Every day at work, with the type of medicine practised by Whangārei doctor Daniel Owens, a life hangs in the balance.
Sometimes, among his colleagues, the stress is such that the life in balance is their own.
Intense pressure, fear of professional backlash and passive support programmes are just some of the reasons Owens believes a stigma around mental health still exists in medicine.
Owens' comments come with the release of coroner Katharine Greig's report into the 2017 death of his friend and Whangārei Hospital colleague Dr Richard Harding, which was deemed a suicide.
Greig, who released a report on Harding's death earlier this year, deemed it a suicide, which she said "highlighted a constellation of factors that likely played a role in his decision to take his life, many of which were associated with his work".
However, Greig clearly stated it was not meant as a criticism of Harding's role at Whangārei Hospital, but rather an observation of the "systemic environment" in which intensivists - critical care doctors - and anaesthetists work.
"These highly-trained senior health professionals work in specialised and high-stress environments in which life and death decisions are part and parcel of their working days as is the risk of long hours and sleep disruption," the report said.
Greig's report cited research from NHS Practitioner Health which stated mental illness was common among doctors, with about 25 per cent at risk.
It said " ... suicide rates are between two and four times those of other professional groups, and in some specialities, there appears to be increased risk".
The report also said the culture of medicine was not generally supportive, with stigma and prejudice exacerbating mental health conditions.
Owens is an anaesthetist and intensivist (a specialist in intensive care) at Whangārei Hospital, just as Harding was.
"There's always been an attitude of 'you're in the trenches, you cope with it'," he said.
"I think there is also a fear that by admitting to having some mental health issues, that will impact on what practice you can do and your fitness to practise."
Having worked in some of London's most intense trauma centres, Owens was quick to reinforce these notions were not confined to a region or country but occurred across the globe.
Owens and Harding, both British, first connected prior to their respective moves to New Zealand and became firm friends upon their arrival.
As Harding battled depression late into 2017, Owens said he suspected his colleague was struggling. However, with reassurances Harding was seeking help, Owens did not expect the loving father of two would take his own life.
"It's still difficult to believe ... he was a lovely guy and we all really miss him."
When asked about the coroner's comments concerning the impact of mental health in the sector, Owens expressed little surprise. He said he knew of at least a dozen doctors who had committed suicide.
While he believed the stigma of having mental health issues as a medical professional was diminishing, Owens said its negative effects on mental wellbeing were due to a multitude of factors.
Chief among them was the stress of the job. As an anaesthetist, Owens was responsible for ensuring a patient's safety during surgery.
Even though the chances of dying from improper anaesthesia administration were significantly less than getting hit by a car, Owens said the risk was ever-present - something that could cause great stress for clinicians.
"You can have a perfectly healthy person come in, they go for an elective operation on their finger and it can go catastrophically wrong and they can die.
"Having to rationally live with those consequences is really difficult."
Furthermore, the pressure on intensive care doctors was substantial. Owens estimated he had an "end-of-life" discussion with whānau members every shift he worked, which became very taxing.
"We know that we have to have those discussions, we train to have those discussions, but it does become very draining."
A key moment in Harding's journey was a professional complaint he received prior to his move to New Zealand. While he was eventually exonerated of any wrongdoing, Owens said the complaint weighed heavily on Harding and had a lasting impact.
"That's a stressful situation if you add on top of that moving house, moving country, a new job.
"I think it probably had just set off something that had been dormant for a while and made him a little bit more susceptible [to depression]."
Having such pressure on their shoulders, Owens said anaesthetists and intensivists could falsely believe that hiding their struggles with mental health protected their professional integrity.
"When you're having to make quick decisions that have such an impact, it's really important that people have confidence in you making those decisions and if you've been suffering from depression, is there that cloud [of fear]?
"I'm not saying that it's necessarily there because I think things are getting better, but I think the perception that [the fear] is there can make accessing help difficult."
The extent of support available to medical staff could be significantly improved across the sector, Owens said.
Given the field's intense workload, Owens believed some health organisations should be more active in how they offer mental health support.
"You've got to take people out of work to remove the triggers and place them somewhere where you've got them for a period of time.
"Everyone feels this pressure but you've got to give them the time otherwise what you're actually doing, in a very well-meaning way, is ticking a box."
Owens, now 47 - the same age as Harding was when he died - said his friend's death had made him realise significant change was needed to curb New Zealand's sobering suicide rates.
In 2017, Unicef report found New Zealand's youth suicide rate - teenagers between 15 and 19 - was the highest in the OECD with 15.6 suicides per 100,000 people.
"For our population size, we've got a problem with suicide which is way out of proportion and I don't think any one health board can do anything about it, I think we need to look at this from a societal level," Owens said.
"I think we have to grasp this as a country and have a well-publicised route people can go to for help."
Northland DHB chief executive Dr Nick Chamberlain said the strain on healthcare services in the region had a critical impact on clinicians' mental health.
"Sadly, intensivists and anaesthetists are a very high-risk group because of the intensity of their work, looking after patients who are often critically ill," he said.
"The unmet need in our community weighs heavily on many of our staff and this creates the moral dilemma of not being able to do everything that we want to for our patients."
However, Chamberlain reinforced the importance he placed on clinicians ensuring their own health was maintained.
"Doctors have long been required to focus on their duty of care to patients but that doesn't mean that their own health doesn't matter, it absolutely does.
"We have a genuine commitment to our staff's wellbeing, helping them find ways to extract the good things from the 'bad days' and making sure that the support is there if they need it."
Where to get help:
• Lifeline: 0800 543 354 (available 24/7)
• Suicide Crisis Helpline: 0508 828 865 (0508 TAUTOKO) (available 24/7)
• Youth services: (06) 3555 906
• Youthline: 0800 376 633
• Kidsline: 0800 543 754 (available 24/7)
• Whatsup: 0800 942 8787 (1pm to 11pm)
• Depression helpline: 0800 111 757 (available 24/7)
• Rainbow Youth: (09) 376 4155
• Helpline: 1737
If it is an emergency and you feel like you or someone else is at risk, call 111.