Improving Physicians’ Mental Health By Treating A Sick Healthcare System

Physicians are in a state of crisis — a mental health crisis. Although doctors have an alarming rate of depression, suicide, burnout, substance use, and PTSD — a rate higher than the general public(1) — they are loath to seek treatment.

The collective denial of medical professionals evokes the phrase “Crisis? What Crisis?” because it depicts a false sense of security amid a calamity (see the cover of Supertramp’s 1975 album of the same title). Let’s take a closer look at the crisis and some possible solutions.

Suicide

The equivalent of one physician per day commits suicide in the United States, the highest suicide rate of any profession and more than twice that of the general population.(2) The dynamics underlying suicide are many and varied — a perfect storm of biopsychosocial factors.

New research,(3) however, suggests that information on a few key risk factors may help predict future suicide attempts with a high degree of accuracy, including a self-reported history of suicide, severity of suicidal thoughts and behaviors, and positive screens for mental disorders. A small percentage of physicians, however, will die unexpectedly by suicide and for unknown reasons.

Burnout And Depression

Approximately half of physicians nationwide are experiencing substantial burnout symptoms such as emotional exhaustion, depersonalization (i.e., negativism or cynicism), and reduced professional efficacy, causing doctors to leave medicine or think about leaving practice.(4)

Burnout is a complex and multidimensional problem, but the major culprits are high work demands coupled with too many administrative tasks, long working hours, and frustration over electronic health records.

Burned out physicians underperform on clinical and administrative responsibilities, threatening to undermine the provision of care.(5) They also are a financial strain on their organizations; the organizational cost of physician burnout can range from $500,000 to more than $1 million per doctor in terms of recruitment, sign-on bonuses, lost billings, and onboarding costs for replacement physicians.(6)

Burnout has been declared a public health crisis,(7) and the syndrome was recently added to the 11th revision of the International Classification of Diseases as an occupational phenomenon rather than as a medical condition. Unlike major depressive disorder (MDD), burnout is situation specific to and driven by chronic workplace stress that has not been successfully managed.

Yet many symptoms of burnout overlap with those of MDD (see Table 1). Mistaking depression for burnout could have dire consequences because erroneously labeling a physician’s distress as burnout may prevent or delay appropriate treatment of depression.

Substance Use

Alcohol has become a tonic for work stress. A survey(8) of 7,288 U.S. physicians from all specialties found that 12.9 percent of male physicians and 21.4 percent of female physicians met diagnostic criteria for alcohol abuse or dependence. Alcohol abuse or dependence was associated with burnout, depression, suicidal ideation, decreased quality of life, decreased career satisfaction, and medical errors.

The identification of problematic drinking and illicit drug use in physicians has been subject to considerable clinical and regulatory attention by state licensing boards, giving rise to physician health programs, which provide a comprehensive system of referral, evaluation, treatment, and long-term monitoring, resulting in five-year abstinence and return-to-work rates nearing 80 percent.(9) However, many physicians believe they have been unjustly diagnosed with a substance use disorder and their licenses have been suspended or revoked without due process. Several have shared their accounts on the Internet.(10)

PTSD

The cumulative stress of practice, or simply witnessing traumatic incidents — called vicarious trauma — may result in post-traumatic stress disorder (PTSD), especially in emergency physicians.(11) Regardless of specialty, all physicians over time are emotionally vulnerable to the ongoing details of patients’ disturbing experiences, suffering, disease, death, emergencies, and unreasonable demands. A significant change to the DSM-5 diagnostic criteria for PTSD included the addition of “repeated or extreme exposure to aversive details of the traumatic event(s),” which applies to workers who encounter the consequences of traumatic events as part of their professional responsibilities.

This new criterion supports the notion that physicians’ exposure to trauma is a job-related risk and suggests that if left unaddressed, vicarious trauma may progress to PTSD.

Road To Recovery

The road to recovery for ailing physicians begins with proper diagnosis and treatment, including maintaining a high index of suspicion for the occurrence of burnout, depression, substance use, and PTSD in predisposed physicians. Individual or peer-group therapy is helpful, along with medication when indicated.(12) Fostering resilience and incorporating the concepts of vicarious trauma and burnout in residency training programs may aid in its prevention.

Physicians, however, must first realize and accept that they need help. It is not uncommon for physicians to recognize symptoms of mental health disorders in themselves,(13) but they often are reluctant to seek professional treatment, in part because doctors who are overworked, exhausted, and discontent have normalized their unhappiness and pretend it’s not as serious as it seems.

Treatment Barriers

More physicians suffering burnout, depression, substance use disorders, and PTSD could be helped if barriers to seeking treatment were removed — especially the stigma attached to mental health treatment. The repercussions of disclosing mental illness could irrevocably affect a physician’s career; yet questions related to mental health treatment are asked on licensing and credentialing applications. Such questions frighten physicians who have sought treatment in the past or are contemplating it in the future.

Physicians are placed in a Catch-22; even though they’re encouraged to seek treatment for mental disorders, regulators may doom their careers if they do enter treatment. Regulators who have concerns that psychiatric treatment might jeopardize physicians’ ability to practice medicine create a perverse situation for opioid-addicted physicians, who are often denied the crucial recovery option of medication-assisted therapy.(14) Public disclosure of a physician’s psychiatric treatment may lead to shame and guilt, exacerbating substance abuse and symptoms of PTSD and depression.

A 2019 survey(4) of more than 15,000 U.S. physicians in more than 29 specialties found that some doctors admit they have received psychiatric treatment but have kept it a secret by driving a considerable distance from their hometown for treatment, not using insurance, and even using a fictitious name. Although healthcare organizations and academic medical centers are becoming more proactive about helping doctors who feel burned out and stressed, independent physicians often are left to their own devices to get help.

Clearly, state officials and legislative bodies should make it easier for physicians to use employee assistance programs, peer support programs, and other mental health services without fear of recrimination. Licensing application questions about a physician’s mental health should be limited and focused on current rather than past impairment. Reframing discussions about “mental illness” as “mental health” may permit suffering physicians to seek psychiatric treatment without being judged.

Leonard Su, MD, a consultant for mental health issues in the workplace, wrote, “Ideally, we would approach all doctors broadly with a focus on mental health, burnout or not. Imagine gathering a small group of doctors in a room. You tell them to talk about mental illness. Nobody speaks. Those with mental illness will certainly clam up, while those without mental illness have nothing to say. Instead, if you tell the group to talk about mental health, it at least provides a forum to discuss things that have otherwise been considered taboo: feelings, emotions, yes, mental health.”(15)

Physician wellness, now regarded as an important quality indicator,(5) cannot be achieved unless doctors are allowed to speak openly, retain respect, and avoid humiliation.

A Sick Healthcare System

Perhaps it’s not physicians who need help as much as does a sick healthcare system. It’s been said that the United States has a great “sick care” system but not a great healthcare system. Once a leader in healthcare, the United States now ranks 35th in the world.(16) Leonard Reeves, MD, a member of the American Association of Family Physicians Board of Directors, observed, “We have a disjointed, siloed, fragmented system that chops a patient into individual parts and maximizes profit.”(17) Reeves lamented, “Where did the ownership of the patient go? Where did the care of the patient go?”(17)

Multiply the angst expressed by Reeves about a million times (the approximate number of physicians practicing in the United States) and it becomes obvious why physicians’ mental health suffers. Here are just a few symptoms of a sick healthcare system:

• The loss of “touch” in medicine — literally, the abandonment of the physical examination.(18)

• Over-reliance on technology — labs, imaging, electronic records, etc.

• Generic vocabulary — client instead of patient, encounter rather than visit, physicians relabeled as providers.

• Extraordinary emphasis on data — HEDIS® measures, utilization statistics, clinical “dashboards,” billing and diagnostic codes, etc.

• Third-party/prior authorization micromanagement of services.

• The gross intrusion (and influence) of corporations in medical practice.

Remedies

A variety of remedies have been suggested for the sick healthcare system, from preventive care to patient-centered care to greater use of artificial intelligence (AI), and while there are pros and cons to all of these and other potential cures, prevention wins out — AI adds to the over-reliance on technology and patient-centered care may have the unintended consequence of putting the onus on patients to direct their treatment, possibly excluding their physician.

Preventive care, on the other hand, calls for a fundamental reordering of priorities that will result in shared values between physicians and the healthcare system. These values are central to patient care and remind physicians why they wanted to become doctors in the first place.

In the seminal article “From ‘Sick Care’ to Health Care: Reengineering Prevention into the U.S. Health System,” authors Farshad Fani Marvasti, MD, and Randall L. Stafford, MD, wrote: “Our very culture devalues disease prevention. Changing the system requires recognition of cultural, technological, and economic obstacles and identification of specific means for overcoming them through alterations in medical education, medical research, health policy, and reimbursement.”(19)

The authors offered many recommendations to heal the sick healthcare system, including:

• Introducing prevention strategies early in the medical school curriculum.

• Emphasizing motivational interviewing aimed at modifying unhealthy lifestyles.

• Addressing psychological, social, and economic determinants of disease.

• Learning about homeostasis and health in addition to traditional disease and diagnosis.

Recommendations geared toward payers and providers included:

• Enabling primary care physicians (PCPs) to become health coaches.

• Placing greater value on the role of the PCP, especially as a coordinator of patient care.

• Strengthening the presence and delivery of primary care medicine in communities.

• Reimbursing expanded health maintenance and prevention services.

• Finding innovative ways to deliver care, such as medical homes.

• Encouraging and rewarding multidisciplinary treatment teams.

• Establishing reimbursement parity for cognitive and procedural-based treatment providers.

A Broken Covenant

Additional recommendations aimed at curing the sick healthcare system have focused on issues of trust and ethics.(20, 21) The noted physician commentator Danielle Ofri, MD, observed that the medical establishment has broken its “covenant” with doctors. She remarked, “Most doctors are not burned out in the traditional sense of the word: most love taking care of patients.... The source of agony is the profession — or rather the corporatization of the profession — that has so impinged upon doctors’ ability to practice medicine. Doctors placed their trust in the medical profession, but that trust has been roundly trounced.”(20)

To regain the trust of physicians, Ofri suggested that C-suite executives witness how care is actually delivered, for example by attending clinics with doctors or making rounds on inpatient units. They also should regularly help staff the front desk and the call centers. Only by leaving the C-suite and immersing themselves first-hand in the delivery of care — both the clinical and administrative aspects — can non-medical executives experience and understand how the system thwarts the efforts of physicians bent on doing their best for patients.

Ofri concluded: “If the profession wants to earn the trust of its members, it might be time to shift the primacy of patient care out of mission statements and into actual facts on the clinical tarmac.”(20)

The implication is that solutions to burnout and curing the sick healthcare system must be grounded in ethics, enabling physicians to act in accordance with their professional values. Doctors must be permitted to advocate for issues that directly impact their patients, and organizational ethics must be aligned with medicine’s professional values, rather than vice versa. Profits must be prioritized toward giving physicians adequate time with patients and ensuring that the clinical ranks are fully staffed and not over-worked.

A “Moral” Approach

A “moral” approach to practicing medicine is, in fact, consistent with the goals of the Stanford University wellness program, considered a national model for combatting burnout.(22) The program seeks to increase professional fulfillment by improving physicians’ work experience and building an efficient, high-quality system that promotes teamwork and work-life balance.

To make physicians’ professional fulfillment a priority, Stanford’s program has ensured that comprehensive culture changes in the organization and practice environment have occurred, beginning with leaders’ commitment to wellness. A top priority is to identify and address basic inefficiencies in the system, such as the daily obstacles and annoyances that turn a clinic day into a frustrating marathon.

A call-to-action(23) by physicians from Stanford and several other institutions referenced cost analyses estimating that for every dollar spent on wellness there is a $3 to $6 return on investment, presumably linked to reduced medical errors, increased productivity, decreased staff turnover, and improved quality of care and patient satisfaction.

Table 2 lists strategies for attaining professional well-being developed by the Mayo Clinic,(24) the American Medical Association,(25) and the National Academy of Medicine.(26) All organizations emphasize the role of physician leaders in promoting wellness and creating less stressful workplaces for clinicians.

Conclusion

In the late 1970s, the British Labour Party collapsed under Prime Minister James Callaghan. His battle with trade unions sparked widespread strikes that crippled public services during the infamous 1978–1979 “Winter of Discontent.”

Upon returning to the United Kingdom from an economic summit in Guadeloupe in early 1979, Callaghan was caught off-guard by a reporter who asked, “What is your general approach [to rectifying the economy], in view of the mounting chaos in the country at the moment?” The prime minister, apparently unaware of the very serious state of affairs that had sneaked up on him, responded, “I don’t think other people in the world would share the view [that] there is mounting chaos.”(27) The headline that subsequently appeared in the British tabloid The Sun was: “Crisis? What Crisis?”

One can only hope that history does not repeat itself with respect to healthcare in the United States. Recognizing and treating un-well physicians is an immediate priority. So, too, is recognizing and treating the sick healthcare system that engulfs physicians. Failure to act on the “mounting chaos” is the real crisis in American medicine.

References

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