Today’s Physicians are Trapped in a “Toxic Culture”
Efforts to improve things amount to a paradigm shift
Even when the health care system is working well, medicine is a stressful profession. Physicians are immersed in a sea of suffering, painfully aware how much is on their performance. Patients count on them to know what to do and to do it flawlessly. No matter how many times they succeed, doctors know that a single mistake can devastate those who rely on them and destroy their own careers. No one can endure this kind of unrelenting stress without support. And indeed, the recent Medscape National Report on Physician Burnout and Depression found that nearly two-thirds of U.S. physicians say they feel burned out (42%), depressed (15%) or both (14%).
Despite this tremendous need, medical culture not only fails to provide support, it actively discourages physicians from even asking mental health professionals for help. Fully two-thirds of those who reported burnout and depression on the Medscape survey said they were not seeking professional help and never had. Female physicians were somewhat more likely to ask for help (58%), but they also reported higher levels of burnout (48% vs. 38% for men).
The acculturation process begins in medical school. Doctors are taught to tough it out in silence. “They learn early in their training to hold the line, to come across as stoic, to turn up ready for work come what may, and never to admit to their vulnerabilities,” says Dr. Clare Gerada, medical director of England’s Practitioner Health Programme and a former chair of the Royal College of General Practitioners.
While research has consistently shown high rates of depression and anxiety among physicians in training, a recent study found only a third of medical students suffering symptoms of burnout seek help. The stigma of being seen as weak and unfit to practice—by colleagues, employers and even patients—keeps all the rest silent. Particularly troubling is research showing that those in the grip of depression feel the stigma even more keenly.
Rather than seek professional help, many physicians ask colleagues to provide “hallway prescriptions” or try to medicate themselves, sometimes with anti-depressants but all too often with alcohol or opioids. A 2012 study in JAMA Surgery found those who were depressed significantly more likely to abuse or be dependent on alcohol. A Mayo Clinic study of those enrolled in physician health programs found half misused alcohol and more than a third abused opioids.
Those few doctors who do seek help often go to great lengths to protect their confidentiality. According to Wible, “They drive out of town, pay cash, and use fake names to hide from state medical boards, hospitals, and insurance plans that ask doctors about their mental health and may then exclude them from state licensure, hospital privileges, and health plan participation.”
“Nearly two-thirds of U.S. physicians say they feel burned out, depressed or both.”
LICENSING CONCERNS. For many, if not most, it is the fear of losing their license that silences them. In 32 states, medical boards require applicants for a license or renewal to reveal any history of mental illness. In fact, according to the recent FSMB report on Wellness and Burnout, questions about sub-stance abuse and mental illness on state medical licensure renewal applications nearly doubled between 1996 and 2006.
A 2017 study published in Family Medicine, found that med-ical boards asked more commonly about mental health issues than they did about physical impairment. According to lead author Katherine J. Gold, MD, MSW, MS, “The problem is that states don’t ask, ‘Do you have a problem right now that affects your ability to provide good care for patients?’” (Instead) they ask broad questions that intrude on physician privacy and prevent doctors from seeking care, but don’t necessarily pick up on impaired physicians.”
Gold and others note that such needlessly broad and intrusive questions violate the American with Disabilities Act. They also do little if anything to protect patients. According to the FSMB report, “While information about a physician’s health status (both mental and physical) may be essential to a state medical board’s solemn duty to protect the public, the FSMB has previously noted that a history of mental illness or substance use does not reliably predict future risk to the public.”
These unnecessarily intrusive questions have a significant impact on physicians in pain. According to a 2017 research study published in Mayo Clinic Proceedings, “Nearly 40% of physicians reported that they would be reluctant to seek formal medical care for treatment of a mental health condition because of concerns about repercussions to their medical licensure.” In states that asked about mental health conditions going back more than a year, 20% more physicians admitted to the same concern. This is especially troubling given FSMB’s finding that the number of states asking for such information actually rose between 1998 and 2006.
“The medical license application questions are getting in the way of very treatable mental health disorders and probably contributing to the high rates of suicide among physicians,” said lead author Dr. Liselotte Dyrbye, a professor of medicine and medical education at the Mayo Clinic in Rochester, Minnesota.
Tragic evidence supporting Dyrbye’s conclusion is all too easy to find. Wible describes a doctor who hung himself from a tree outside the Florida medical board office after be-ing denied his license. Gerada recounts the following story:
“Dr. Wendy Potts was a general practitioner who also had bipolar disorder. When she began to write a blog about her experience of suffering from a mental illness, a patient complained. Potts was referred to local disciplinary processes and to the General Medical Council. She went on to take her own life. At the inquest, the coroner said the system had lost sight of the patient behind the professional.”
LACK OF SUPPORT AND TEAMWORK. First responders endure many of the same stresses that physicians do. They, too, witness human suffering and have to make life-and-death decisions under difficult conditions. But unlike doctors, first responders are actively encouraged to get the help they need. The Center for Disease Control and Prevention (CDC) explains, “Stress prevention and management is critical for responders to stay well and to continue to help in the situation.”
After advising responders to be on the lookout for signs of burnout and PTSD, the CDC urges them to partner with others so they can support one another and monitor each other’s stress levels and workload. They instruct responders to limit working hours and avoid working alone, to work in teams and share feeling and experiences with teammates, to get enough sleep and exercise and set clear boundaries. “Know that it is okay to draw boundaries and say ‘no,’” they caution. “It is important to remind yourself: It is not selfish to take breaks. The needs of survivors are not more important than your own needs and well-being.”
Physicians almost never get such sensible advice. It’s simply not part of the culture. Which is why, when the University of California at San Diego (SCSD) decided to do something about the high rate of suicide among its physicians, they looked for models to emulate not at other hospitals but in the military, another profession plagued by high stress.
According to Christine Moutier, MD, chief medical officer at the American Foundation for Suicide Prevention, “We modeled our efforts, in part, on the evidence-based strategy of a U.S. Air Force program that achieved an astonishing 33% reduction in suicides between 1996 and 2002.”
“Air Force leadership addressed the importance of recognizing changes in mental health, and policy changes protected the privacy and professional reputations of those referred for help. The Air Force program taught members how to intervene at the first signs of distress, possibly long before an imminent risk of suicide, and to recognize more acute warning signs of suicide risk.”
Underlying the Air Force strategy is an assumption almost totally alien to medical culture. “Our profession is built on the bedrock of trust,” said Army Chief of Staff Gen. Ray Odierno. Soldiers know, he explained, they have to be there for each other in life and death situations. They have to work as a team.
During the filming of her recently completed documentary about physician suicide, “Do No Harm,” Emmy-winner Robyn Symon was struck by the absence of such comradery among doctors on the front lines of health care. Instead of supporting colleagues in distress, she said, “Physicians start to distance themselves from the person who’s struggling. Instead of reaching out, which you would think would happen in the medical field, these people who have a passion for helping others, find themselves turning away from their own colleagues.”
Symon said the physicians feared guilt by association. They worry, “If I try to help him, maybe they’ll think there’s something wrong with me, or I’ll get sucked into this malpractice case.” This defensive behavior leaves the most desperate feeling isolated and alone. And “it eats at the soul” of those who turn their backs. The result: in 2008, only six percent of physicians described their morale as positive.
MAKING CHANGES, CREATING A CULTURE OF WELLNESS. Cultural change is never easy or quick, but at least the goals are now clear. A recent article in NEJM Catalyst, “Physician Well-Being: The Reciprocity of Practice Efficiency, Culture of Wellness, and Personal Resilience,” defines a culture of wellness as “a set of normative values, attitudes, and behaviors that promote self-care, personal and professional growth, and compassion for colleagues, patients, and self.”
Achieving this goal requires a paradigm shift. Clinical leaders must reject the historic “iron-doc” culture, say the authors, “by encouraging physicians to extend to themselves and their colleagues the same natural compassion that they show to their patients. Leaders should expect physicians to attend to their own well-being and should view self-care as a professional core competency, abandoning the antiquated and dangerous misconception that self-care and patient care are competing interests.”