Reluctant patients: The mental health of doctors

The British medical journal The Lancet surveyed a number of studies that discuss troubling statistics on suicide and depression among American physicians. The subject is not new, but the studies attempt to provide a few new insights.

A 2004 analysis in The American Journal of Psychiatry found that male doctors were 1.41 times more likely to commit suicide than other men. The statistic for female doctors was significantly higher, 2.27.

The cause of the increased rates is not known, but the problem seems to start in medical school.

At medical school, competitiveness, the quest for perfection, too much autonomy coupled with responsibility, and the fear of showing vulnerability have all been cited as triggers for mental ill health.

The stigma of not being able to cope

A study in JAMA published last year looked at the fear of showing vulnerability. It found that 53% of medical students who had high levels of depressive symptoms were concerned about revealing their state of mind. They felt such honesty would be risky for their careers. Many saw the mere act of asking for help as an acknowledgment that their coping skills were inadequate.

Medical students are under extraordinary demands. They feel they are making life and death decisions and that they can never be wrong. There is such tremendous pressure to be perfect that any sense of falling short makes them very anxious.

If medical students are critical of each other about depression, how does that transfer to patients? We don’t want the medical education experience to make them less tolerant of mental illness. Stigma seems to be lessening among the general public. But it is possible the medical professional is lagging behind.

Health care reform, with its increased regulatory requirements, may well increase the stresses felt by doctors. There’s concern that physicians will decide not to practice anymore. (See the recent book Out of Practice: Fighting for Primary Care Medicine in America, in which a primary care physician describes his decision to end his practice at age 51). Those who continue often choose to deal with their distress in private rather than risk the stigma associated with depression or burnout.

Increased rates of self-medication, alcoholism, and other harmful behaviours have been reported among doctors who try to cope with stress and burnout on their own for fear of losing their medical licences if they report mental stress.

Despite medical schools offering an array of counselling and wellness services, it seems that students remain scared of stigmatisation and adverse effects on their careers if they seek help for any mental health issues, which can then persist and worsen over a physician’s career. Researchers have found that around a quarter of young doctors suffer from depression, more than half experience burnout, and more than 10% may have thoughts of suicide.

Is a high stress career worth it?

The Lancet quotes a general practitioner, David Ores, who feels hospitals and clinics exploit and over-work medical students.

I once walked out of a surgical residency because I didn’t like the way they bullied and yelled at me but not everyone would do that. Students are exposed to brutal violence in ER rooms, are underpaid, and basically end up suffering from PTSD [post-traumatic stress disorder]. But no one comes to talk to you and you’re left on your own.

Dr. Ores decided against a career in surgery and now treats low-income patients in New York City. “I feel I can actually help people. So much is out of your control in the ER room or operating theatre.”

Feeling things are out of control, among other things, can lead to unprofessional behavior. A study published in JAMA in 2010 surveyed 2500 medical students and found a correlation between unprofessional behavior and mental factors such as burnout, emotional exhaustion, and detachment. An interesting nuance was the distinction between behavior associated with professional distress as opposed to personal distress.

These findings suggest that the association between cheating/dishonest clinical behaviors and students’ views regarding physicians’ responsibility to society are more specific to burnout (ie, professional distress) rather than simply distress in general. The fact that students frequently engage in dishonest behaviours despite knowing they are inappropriate may imply that some elements of the learning climate foster dishonesty.

For doctors who suffer from high stress and burnout and who remain reluctant to seek help, the ultimate tragedy is suicide. According to a study published this January in Archives of Surgery, one out of 16 surgeons reported suicidal thoughts in the previous year. Few sought psychiatric or psychological help, however. Ominously the study commented: “Access to lethal medications and knowledge of how to use them has been suggested as one factor [for suicide].”

Marriage partners

The last study surveyed by The Lancet was one on surgeons and their “domestic partners” (DPs) – their spouse or partner. Of the almost 8,000 surgeons responding to a survey, 90% had DPs. Half of those DPs did not work outside the home, 16.4% were physicians, and 34.9% were employed, but not as doctors. The conclusion:

Physicians married or partnered to another physician were more likely to have depressive symptoms and low mental quality of life than surgeons whose DP stayed at home …. Surgeons whose DP stayed at home appear to be more satisfied with their career.

I’m reminded of one of the doctors in the NOVA documentary “Doctors’ Diaries,” who felt very strongly that his wife should stay home and take care of the children. He’s quoted as saying “One of the problems I ran into early on with my wife was I would act like, ‘How come you haven’t finished the tasks I set aside for you at home?’ ” (I believe he later divorced, but I could be mistaken.)

I wonder if there’s an age factor operating here — wives who don’t work may belong to an older generation. The study, which appeared in the Journal of the American College of Surgeons, reports: “Surgeons whose DP was a physician were younger, newer to practice, were more likely to delay having children and to believe childrearing had slowed their career advancement, and were less likely to believe that they had enough time for their personal and family life compared with their colleagues whose DP was a working nonphysician or stayed at home.”

The upshot of all this is that doctors need to feel free to seek professional advice when they need it. Other than measures to protect confidentiality, however, it’s not at all clear what can be done to create a climate that promotes the mental health of doctors.

Update:
How to prevent suicide in physicians (KevinMD)

Dr. Zakari Tata is planning to write a series of essays on this topic. His first essay concentrates on the many challenges of residency.

Physicians have unique social situations. They are highly respected in society and it is difficult for their friends and family to give them advice. The reason is usually because they feel the physician “knows everything.” In addition, during the intense years of residency training, physicians may not be very accessible to their friends and family due to long hours of work and study resulting in relative social isolation for some. Residency is particularly stressful for many other reasons …

Related posts:
Are doctors tired of practicing medicine?
Czech doctors resign in protest
Should doctors work weekends?
Physician as lone practitioner
Doctors in the trenches speak out – Part One

Resources:

Image: The Junior Doctor

Sharmila Devi, Doctors in distress, The Lancet, February 5, 2011

Eva S. Schernhammer, M.D., Dr.P.H., and Graham A. Colditz, M.D., D.P.H., Suicide Rates Among Physicians: A Quantitative and Gender Assessment (Meta-Analysis), The American Journal of Psychiatry, 161: 2295-2302, December 2004

Liselotte N. Dyrbye, MD, MHPE et al., Relationship Between Burnout and Professional Conduct and Attitudes Among US Medical Students, The Journal of the American Medical Association, 304(11): pp. 1173-1180, September 15, 2010

Tait D. Shanafelt, MD et al., Suicidal Ideation Among American Surgeons, Archives of Surgery, Vol. 146 No. 1 pp. 54-62, January 2011

Thomas L. Schwenk, MD et al., Depression, Stigma, and Suicidal Ideation in Medical Students, The Journal of the American Medical Association, 304(11): pp. 1181-1190, September 15, 2010

Liselotte N. Dyrbye, MD, MHPE, FACP et al., Physicians Married or Partnered to Physicians: A Comparative Study in the American College of Surgeons, Journal of the American College of Surgeons, Vol 211 Issue 5, pp. 663-671, November 2010

Frederick M. Barken, MD, Out of Practice: Fighting for Primary Care Medicine in America (The Culture and Politics of Health Care Work)