Launch episodes of the Surgical Spirit podcast are coming thick and fast! I hope you’re ready for some stirring discussion this time around, as I’m joined by Dr. Gregg Lydall of Guernsey’s Thrive 2020 initiative.
With a focus on mental health issues, Dr. Lydall and I dive into our memories from medical school, how to deal with work-life balance, training doctors in the developing world, the importance of strong communities, the reasons why so many doctors may struggle with mental illness, and tons more.
As always, you can click here to listen to the full episode now, or read on for a short written excerpt from the show before you check out the full thing.
Dr. Haidar Al-Hakim: What was your best memory in medical school in South Africa?
Dr. Gregg Lydall: Aw, so many! Whenever I go back to Johannesburg, which is where I grew up, or Cape Town, where I have a lot of family still, there’s just something really really special about it. I mean I think it’s a developing world thing as well. There is more energy and excitement – but I think part of that comes from desperation and survival. You’ve got to have that. So many people have got to keep running every day, or metaphorically they will get eaten by the lions.
So… gosh, my best memory… well, I mean medical school in Johannesburg – the whole thing was a blast. We were just so fortunate. First year of med school was ’94, which was the first democratic elections in the summer, so I’d just turned 18 (so the first time I voted was democratic, post Apartheid). It was the Rainbow Nation as they were calling it – it was a new era, new birth. There was very much a sense of hope and excitement, lots of the unknown and South Africa was coming out of isolation and into the international community. We got people visiting from all over and visiting med students, professors… it was awesome.
And then I have to say ’96 – South Africa winning the Rugby World Cup. I remember I was at medical school studying anatomy, deep in the dungeons, and we had a little bar lounge you could go to. I took a break and this rugby match was on, and I was like I can’t believe I forgot about the World Cup final but there are exams on the go, you know? I thought I would just go for a half hour break, and ended up being several hours. We were within shouting distance of the Ellis Park stadium so could actually hear the roars. And then the whole Nelson Mandela wearing his Springboks jersey… it was incredibly special.
It was a great time to be young and alive and studying the best profession in the world.
Dr. Haidar Al-Hakim: [South Africa appears to produce people of] very strong character. Is that something you found clashes when you came here to the UK? Or did you just sort of wilt and continue within the system? Did you change or did the system change around you?
Dr. Gregg Lydall: [laughs] Well, change in the NHS takes a very long time! I’m probably going to make enemies here, but this is what I hear – South African doctors, when we head overseas, because the way the system is designed there you see and do stuff much younger than British or European or American doctors [would]. Literally, my first on call as house man, I was in theatres doing an open cardiac massage of a guy who had been stabbed in the chest. The day before that I was a med student – twenty-four hours later I was doing this while the chief surgeon was sweating and swearing at me.
There’s a couple things to say about it – the first thing is you see and you do a hell of a lot, so you upskill very quickly, so if you ever need a chest drain or a central line or a procedure done, then you want a doctor who’s trained in the developing world. And then of course we come over to the NHS or wherever, and we’re all cocky and outspoken and arrogant – and that’s the culture as well that we train in. That’s just what it’s like. There’s very much an old school sort of hierarchy where the doctor’s word is the law sort of thing, especially if it’s the consultant or the professor. No-one doubts it.
So it was an interesting transition – but having said that, I soon learned to love the NHS and compared to where I’d come from in Africa it was incredibly well resourced, incredibly safe, patient focused… and I love that it was a safety net and anyone can access it irrespective of means. In my home country you were either insured and got private care which was top notch or – as eighty percent of the population experienced – you ended up in the government sector where we all trained as students and registrars, and it was touch and go with whether you got the right help or not because there was massively overwhelming demand and massively insufficient resourcing.
I am just amazed at how much we were able to do with what was available. It was an incredibly efficient system but if you needed a hip replacement you could wait years and years and years – and there was a budget for x number of hips and that was it. If you didn’t get it you didn’t get it, and that was that. The other bit was the youngsters like myself seeing and doing stuff – the horror of what happens to humanity and what humans can do to one another. You can become dehumanised and it’s just about getting through the shift, and there’s a very high risk of burnout.
I have no doubt that there was a very high prevalence of mental health problems amongst my cohort. Your listeners may be aware of one of South Africa’s top cardiologists who recently ended his own life, probably around the end of July 2018, who was a shining light. Yet, for reasons that I don’t know – I mean, he was head of department for Cardiology and all of that at Cape Town – but he couldn’t go on. So there’s a huge human toll upon clinicians. Not just doctors, of course. It’s everyone working within the system.
Dr. Haidar Al-Hakim: That’s where come on to the stigma, isn’t it? I mean, the stigma is massive in countries like Iraq, and probably in countries like South Africa. For mental health in general.
Dr. Gregg Lydall: Yeah, sure, sure. I enjoyed psychiatry at medical school. I did an attachment for nine months in South Africa – and of course now I’m a psychiatrist and I see its worth, but at the time, when you’re dealing with gunshot wounds and HIV and a tuberculosis epidemic, you don’t think of mental health as important. And then, because it’s a kind of softer, slower specialty – unless someone is ragingly psychotic in an emergency department – you tend not to see psychiatric patients, or certainly not many of them, and you kind of forget about it in the hospital setting.
And then you come over to the NHS and mental health is everywhere – so that was really interesting to me and that made me think, well, what is it about mental health in developing versus developed countries? Because sometimes I think to myself, with these patients in the West, gosh you really have it so well – you’re so fortunate. You’ve got a roof over your head, you’ve got food to eat, and yet here you are, suicidal in front of me. I used to catch myself thinking these thoughts – and of course it’s really not fair on the individual, because it is what it is for them. It’s no good saying there are starving children in Africa, why can’t you be happy – because it just doesn’t work like that.
Dr. Haidar Al-Hakim: But why is it mainly in mental health? I mean that’s something that has become synonymous with stigma.
Dr. Greg Lydall: Aw, so many things, so many reasons. It’s harder to see, it’s harder to understand. People who are mentally ill bring out difficult feelings in other people, and they bring out fear. Fear of the unknown, fear of the inexplicableness of somebody’s behaviour or way of thinking. Before we had science we would often say people were possessed and take them down the religious route, or say they were criminals and take them down the criminal justice route. The stigma is a mark and it marks you out as different.
What I was going to say earlier was, in a high pressure system like in the developing world, as a healer there is no time to think about your mental health – but if you are suffering, it’s because there’s so much on your shoulders. One doctor makes so much difference in a resource-poor setting that there just isn’t the time, and you get caught up in the system and there isn’t the bandwidth to think about your own care. You just have more and more patients to deal with, and of course it becomes a vicious cycle and I think that explains why doctors have higher suicide rates. I think the highest of most professions. I don’t know what the data is but I wouldn’t be surprised if there were higher rates in more resource-poor settings.
I’m pretty sure it’s because good people go into medicine and then they end up in a system that cannot deliver what the doctors know is right. And then they burn out, and I think that’s the next step before depression, and then addiction, and so on. As you know of course we have access to means as doctors and we know what keeps you alive and what doesn’t. And so that’s why doctors have higher suicide rates.
It’s tragic, really. We need to do something about it. We need to be able to me much more open about mental health, as a profession, and the more we talk about it the less stigma there is going to be.
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