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.
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."
Particularly in the current difficult economy, where doctors enjoy larger incomes and greater job security than most Americans,physicians may be reluctant to acknowledge openly how stressful practicing medicine can be. But that stress is real, and it does take a toll. Long work hours, sleep deprivation, college and medical school debts frequently in the hundreds of thousands of dollars, fear of being sued, fear of not performing "perfectly," difficulties (particularly for female physicians) in balancing work and family, not to mention mounds of paperwork, committee meetings, and teaching responsibilities all weigh heavily on physicians, and sometimes even make us ill. Astonishingly, in one survey nearly 20 percent of medical trainees rated their mental health as "fair to poor."
"If we look at psych indicators—depression, burnout, substance abuse, suicide—they show that medicine is a high-risk profession," says Shapiro. "These are folks who are pretty consistently stressed out. Because the health-care system rewards the proceduralists, primary care docs can't generate enough income to support themselves. To make a living, they have to see more patients in less time, and that contrasts with what they came into medicine for. They experience themselves as chronically rushed and not listening to patients as carefully as they want. They're like air traffic controllers with too many planes in the air."
"Some doctors end up giving poor care because they try to give the best care," says Ricki Bander, a California psychologist who has specialized in training physicians. "They try to handle everything, even when they don't have the resources. This is especially true of doctors in rural areas, where there is a lack of specialists." What's more, she says, "doctors focus on what's going wrong. There is the constant worry: 'Am I getting it all?' It's a big stress."
Givers vs. Receivers
It's ironic that so many doctors are reluctant to seek medical and psychiatric care, especially since they tend to have good health insurance and easier access to care than most people. Mamta Gautam, a psychiatrist in Ottawa who specializes in physician mental health, suggests several reasons. "Part of the culture of medicine," Gautam explains, "is that we are care-givers, not care-receivers. We're seen as being better doctors because we work harder."
Plus, she adds, "we're bright and so we can use intellectual defenses that allow us to avoid care," from denial ("I'm fine") to rationalization ("It's just because I haven't had a vacation") to minimization ("I'm only a little irritable"). Further, physicians are used to being in control, and illness often involves loss of control. Erik Fromme, who practices palliative care in Portland, Oregon, has seen even terminally ill doctors reluctant to take pain medication for fear of not being cognitively sharp.
One of the biggest barriers to attending to their own needs, especially for psychological problems and substance abuse, is the conspiracy of silence that renders doctors reluctant to raise concerns about a colleague. Physicians worry—realistically—about losing prestige with patients and colleagues, jeopardizing medical licensure, and losing income.
The Joint Commission, which oversees hospital accreditation, has tried to break the conspiracy of silence by advising that American hospitals and licensing boards develop programs to identify physicians' mental health and substance abuse problems separate from the programs that discipline physicians.
The Worst Experience
Everyone worries about being sued for malpractice. At some point in their career, many physicians face not just the biggest stress but what is often considered the most broken element in an ailing health-care system—a malpractice suit. Primary care doctors like me are less likely to be sued than certain specialists. Among radiologists who do breast imaging, 8 percent reported one claim in the past five years.
A survey of urologists listed in Best Doctors in America found that 77 percent of respondents had been sued at least once. Concluded the researchers: "Most urologists can expect to be sued at least twice in their careers. There does not seem to be a direct or inverse correlation between professional reputation and the incidence of being sued."
"It's part of the trade," says Bander, "but you begin to doubt everything you do." Whether the suit is frivolous or warranted, it is an enormous burden that endures usually for years, undermining self-trust, making doctors fearful and irritable.
"Twenty percent of physicians describe it as the worst experience of their lives," reports Shapiro. He treated a young rising star in obstetrics who was devastated after delivering a child with cerebral palsy. It wasn't clear she was at fault but a lawsuit followed. "The doctor was talented and compassionate, the exact person you'd want to see. But she blamed herself. The experience drove her out of medical practice" for a long while.
There are other stressors unique to doctoring—the need for fast processing of loads of information; daily exposure to emotionally charged encounters with suffering, fear, failure, and death; and difficult interactions with families. In one survey, 49 percent of physicians felt they neglected their own health. Denial thrives in part because doctors believe their own health is interpreted as an indicator of their medical competence.
Happy Docs, Happy Patients
It is difficult to measure in a quantitative manner the effect of physicians' health and well-being on their patients' health and well-being, but some researchers have tried to do so. One study found that the patients of doctors who reported being happy and satisfied with their jobs were more likely to have normal blood pressure and blood sugar than patients of unhappy doctors.
Some doctors have found that taking better care of themselves helps them take better care of their patients. After Alex Lickerman returned to work despite constant nausea, he turned to his physician friend yet again. The friend made a suggestion that Lickerman initially resisted: Maybe the nausea was a symptom of anxiety. A psychiatric consultant concurred and diagnosed post-traumatic stress disorder, the trauma being his recent spate of medical problems.
"The few times in the past I'd been sick," recalls Lickerman, "it was limited, easily defined and treated. Now things seemed so out of control. My ability to deny that something could be seriously wrong with me was gone. Every time I got a new symptom I had a level of anxiety out of proportion to anything I'd felt before. Every symptom represented a potentially life- threatening condition."
A prescription for the anxiolytic clonazepam banished his crippling nausea in one dose, but Lickerman did not want to stay on medication. Instead, he chose a form of Buddhist practice to get to the core of his problem—"the eruption of my fear of death. I was left by this experience unable to deny that I was mortal."
Three years later, Lickerman feels the experience has made him a better doctor. "It strengthened my empathy muscle," he reports. It has also made him more humble. Although he never thought of himself as an unsympathetic doctor, it wasn't until his own series of illnesses that he felt truly equal to his patients. "Before, there was always a subtle arrogance there, a feeling of 'us' vs. 'them.' Now I look on my patients not as patients but as people, like my family and friends." And Lickerman can never underestimate the power of psychological distress to affect his patients. "I've come to realize that as much suffering as physical illness causes, emotional suffering is much harder to deal with."
Curing the Strain of Chronic Care
A major source of the stress many doctors experience comes from seeing many patients whose medical problems will never be fully resolved. "Seventy-five percent of American health-care dollars go to patients with chronic illnesses," Shapiro points out.
That's why Ann Haiden, a primary care doctor in Los Gatos, California, abandoned a traditional medical practice. "I was going around in circles trying to diagnose and manage chronic health-care problems rather than getting to the root of them and fixing them." She now practices holistic medicine, which she feels is healthier both for her patients and for herself.
A few years ago, Boston internist Li Tso decided, as he says, "to practice what I preach." He began exercising and eating more healthfully. Many of his patients have told him that his weight loss inspired them to make lifestyle changes themselves.
The actions of a few individuals, however, are scarcely enough to impact a profession that acculturates physicians to a self-sacrificing but unhealthy ideal. That's why Scott Rodgers, a psychiatrist and associate dean at Vanderbilt School of Medicine, has spearheaded a pioneering wellness program that aims to prevent stress and burnout among medical students.
There have long been programs that address the mental health needs of medical students, but they tend to focus more on responding to existing problems—depression, anxiety, substance abuse—than on preventing them altogether. The Vanderbilt wellness program, jointly administrated by faculty and students, tries to make it clear to the students that their health and well-being isn't something they can put on the back burner until "later"—a way of thinking Rogers calls the "white-picket-fence syndrome," as in, "I'll be healthy and happy in 10 years when I'm married and live in a house with a white picket fence."
There are no data yet proving that programs like the one at Vanderbilt ultimately improve patient care. Still, I can't help but believe that they will.
Read Suzanne Koven's PT blog, Cases and Stories.