A Growing Need to Heal the Healer

The authors of this post are Giselle Appel, a second-year MD student, and Yochai Re'Em MD, a psychiatrist based in New York City.

We are now two years into the pandemic, and despite the public messaging aimed at moving beyond Covid-19, healthcare workers remain overwhelmed. The trauma sustained during the pandemic has undoubtedly established its foothold, leading to complicated feelings about personal identity, moral conflicts, and clinical responsibilities. These burdens weigh heavily, and when left unaddressed can lead to setbacks in personal and professional settings, impacting medical and psychological wellbeing, and potentiating preexisting concerns about substance use.

With long hours and stressful, often traumatic, shifts, many are at risk for substance use problems in an attempt to cope with the sense of hopelessness one might experience while working in healthcare. It should be noted that substance use has affected healthcare workers long before the pandemic hit – 13% of male physicians and 24% of female physicians will develop an alcohol use disorder or dependence during their careers.

As trainees, we have witnessed the tendency of fellow trainees to minimize our own needs. It is far easier to talk about feeling “tired” or “disengaged”, rather than honestly sharing the psychological and emotional impact that being overworked and underappreciated might have on us and how it might manifest — such as through depression, anxiety, or problematic substance use. Academic medicine perpetuates this in many ways. The medical training institution often speaks of the importance of making decisions that support wellness, yet when such a decision might compromise added productivity, we are left feeling stuck and most of us continue to prioritize work at the expense of that which sustains us. We witness our peers forging on with the status quo, oftentimes not bearing witness to the sacrifices being made behind the scenes, which adds further pressure onto the system.

The term “burnout” has become a common lexicon within healthcare as it relates to how trainees describe themselves. For many, it serves as a placeholder for mental health or substance use problems, such that they might avoid the risk of stigma, retaliation, or helplessness arising from a lack of resources or access to care. Using this language ultimately leaves many feeling trapped when more debilitating symptoms arise. Hiding these truths to avoid negative labels can lead to internalization of low self-worth, which might lead to worsened symptoms, or one to relapse or initiate the use of substances in order to cope on their own. Others, with few places to turn, might resort to taking their own life.

About every day in the United States, a physician commits suicide — twice as likely compared to the general population. According to a 2021 survey by The Physicians Foundation, 20 percent of physicians said that they knew of someone who had considered, attempted, or died by suicide during the first year of the pandemic. A recent large survey of healthcare workers in Australia found one in ten experienced thoughts of suicide or self-harm during the pandemic. Unfortunately, this isn’t unique to the years of the Covid-19 pandemic. Data predating the pandemic suggests that female nurses were at twice the risk of suicide compared to women in the general population.

Breaking the Silence

Silencing occurs early on in medical training. For physicians to obtain licensure in any state or district of the United States, they must fill out a comprehensive application that asks questions regarding their psychiatric history and mental health. Due to the vague nature of these questions, many physicians feel reluctant to disclose or seek help in the future when they might be struggling. Depending on the responses by the applicant, the medical boards then have the authority to investigate, requesting deeply personal and private psychotherapy or medical notes from the physician’s clinician. Under some circumstances after view, the physician might be required to undergo supervision or worse be barred from clinical duties and responsibilities.

There is evidence that this practice might be changing for the better, however. A 2021 study compared the recommendations of questions by the Federation of State Medical Boards (an organization that advises state medical boards) with how state medical boards currently frame the question of mental health diagnoses on their licensing applications. One of the recommendations by the FSMB is to frame the question as it relates only to current impairment (i.e. questions are limited to conditions resulting in impairment) or only current diagnosis (i.e. questions are limited to conditions within the last two years). Since 2017, the number of state medical board applications that have framed the question as relating to “current impairment” has increased from 41% (21 states and territories) to 72 % (41/54 states and territories) in 2021.

When trainees are silenced, they’re not the only ones who are impacted; internalized stigma impacts negative patient outcomes. If medical institutions encourage physicians to “pull themselves up by their bootstraps” or fail to acknowledge the manifestations of mental health (such as increased substance use or psychiatric disorders), there will be worse care delivery and attitudes toward patients. Physicians already generally view patients with psychiatric and substance use disorders as worse than the majority of medical conditions, and such attitudes result in worse quality of care. How can we expect a workforce to treat patients with dignity and encourage their mental health well-being when the institutions fail to deliver the same for their employees?

Creating a System that Supports its Workers

Creating more supportive work environments, particularly with senior leaders speaking up and sharing their own stories can shift this negative discourse. Vulnerability breeds trust among a team and can serve as a powerful tool for encouraging others to not suffer in silence surrounding their use. Sharing personal narratives might encourage other physicians to reflect on their own journey, how it impacts them currently as a physician, and be more self-compassionate when stressors feel insurmountable. Holding events where faculty disclose their experiences with personal mental health struggles might encourage younger trainees to not be afraid to seek help before it becomes harmful.

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One way we can protect our healthcare workers is to encourage therapy even when things are going “well”. Institutions can facilitate greater space and time to process the events over the past two years. This might include psychotherapy, counseling, and perhaps medications, to help improve worker well-being. In that same vein, if it is determined that an individual might benefit from more intensive support or treatment, the institution should encourage the option of paid time off. This already exists as paid family leave at most locations, however, the individual must not have their career penalized if they should pursue this option.

Healthcare trainees and workers cannot suffer in silence any longer. While they may be depicted as heroes and the backbone of our communities, they should not be held to superhuman standards. As the pandemic enters its third year, the healer must be given opportunities to heal themselves, if our health system is to survive.

If you or someone you love is contemplating suicide, seek help immediately. For help 24/7 dial 988 for the National Suicide Prevention Lifeline, or reach out to the Crisis Text Line by texting TALK to 741741. To find a therapist near you, visit the Psychology Today Therapy Directory.