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The good physician treats the disease; the great physician treats the patient who has the disease.—William Osler
Physician heal thyself
Medicine is a tough profession, tremendously rewarding and terribly demanding. I love being a doctor, I love helping people with their toughest problems, but I can't stand what medicine is becoming.
State of the union
For many doctors, healing is a calling, not just a job. Along with a handful of other professions, doctors are privy to the most sacred and difficult aspects of human existence, sharing the joys and triumphs when people and their families overcome or endure in the face of illness, and sharing and witnessing the grief, horror, beauty and ideally peace and love when people succumb to terrible diseases we have no way yet of effectively fighting or preventing, let alone understanding. Along with warriors, first responders, therapists, human rights workers, clergy, and a handful of others, physicians are in the front lines.
No wonder that compared with the general population, Shanafelt and colleagues (2012) found that work-life dissatisfaction was nearly double for physicians, 40.2 percent reporting dissatisfaction versus 23.2 percent for non-physicians. Burnout rates were higher across the boards for physicians as well, with nearly 50 percent burnout rates on average. ER docs have it the worst, with close to 70 percent reporting burnout, followed closely by general internal medicine, neurology, family medicine and a host of other demanding subspecialties. General pediatrics, dermatology, and preventive, occupational and environmental medicine had the lowest burnout rates, just short of 30 percent.
According to a 2016 Mayo Clinic survey, the situation is not improving. Of nearly 36,000 physicians, 6880 responded to the invitation to participate in a study of burnout. Burnout was up, with 54.4 percent of docs reporting at least one symptom of burnout in 2014 up from 45.5 percent in 2011. Likewise, work-life satisfaction went down from 48.5 percent to 40.9 percent in the same time frame. Compared to the average US citizen, physicians were 1.97 times more likely to experience burnout and 0.68 as likely to enjoy work-life satisfaction.
Beyond burnout
Studies of burnout and stress are important, but do not reflect rates of mental health and risk for dire outcomes, including suicide, among physicians, notes Petrie and colleagues in their recent Lancet Psychiatry review and meta-analysis, Interventions to Reduce Symptoms of Common Mental Disorders and Suicidal Ideation in Physicians (2019). They report that prior research shows that, in addition to burnout, physicians also have more depression symptoms, anxiety and suicidal thinking than others. Physicians have a higher risk for suicide compared with other professions as well, ranking in the top ten according to a 2013 study. The Lancet authors report that while other occupational groups have high rates of mental health symptoms, physicians are more likely to have suicide as the cause of death, adjusting for other factors—chillingly, they note that one physician dies from suicide every day in the US.
On a personal note, I'd like to add that the when a physician commits suicide, it rocks the whole community. Health care systems respond with wellness meetings and other interventions, but trainees anecdotally report feeling uncared for and skeptical of administrative responses. They tell me not only is it “too little, too late,” but they simply don’t believe that the higher ups really care or are willing to devote the resources to address the systemic issues. They often consider wellness programs to be lip-service, alongside efforts to control hours and bureaucratic chores—trainees anecdotally confide that they are told to report they work fewer hours than they actually do in order to help meet regulatory requirements, describe that doing the paperwork and making sure the business of medicine runs well takes precedence over care, and bemoan the lack of adequate training and educational opportunities. Some of these complaints may be the voice of burnout speaking, disillusionment, fatigue and cynicism obscuring real, positive aspects of the work when an opportunity to vent arises, but nevertheless must be taken with utmost seriousness. They do not feel heard.
The Lancet study authors highlight similar concerns, reporting that workplace factors contribute to physician suicide, “including a large workload, long and irregular working hours, competitiveness of training programmes, pressure of patient and service demands, the consequences of any errors, poor work–life balance, and the risk of moral injury if physicians are forced to work in ways that conflict with their ethics and values.” They describe that the culture of medicine itself contributes to mental health problems, preventing physicians from seeking help, with factors including stigma against mental health problems, burdensome regulatory practices, and concerns about being able to seek care themselves due to confidentiality. I can tell you, again from personal experience both as a surgical resident and also as a psychiatrist, that medical training is rough, at times abusive, and emphasizes stoicism. In spite of positive changes in recent years, programs which encourage openness and help-seeking, stigmatizing labels still haunt medicine as they do for military personnel. Letting one’s team down, being “weak”, not being able to “take it”—this kind of behavior from colleagues, often from someone with power to control one’s career direction or some other power imbalance—makes revealing the need for help a risky business. I've been on both sides of that dynamics, and neither is healthy.
According to Lancet authors, in spite of growing research on burnout in medicine, there is little attention to both the presence of diagnosable mental health issues or interventions to prevent and treat mental health issues and suicide. Of course, it's no mean fear to conduct a good study of these issues, not the least of which is difficulty assessing a very large and complex set of data, as well as in distinguishing causation from correlation. Is being in the field of medicine the cause of these problems or would they have happened anyway?
In order to better advance the current state of understanding, they set out to conduct a literature review and meta-analysis of the existing research. Culling through major databases and reviewing thousands of published papers for eligibility, they found only a handful of well-designed studies looking mainly at physicians and mental health-related interventions and outcomes. The vast majority of the studies excluded were ineligible due to methodological issues, lack of attention to the core issues of interest, the inclusion of groups other than physicians and closely related professions in the analysis, and related factors.
Researching findings conspicuous for the absence
Their review and analysis resulted in two main findings. Strikingly, there is little quality research on physician mental health and suicide. In spite of decades of research on burnout and stress, there has been little attention to the hardcore issues of depression, anxiety, suicide and related issues.
In my professional life, I have experienced this blockade first-hand. Early in my career, I was asked to participate in a physician-wellness study survey. I was asked to be on-call in case they found any residents who needed psychiatric care. I also recommended that they study depression and suicide risk as part of their survey. After that, I didn’t get a call-back and was not invited to participate. No one told me though, they just stopped responding to emails.
The second major finding Lancet authors report is that interventions can be effective when they are available. Interventions reviewed, including individual and group, were moderately effective at reducing symptoms of depression, general mental distress, anxiety and suicidal thinking (evidence for the latter two, though, were only from one study). The quality of the data, even in the best studies, was poor, in keeping with the systemic stigma against knowing what is going on with physicians when it comes to mental health and suicide.
For instance, the studies were all self-report, none including formal diagnostic measures or clinical evaluation which is the standard in related research on non-physicians. The Lancet study revealed that interventions, mainly cognitive-behavioral and mindfulness-based, reduced self-reported symptom burden, but was unable to show they prevented depression or suicide. The research simply wasn’t there to review because it hasn’t been done.
Remarkably, there were no studies of organizational interventions which would be expected to help, including “rescheduling of work hours, reducing workloads, and modifying local working conditions,” all interventions shown in other fields to help with burnout and stress. As noted above, anecdotally, when a physician suicide the systemic response is reactive. There are healthcare-system wide meetings, there are spot-interventions for colleagues directly affected, and individuals are told to seek treatment with a therapist, but there are no studies looking at whether organizational interventions will actually prevent these terrible events, and only emerging efforts on the part of organizations to take a close look at this troubling and easily shunned area of major concern.
The take-home
This review and analysis in Lancet Psychiatry by Petrie, Crawrod, Baker, Dean, Robinson, Veness, Randall, McGorry, Christensen, and Harvey is a major milestone in understanding and appropriately responding to the mental health crisis facing medicine today. The research is startlingly scant, perhaps unforgivably. Rather than dwelling on the past, the alarm is sounded that greater attention must be paid to physician well-being. Better research using clear diagnostic measures and evidence-based interventions, on a large scale, is badly overdue.
We need to look at interventions and preventive measures directed at individual and groups, and equally importantly at systemic and organizational interventions to change the very culture of medicine. In order to do this, we need to not only put programs into place, but also take a deep-dive into the culture of medicine to understand why a field devoted to caring for others is unable to properly care for itself. We need to do this not only so that physicians can be safe and well, but also because we help those we serve by modeling good health practices. When we fail to do that, we let down not only ourselves, but patients and society.
Fortunately, research studies like this one and others already underway address part of what is missing. Medicine is changing albeit seemingly too slowly at times, for the better. It's important that physicians training now and those who were trained in the last few decades continue to take a stand, not just with research and policies, but also on the ground, in the wards, on Grand Rounds, in the classrooms, and in lecture halls.
