Imagine you have a patient who says they have been feeling depressed for the past 3 months.
They report a decreased appetite, insomnia, lack of interest in things they used to enjoy, and difficulty getting out of bed in the morning. We are taught in medical school the classic signs of major depressive disorder, and this patient has them. As their doctor, you may rule out other causes of these symptoms, but you would also look at the possibility of starting them on medications and referrals for therapy. You would determine whether they are a harm to themselves or others. Assuming there is no other further underlying psychiatric illness or complicating circumstances, you would not stop this patient from returning to work.
Would this change if your patient was also a physician?
Superhuman Requirements in an All-Too-Human Field
Physicians and medical professionals are held to a standard that often takes away their humanity. This can come with both positives and negatives. You have worked hard for many years, and it is a good feeling to know that society acknowledges this. It may be important for your patient interactions to be seen as a valid source of information. That being said, we are also at risk for being faulted for being a normal human being. This was exemplified in the "#medbikini" debate, where physicians were called out for being unprofessional because they posted photos on social media showing themselves wearing a swimsuit or drinking alcohol outside of work (to name just 2 examples). It's the same double standard with mental health. A physician with depression is seen as unacceptable or even dangerous. Yet we educate our patients on how common depression can be and how important it is to seek help. We encourage them to return to their normal lives after getting help. But when it comes to ourselves and other physicians, we've been conditioned to view mental illness as a weakness. Physicians who admit they need help are seen as groundbreakingly brave because others are unwilling to do the same.
It should not be this way.
Entering medical school, students have lower levels of depression than age-matched college graduates, but their rates of suicidality and burnout exceed their peers within months of the academic year starting.1 The prevalence of depression or depressive symptoms among residents has been estimated at 28.8%, with the prevalence increasing each year.2 Perhaps most disturbing is the estimation that male physicians have a 40% higher suicide rate and female physicians have a 130% higher suicide rate than the general population.3
I was unfortunate enough to see the effects of suicide in both my undergraduate and my medical school career. Looking back, I realized the rhetoric surrounding these situations differed. In undergrad, the focus was on the person and the things they had accomplished, the people who loved them, and how much they would be missed. While these things were also mentioned when hearing about the medical professionals who died, there was also the sense of the wasted potential and how no one knew they were struggling. How they had worked so hard and had wanted to do so much, but ultimately could not because of their hidden mental illness. What strikes me is the focus on career in this narrative. We place so much weight on being in the medical profession that our careers should somehow make us immune to the very common pathology of mental illness. Perhaps that is why it is so shocking when someone who pursued a career dedicated to helping others was unable to get help themselves.
Why don't doctors get the help they need?
One large reason is stigma. This is what most medical institutions focus on. Many institutions send an obligatory yearly survey assessing for burnout. Many institutions offer counseling or therapy. There are conferences dedicated to discussions on physician wellness and burnout. However, I would argue that a huge barrier is the fear that seeing a therapist will affect the ability to get or renew your medical license. In medical school, I knew a student who self-discontinued her medications for anxiety because she did not want to have to report those medications to her residency or the state medical board when she graduated. The fear of having to report to the state has been ingrained into us. As I look into therapy options for my co-residents, the No. 1 question I and many people have is whether this will affect their ability to renew their licenses. It is a valid question.
Before addressing this issue, let me be very clear: A physician should not be working if their judgment or functioning is impaired by psychiatric illness. However, physicians who are completely functioning while being treated for a mental health illness should not face any difficulties with renewing their licenses. This is not a novel idea. In 2018, the AMA released a statement that encouraged state medical license boards to only ask about mental health conditions that would impair judgment, adversely affect the ability to practice medicine, or present as a public health danger.4 A study looking into initial state licensing questions found that only 18 states are in compliance with the American Disabilities Act standards for asking about mental illness (these states either do not ask a question or only ask about current impairment).5 Another study looked at both initial and renewal applications for medical licensing. They found that only one-third of states either did not ask about mental health or only asked about current impairment. They also found that nearly 40% of physicians reported they would be reluctant to seek help for their mental health due to licensing concerns, with a higher reluctance among physicians working in states with non-compliant licensing questions.6 How is this acceptable, especially as our awareness of physician depression grows? We do not want to be seen as less of a doctor. We do not want delays in getting our licenses. We do not want mental illness to affect our careers. So why would we seek help?
As the COVID-19 pandemic pushes physicians in their careers and in their daily lives, the risk of depression, anxiety, and mental illness grows greater. I do not have all of the answers, but I do believe physicians should be able to seek and get help without repercussions, just as I believe this should be the case for anyone outside of medicine. This starts, in part, by pushing to remove questions on license renewals and applications regarding mental health. We cannot preach wellness without removing the real barriers to getting help first.
Help Is Available
The ACEP Wellness & Assistance Program offers ACEP members exclusive access to 3 free counseling or wellness sessions. Your mental health is important. This program is strictly confidential and is free with your ACEP membership. Get details at https://www.acep.org/life-as-a-physician/wellness/.
Additional peer support, crisis support, and physician wellness resources are available at https://www.acep.org/corona/covid-19-physician-wellness/.
References
- Kalmoe MC, Chapman MB, Gold JA, Giedinghagen AM. Physician Suicide: A Call to Action. Mo Med. 2019;116(3):211-216.
- Mata DA, Ramos MA, Bansal N, et al. Prevalence of Depression and Depressive Symptoms Among Resident Physicians: A Systematic Review and Meta-analysis. JAMA. 2015;314(22):2373-2383. doi:10.1001/jama.2015.15845
- Schernhammer E. Taking their own lives -- the high rate of physician suicide. N Engl J Med. 2005;352(24):2473-2476. doi:10.1056/NEJMp058014
- AMA adopts policy to improve physician access to mental health care. American Medical Association. https://www.ama-assn.org/press-center/press-releases/ama-adopts-policy-improve-physician-access-mental-health-care-0. Published 2018. Accessed September 7, 2020.
- James T.R. Jones, Carol S. North, Suzanne Vogel-Scibilia, Michael F. Myers, Richard R. Owen. Journal of the American Academy of Psychiatry and the Law Online Dec 2018, 46 (4) 458-471; DOI: 10.29158/JAAPL.003789-18
- Dyrbye LN, West CP, Sinsky CA, Goeders LE, Satele DV, Shanafelt TD. Medical Licensure Questions and Physician Reluctance to Seek Care for Mental Health Conditions. Mayo Clin Proc. 2017;92(10):1486-1493. doi:10.1016/j.mayocp.2017.06.020