She was 21 when she went in, 27 when she got out, and 29 when she recalls the six years of hell in between. A cardiothoracic ward, orthopaedics, general medicine, rehab units; it didn't seem to matter where Sarah went or what kind of nursing she turned to, the issue was always the same: "No matter what good you did that day, at the end of the shift you never feel like you've done enough."
Patient 'A' might be happy you were able to re-dress their wound and manage their pain, she says, "but patient 'B' has extreme nausea and you haven't had a chance to get them the adequate medication.
"Meanwhile, patient 'C' is unwell but also lonely, and you didn't get a chance to come back with an extra cup of tea that would have meant more to them than any medication. When you leave the shift, you're not thinking about what a good job you did on patient A. You're upset at yourself for what you weren't able to do for patient B, C, and D.
"Mix that with long hours and general exhaustion and it's going to take a toll."
One day, the unthinkable happened: A patient collapsed and died while she was on her tea break. "He was supposed to be discharged that day, and after a week of supervised showers I left him to it," Sarah says.
"The doctors assured me that even if I had been there, medically it wouldn't have made a difference. But because I left, it was his wife who found him on the ground and she blamed me. I knew I wasn't to blame but because of my actions his wife will be stuck with that final, horrific image of her husband forever."
Sarah became "seriously" depressed, and too anxious to leave her patients alone for extended periods. That meant skipping breaks and barely touching food or drink during her shifts. She was told she could talk to a therapist at the hospital about the incident if she wanted to, but "it was such a process" she decided to "just get on with it."
This, Sarah says, was the prevailing attitude in the wards. "When you're a young nurse, you never want to appear weak. Keeping a brave face was important. Everyone is having a tough time on some level, but no one really talks about it.
"You gossip and complain, but you never want to be the person who can't handle it."
That medical practitioners have higher rates of anxiety and depression than the general population is well-documented. Doctors, nurses and medical students are—ironically—one of the least likely demographics to seek help for their own mental health issues.
The same research shows that this is especially pronounced for female health practitioners, with one of the most comprehensive studies of its kind published just two months ago in The Medical Journal of Australia. It found that female nurses suicide at nearly four times the rate of working women in the general population; for female doctors, the rate was three times higher.
The rate for male doctors, while high, was equal to that of the general male working population. Deakin University's Dr Allison Milner, the study's lead author and an expert on occupational suicide, believes the factors are manifold. For a start, "Long working hours, the high demands of the job, juggling motherhood, and dealing with patients and their families."
"Both of those roles [nurse and doctor] are emotionally demanding," Milner continues. "There is also the fear of making mistakes. The doctor or nurse who makes a mistake can cause dire consequences for the patient, and flow-on ramifications for the family."
Milner extracted her findings from the National Coroners data for 10,000 suicides between 2001 and 2012. Women, she says, often try to do everything, and women in medicine are no exception. Many struggle to combine work and family, and to deal with "the stresses associated with trying to sit within the parameters of the medical profession, which may not be the most flexible for women."
Then there is the ready access to (and working knowledge of) prescription drugs—a "definite" factor.
Lastly, but crucially, "There may also be greater stigma, because in Australia there are licensing board regulations that mean if the practitioner admits to having suicidal thoughts or mental problems generally, they may not be able to practice."
Milner is talking about Australia's national mandatory reporting legislation, which states medical practitioners must report colleagues they have "reasonable" reason to believe are suffering from "impaired" mental health. If the terms sound hazy, that's because they are, which is part of the problem.
"This law may have made it even harder for severely depressed doctors to present for treatment," says Marjorie Cross, secretary of the Australian Federation of Medical Women (AFMW), and a general practitioner. "Stigma around mental health issues remains an important issue within the medical professions.
"It's an obvious point that most women in these professions do not have serious illnesses and nor do they suicide," Cross adds. However, the stark results of Milner's study do not surprise her—"and I would guess that the actual incidence could be [even] higher".
She lists off a tri-fold combination of stress, discrimination, and lack of power. "I can guess at the disappointments a woman might feel if she is overridden for job placements because of her gender ... There are stiff and difficult expectations of long hours for doctors in training, which can mean delays to childbearing. There are well-documented and recognised issues of bullying and harassment.
"All the issues that impact on anyone's mental health, such as early childhood trauma and intimate partner violence, also affect women in our profession, but perhaps are not looked for—nor readily acknowledged.
Bullying and sexism in the medical industry was thrust into the spotlight last year when a female surgeon made allegations of rampant discrimination and harassment. "What I tell my trainees," Dr Gabrielle McMullin told the ABC, "is that if you are approached for sex, probably the safest thing to do in terms of your career is to comply."
The independent report that followed surveyed 3,500 surgeons and found a "toxic culture" in surgery departments across Australia; nearly half of all surgeons had experienced discrimination, bullying or sexual harassment.
Then there is the medical glass ceiling. While two in five employed medical practitioners in Australia are women, they are still woefully underrepresented in leadership and specialisations, for reasons more complicated than the so-called lag phenomenon related to women's presence in medicine. Factors, as researchers have pointed out, include reduced perceived credibility, a heavily gendered working environment, being funnelled into specific areas of medicine, and inflexible hours for mothers.
Melanie*, an emergency medicine doctor in Queensland, sought the help of a psychiatrist for the first time in her life just two years into her own medical career. She had become depressed and was experiencing suicide ideation.
"I'd worked in various industries for many years before medicine," says the 31-year-old, "and I have never encountered the level of sexism, bullying and nepotism that I experience on a daily basis as a female doctor."
Male doctors, she says, command more respect in the hospital environment on the whole, which means she is left to do many of the nursing duties herself. That means a heavier workload and less face-time with patients, which in turn makes it hard to meet her patient quotas.
"When we get sexually harassed by patients and male colleagues, we have to take it," she adds. "You're meant to giggle and say nothing." Like most industries, there are official channels for reporting harassment. But doing so, says Melanie, is thought by many to "jeopardize your career prospects".
"I've worked in other countries, and the level of sexism in Australia is appalling. It's a huge contributor to job dissatisfaction for female doctors. I have had countless discussions about this with other female doctors."
And yet, "God forbid you mention to a colleague that you're depressed."
Psychiatrist Dr Geoff Riley, who specialises in treating other doctors, says the female doctors and nurses he sees have very consistent complaints. "It just repeats and repeats itself," he says. "It comes up time and time again."
That is, "Women are still operating in a boys' club and trying to keep up. Women [are] not being valued as much, and just generally not being recognized. It's mostly about women having to be all things to all men, trying to keep up at home, being perfect at work. Often they're smarter but less valued, and don't get promoted as much. It ends up in depression, predominantly, and often anxiety.
"The other thing that happens is that [there are] marriage issues, partly because of this imbalance at home, and the stresses and pressures of trying to keep it all afloat."
Female doctors and nurses can also become an unwitting emotional lifeline for patients, says Riley. "They carry that extra weight of [emotional labor], which can be quite debilitating. There is no question that this is true."
In 2013, mental health organisation Beyond Blue published a landmark study into the mental health of Australian medical practitioners, confirming what many already knew: Compared with both the general population and men in medicine, female doctors have higher rates of "psychological distress" and are more likely to experience "conflict between career and family/personal responsibilities".
It also found women in medicine more likely to have ideated and or attempted suicide within the past twelve months—as Milner's recent research confirms. Beyond Blue held a subsequent "roundtable" with the Australian Medical Association, to formulate an action plan that "aimed to encourage the medical profession to take a leadership role in this area."
But, says Marjorie Cross of the Australian Federation of Medical Women, "There are [still] very scarce psychiatric resources for anyone in our community. Psychiatrists skilled at caring for colleagues are even less available to doctors and nurses." There are phone lines practitioners can call, but Cross says they are undermanned and underutilized.
When asked for comment, AHPRA—who set Australia's mandatory reporting laws—simply pointed to a statement online from April 2016 that announced an investment of "$2M each year towards a national health program for doctors and medical students in Australia". Services include "confidential health-related triage, advice and referral services", plus "training to support doctors to treat other doctors" and "awareness raising and advice about health issues".
It is unclear how these services will sit alongside the mandatory reporting laws, although they will be undertaken at "arm's length" by a subsidiary company, presumably to reduce fear of exposure.
Milner is hopeful. She doesn't know yet what action might be taken as a result of her findings; it's too early to tell. "But the Beyond Blue study was really taken up and embraced by the medical profession in Australia," she says. "So I think we are on the route to doing something about suicide. I don't think there isn't anything being done."
Melanie went to see a psychiatrist only after her GP promised she would only be reported if deemed a real danger to her patients. "I was terrified," she says. "But I trusted this GP more than any other I'd seen, so I nervously agreed to the referral."
She says working as a doctor has gradually eroded the qualities she believes led her into the field in the first place: "Empathy, true caring for others, and a desire to help."
Some have suggested that the elevated levels of mental distress in health professionals might be due to the intrinsic nature of the practitioners themselves. Presumably, if suicide rates are a guide, this would then apply more to female doctors and nurses.
In response to Milner's study, suicide expert Professor Robert Goldney wrote in the Medical Journal of Australia: "A less frequently canvassed factor may be that people select for themselves the helping professions, in order to fulfil their own dependency needs ... none of us is impervious to our personal needs."
This may carry some weight, says Marjorie Cross. "[But] I would firmly believe this notion should be reflected without a gender bias."
In any case, for Melanie it's over. She doesn't know what she'll do next and she has $300,000 in student debt, but her relief at exiting the profession is palpable. "I personally felt helpless, unsupported, and responsible for anything that might have gone wrong," she says. "And when something goes wrong in medicine, it goes very wrong."
If you or someone you know is suffering from mental health problems, including thoughts of suicide, talk to your general practitioner, call Lifeline Australia on 13 11 14, dial emergency services in case of emergency, or refer to the additional information provided here.