Fire in the belly: Are Doctors Breathing In Anxiety And Breathing Out Depression? – Dr Lisa Koo


from Luke’s Journal 2020 | Breath of Life | Vol.25 No.2

In order to gain a better understanding of the effects of mental health on a medical professional, Dr Jill Benson (from Doctor’s Health SA) and Joel Derham (from SAMET) had a Question and Answer session with Dr Lisa Koo. Lisa was born and raised in Adelaide. Her father and eldest sister are also doctors. She graduated from Flinders University in 1997, followed by internship and then GP training. She went back to the Clare Valley in 2005 and has worked in private practice at the Clare Medical Centre as a rural GP. She sees nursing home patients. She also works at the local hospital doing emergency, anaesthetics, and looks after inpatients in the disciplines of general medicine, surgery, paediatrics, psychiatry and palliative care.

The Symptoms

What were the main challenges that you faced during your early years in medical training?

I enjoyed university, but had supplementary exams in my first four years. When I commenced internship, I was not fully prepared. I possibly was dysthymic as an intern, but because I struggled in my studies through high school and university, I did not feel that much different.

What were some of the contributing factors or challenges you faced with your health? What did you find helpful?

As a RMO: I dated my first boyfriend at the age of 24. Six months afterwards we broke up, I was crying a lot and was pining for the past. My registrar at the time, Kelton Tremellen, and another senior registrar, Anna Bof, realised that I was depressed. Kelton took me aside one day and said, “Lisa, you’re not your usual self.” I appreciated his concern and the suggestion that I get help. I saw a GP that I knew through my Christian doctor circles (Christian Medical and Dental Fellowship of Australia). I had a break from work for seven weeks. It was a very ‘black’ period, but by the end I felt so good, and so spiritually alive. It was a definitive time for me.

19 years later: March 2019. The day I decided to get help was a day that I was on call. I was managing a STEMI and instructing the nurses, phoning Medstar and arranging ambulance transport. In the meantime, other patients were arriving and waiting to be seen. Whilst the nurses thought I handled this well, anxious thoughts were distracting me whilst I was multitasking and I realised I wasn’t coping. In hindsight, I had been anxious for the past 12 months or so. I was mildly anxious for several days leading up to being on call and doing certain anaesthetic lists. My anxiety worsened so that I no longer needed those triggers, and I was waking up feeling faintly negative every day, including my days and weekends off.

I was suffering from compassion fatigue and burnout. I thought everyone got more tired and world-weary as they aged! I also thought I was not being ‘spiritual’ enough, so once I ‘fixed’ this I’d be better.

Was there something else that people could have done that would have been helpful?

Years later, a GP friend mentioned that she thought I had been depressed in internship. She did not let on at the time, but to me it didn’t matter, because she was very supportive in a responsible, sisterly sort of mentor way!

I guess she could have said “I think you’re depressed and maybe you need to see a GP”, but she knew I had a good supportive network of friends, and I was still functioning. If I had seen her as a patient the outcome may have been different. Personally, I am not good at diagnosing mental illnesses in friends, because I view our conversations as debriefs with each other, rather than diagnosing them with an illness. My friends are not my patients – I am there because I am listening and responding to them as a friend. But if I have a patient in front of me, I’m making an assessment about what mental illness they may have, and asking pertinent questions to establish a diagnosis. Unless you are asking those specific questions, or picking up on subtle signs, you can miss that someone is unwell.

We all get stressed, especially with time management, or being on call. How do others recognise the difference between ‘normal’ stress (being grumpy), and a mental illness? Often we can’t. It was really up to me to ask for help, as I must have looked my normal self to the hospital nurses, and the staff at the Clare Medical Centre, where I’ve worked for 14 years. I did my own DASS 21 that day – I scored moderate anxiety (I thought I was mild), and surprisingly – but not so surprisingly on second thought – mild depression.

It was only after I started to improve that I realised why I had been internally resentful, and grumpy at home. When I apologised to my husband for my past behaviour, he said, “I hadn’t noticed a difference.”

You can put on a really good face (very few of my patients show a flat affect), and if you’re not asking deep questions, you can miss it. I think that’s why people don’t always recognise suicidal people. You can convince yourself that you’re fine. You can also give yourself many reasons not to tell others – maybe from catastrophizing or minimizing your feelings, or from being critical of yourself, or from assuming you can fix it yourself. Anxiety and depression exacerbates these ‘unhelpful thinking styles’.

Once I asked for help, the support was amazing. I had a break from doing on call, we came up with solutions for managing anaesthetic lists, and patient-free breaks were included in my daily schedule.

Did you ever feel as though you couldn’t show the effects of your illness or ask for help, as it was your role to help other people with their health?

Living in a small country town I wondered, “Am I allowed to be transparent with my mental illness or will my patients perceive me as being incapable of treating them?” When I told my colleague he asked: “Have you told anyone else?” I said, “My husband.” 

“I’m supposed to be the one on top of it all that sorts out other people’s problems.” you told anyone?”

It then dawned on me that I hadn’t told anyone else. The next morning, my husband and my children were away and I felt so alone, trapped in my house. I thought, I can’t walk down the street in tears because everyone knows me, and I didn’t want them to know. I’m supposed to be the one on top of it all that sorts out other people’s problems. What do I do? (I ended up contacting a work colleague).

I recognized pretty quickly that I was over-identifying with my anxious patients. They were becoming ‘heartsink’ patients and I was getting emotionally drained. When you’re in that pattern of negative thinking you assume that everyone else thinks like you do. I didn’t want to talk to my GP friends in Adelaide because I didn’t want to emotionally overwhelm them with my problems. So when patients tell me they don’t want to burden anyone else, I kind of get it.

But of course, now that I’m well, I can openly talk about it, and listen to people who have mental health issues because it doesn’t burden me anymore. My irrational reasons for keeping quiet have been confirmed as incorrect assumptions.

There is professional stigma, too. The Medical Board is different now but, in the past, if someone admitted that they were mentally unwell, they would be fearful of it affecting their registration and being treated punitively, like being struck off. For doctors beginning their training, there is fear of it being seen as a weakness, and concerns with it affecting career progression.

Would you say that in your view that it is easier to talk about and more accepted in the workplace now?

If I had schizophrenia or bipolar disorder, I would not be talking in public to you. However, anxiety and depression affect 1 in 3 Australians in their lifetime, so we should be talking about it!

One of the most therapeutic things to do is to actually come clean and talk to the appropriate people and get help. Initially, I chose only to tell two of my senior administrative staff, and a couple of my senior colleagues. It would have been counterproductive to tell everyone, because I didn’t want to be wrapped in cotton wool, so I could keep functioning as normally as I could.

‘Don’t underestimate the emotional burden that doctoring can have on our lives. It’s not ‘normal’ for a layperson to listen to hundreds of people debriefing about their deepest emotions and physical sufferings, so what makes us think that we think we have immunity?’

In the past, I thought that a GP admitting they have mental health issues is like a beautician having uncontrollablybad acne! Now that I have an intimate understanding and realise the benefits of treatment, I want to tell others! I feel better! I am enjoying my work (most of the time), my family and the world around me. I want others to experience that joy, too. There must be other doctors out there who are anxious or depressed who aren’t getting help, or who have halted a particular career path because they haven’t thought of getting help. Mental illness affects the way we function as professionals. If we struggle looking after our own basic needs, how do we have the energy to look after others?

‘Mental illness can rob us of being confident of our own abilities, affect our competence, and diminish our compassion.

Mental illness is greedy. It is selfabsorbing, and we can be slaves to it, and behave in whatever way that makes us feel in control.’

We are human. We like to feel in control. But if we are not coping, this might mean just that little bit more alcohol; or shopping; or ordering our patients more investigations to exclude that elusive cancer; or ordering nursing staff around with whatever erratic idea comes to mind!

The Solutions

What were some of the ways in which you overcame some of these issues? Was there a key moment or turning point?

I am indebted to Kelton Tremellen who picked up that I was depressed in 2000. My spiritual life took off as well and my relationship with God became essential and life-affirming. I will be eternally grateful to my dear friends, Catherine and Brenton Wait, who offered me their place to sleep at night, as I was scared of sleeping alone. In those weeks, their toddler was learning to walk. I watched him take his first steps in those 7 weeks; it was such a powerful metaphor for me. I also went on antidepressants and eight weeks later I was really happy and grateful. It was a very dark time, but also a very special time.

2019 was different as I’ve been a doctor for 20 years, and I’m married with young children. My workplace is very supportive. I was very happy to see one of my colleagues (as a patient) but was advised, “You are better off getting external help, especially as this is work-related stuff and we’re more like family.” So I made an appointment with Dr Jill Benson at Doctors Health SA.

I went on medication (I have no qualms about being on medication; some people feel like they’ve failed) and am seeing a psychologist, Rosie Walsh in Gawler. I was having noticeable gains of feeling positive within two weeks of starting the antidepressants. The psychological techniques beautifully dovetailed as prevention and treatment.

‘Psychology: it distills the unconscious, like a good wine or perfume. It brings it into consciousness like distilling the best ingredients of life.’

Sessions have taught me about mindfulness (I find engaging the five senses using the Grounding technique helpful). I was pleased to learn that physical activity was only a small part in increasing endorphins! Progressive muscle relaxation helps me to sleep.

Now I realise that none of us are perfect thinkers. We could all do with a little help.

Hugh Kearns and Maria Gardiner’s course for professionals is also excellent. Look up The Ultimate Time Management Guide for GPs on their website.

“Some of my patients are so socially isolated; it’s good to be a friendly person in their life that day.”

Do you feel as though there is a sufficient level of support services for people who may have been in the same position as you? Are they approachable and are people likely to turn to them for help?

Yes, there are services out there. But one of the biggest barriers is people having the insight to seek help, and wanting to seek help (stigma).

So psychological support services haven’t improved?

They have improved in the country, but mental illness is a burgeoning field. Rural people can access government-subsidised psychology sessions for free, but our current local waiting list is about six months. Our visiting psychiatrist is booked out for that long too.

There are so many services out there that I don’t remember what they all are. There’s no central website to say this person has started up in our area, or that organisation has left. The more services we have the more confusing it gets. Seeing a good GP is still the first point of call for knowing what services are out there.

Had you observed any similar issues with colleagues during your time? Did you get a sense of this being a common problem amongst other junior doctors?

With our small intern cohort at Modbury Hospital in 1998, we were all pretty good at being open with each other, but I don’t think mental illness was really talked about back then. As an RMO, my LMHS consultant bosses respectfully acknowledged that I had time off, but I didn’t have any in-depth conversations at work. Everyone else seemed to be okay.

Now that I’ve been anxious, and I’m a more experienced clinician, my ability to detect it in other doctors and patients has become very sensitive! Our reception and nursing staff also notice when doctors are grumpy! The main issue seems to be managing on-call.

Nowadays, I quite happily open up to select people. I’ve had some really good conversations with other doctors who have also quietly admitted that they’ve had issues. With patients, I am sharing psychological techniques. I can offer something more than my usual psychoanalytical approaches which rarely fix my patients. I think, as human beings, we feel acknowledged when there is a small amount of self-disclosure. People are relieved that they aren’t the only ones who feel like they are going crazy, and that even those who look like they’ve got it all together can struggle. Some of my patients are so socially isolated; it’s good to be a friendly person in their life that day.

Do you have any advice for any junior medical officers who have been in a similar position?

If you’re struggling to talk to someone you trust. See a GP. If you don’t quite gel with that GP, please don’t give up. Find another GP you feel comfortable talking to. I recommend Doctors Health SA, because they are specifically set up to understand and treat the needs of doctors and medical students.

If you see someone else is struggling, gauge how they are going. You may end up advising them to see a GP. Be mindful of being overwhelmed. Being there as a friend is the best starting point and then go from there. Remind them that they are not alone.

Editor’s note: This article was first published in the South Australian Medical Education and Training (SAMET) newsletter, and then again in

Dr Lisa Koo was born and raised in Adelaide. Her father and eldest sister are also doctors. She graduated from Flinders University in 1997, followed by internship and then GP training.

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