My first month as a medical intern, over 20 years ago, I learned many important things: how to distinguish heartburn from a heart attack, how to treat pneumonia and alcohol withdrawal, how to perform a spinal tap. What I did not learn was how to manage the stress of carrying an enormous workload and great responsibility while getting little sleep and eating a diet consisting of greasy food from the hospital cafeteria and candy bars from vending machines. Stress management was not taught because the stress of being a physician wasn't acknowledged. When we were tired, anxious, sad, or sick, we just kept working.
Like athletes and soldiers, we physicians pride ourselves on working through injury, pain, fatigue, and assorted conditions that might sideline other professionals. For decades, doctors have sacrificed their own health and comfort for the sake of their patients, an ideal that has been reinforced by various media, from the embittered and overworked physician in the 1950s film The Last Angry Man to the scores of hard-drinking medical professionals in Scrubs, House, and Grey's Anatomy.
It would not surprise most people to learn that doctors have higher rates of suicide, alcohol and substance abuse, and job burnout than most people. In the past we might have written off these problems as a natural consequence of doctors working long hours in a highly stressful job, an occupational hazard of people caring for sick people, regrettable but unavoidable.
In the past few years, however, studies have shown that the mental state of physicians has much broader repercussions; it affects not just the doctors themselves (and their families) but also the quality of care patients receive. In fact, a recent article in the premier medical journal The Lancet contends that the emotional well-being of doctors is a major index of the quality of the health-care system as a whole. That makes physicians' wellness—particularly our mental health—a necessary part of any discussion of the health-care system—and of health-care reform.
Schooled in Self-Denial
"One of the last things to go when physicians are burning out is their attention to their patients," observes Dan Shapiro, professor of medical humanism and chair of the department of humanities at Penn State College of Medicine. Unfortunately, he says, "the baseline physician is walking around fairly burned out." Part of it has to do with the way the health-care system is organized and physicians are compensated, part of it has to do with who is selected to be a doctor (very competitive and perfectionistic types), and part has to do with the way doctors are trained.
"We teach doctors that they have to be self-denying," says Shapiro. "It's very adaptive and necessary sometimes, such as during long surgeries. But it can become a dominant way of being in the world, and then it is destructive." Even when sick, physicians frequently don't go to doctors, opting instead to work through illness and injury, and to diagnose and treat themselves. Many doctors do not even have physicians and avoid routine screening tests.
A large majority of doctors in residency training say that they would keep working if they had vomited all night, saw blood in their urine, or experienced extreme anxiety. Of course, if doctors avoid seeking medical care it is difficult to estimate accurately how frequently or severely they are ill. Still, surveys of doctors suggest alarming rates of stress and job dissatisfaction, risk factors for ill health.
Stress Indicators
One month after his 40th birthday, Alex Lickerman, a primary care physician at the University of Chicago, felt ill while attending a brunch. He lost his appetite, became nauseated, and began to feel pain in his right lower abdomen. After consulting a physician friend, Lickerman entered the hospital for what he assumed would be a routine appendectomy. In the middle of the night after he was discharged, he started vomiting violently and passed out, awakened only by his wife's alarmed screams. Rushed back to the hospital, he underwent emergency surgery, which showed massive internal bleeding, the source of which was never discovered.
Not long afterwards, he started experiencing chest pain, which he diagnosed as muscle strain. Luckily, he consulted his physician friend again. It turned out that he had a life-threatening blood clot in his lungs. Lying on a gurney in the ER awaiting treatment for the clot, he became very anxious. "I thought I could really die, a thought I had never had before," he recalls. "I really freaked out."
When he was ready for discharge he started having back pain, then severe diarrhea, chills, and fever, side effects of an antibiotic he had been given. Just when that problem was resolving, he developed a rash all over his body, an allergic reaction to another antibiotic. And when Lickerman was finally well enough to return to work, nausea struck again. Although he saw his patients, he was so distracted by discomfort and worry that he could barely focus on their problems. "I was out of my mind, I was so anxious."
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