survive the intensive tuition), and carers (the reason why they were drawn to the profession in the first place).

“People with this combination of personality types ‘chew through’ a lot of neurotransmitters; especially if they work very long hours or do after-hours work.”

Symons believes that medication is very important in allowing the brain to replenish its levels of neurotransmitters/brain fuels, but emphasises that medication should never be taken to support an unsustainable lifestyle.

“You take medication to feel better, and then do a complete assessment of the lifestyle that got you in this position, then change the lifestyle and/or modify your personality to ensure that you are no longer predisposed to it."

Symons’ journey, and the Brain Fuel Depletion model, are outlined in his forthcoming book – co-authored with Jumeaux – Brain Fuel Depletion: At Last Making Sense of Anxiety and Depression, to be published electronically next month.

In it he argues that the key to brain fuel repletion is simplifying one’s lifestyle. Now Director of the Positive Workforce Foundation, Symons says he is much tougher about protecting himself.

“I used to do eight things, now I do three,” he says. “I can still be effective. If you do too much and work 80 hours a week you end up feeling bad and you’re no good to anyone.”

“I used to think anything was possible, now I realise there are some things I just have to let go. I’m much more ruthless because I am not prepared to pay the price. Outside work I don’t take on as much, if I am busy I tell people I can’t fit something in.”

Symons adds that burnout is not a syndrome exclusive to veterinarians. He recalls a recent speaking engagement with a group of young lawyers.

“[My talk] seemed to strike a chord with a room full of motivated lawyers – quite a number of whom told me they were going back to the office after the event. Everybody knows they need to protect themselves, but long-term ingrained habits and personal characteristics are hard to change, because – after all – they are the attributes that have got you to where you are.”

Symons’ advice is to identify and change the habits that may lead to burnout – before they irrevocably change us.



Remember you don't need to be suicidal to seek help. You can contact these organisations anytime you need support.

Lifeline 24 Hour Crisis Line 13 11 14 or online chat

Australian Veterinary Association telephone counselling service: 1800 337 068

The Australian Veterinary Association has a stream of the 2014 Annual Conference devoted to graduate support and wellbeing. For more info visit here.

And for very mild stress, don't forget this.