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Physician, Heal Thyself

by Tegan Clarke

 

A friend of mine shares that starting an SSRI for her anxiety has been life changing. Another that he’s grateful to have had the ability to step away for a few weeks to grieve his late father. And another that she has been able to seamlessly maintain the care she has been getting for more than a decade because of the psychiatric care freely available to students through the school.

My friends and I openly and unabashedly discuss our mental health with one another. We are a part of a generation of physicians and trainees who have cut our teeth in one of the most trying times to be in medicine in recent memory. As such, we are acutely aware of the importance of physical and psychological well-being. We do not view being givers of care and receivers of care to be mutually exclusive. Many of my classmates take advantage of confidential resources available to us, including psychiatric services, without any sense of shame. The shame appears instead when we are motivated – or even tacitly encouraged – to lie on state licensing applications that ask intrusive questions about the ways that we have taken care of ourselves.

We are encouraged by the school to take advantage of available resources to promote our own wellness. Yet state licensing boards may penalize us for this very thing when we graduate. AMWA, the AMA, and increasing numbers of other medical societies urge state medical boards to refrain from asking about past mental health diagnosis or treatment, and the Federation of State Medical Boards (FSMB) has discouraged the use of ADA-impermissible questions by state medical boards (1). But until all states have made that change, it’s hard to not feel that, by using the resources available to us, we are walking into a trap. About 90% of state medical boards still include questions about an applicant’s mental health, some reaching back well before medical school, regardless of whether that illness causes any current impairment (2,3).

The journey to become a physician is difficult in so many ways. The emotional and psychological demands of training are only amplified for students with marginalized identities, who report higher rates of burnout, mistreatment, and discrimination during its course. In one study, almost two thirds of female residents reported mistreatment based on gender (4). 16.6% of respondents reported racial discrimination from patients and their families, attending physicians, hospital staff, and/or co-residents (4). In another study, LGBTQ+ residents were significantly more likely to experience discrimination than their non-LGBTQ+ peers. 5 Burnout and suicidal thoughts have repeatedly been shown to have a dose-dependent relationship with exposure to mistreatment (4,6,7). While these studies also signal a deep need for a cultural change in medicine, we cannot wait passively for this to occur while the COVID-19 pandemic fades and threatens a worsening physician mental health crisis in its wake. As our medical workforce grows increasingly diverse (8), we must equip ourselves with the tools needed to better insulate ourselves from the extraordinary demands of our careers.

Despite improvements, medical training remains a formidable path. During our training, we trade our time, energy, and relationships for work hours equivalent to two full-time jobs and sleep deprivation so intense as to cause functional impairment (9-13). Those same working conditions predispose us to mental illness (14) – the treatment of which so many of us fear professional repercussions that we ultimately receive no treatment at all. Others may choose to hide a mental health diagnosis like a shameful secret (15). It is little wonder, then, that although students enter medicine with mental health on par with or better than age-matched peers, we are three times more likely to kill ourselves (16,17). Half of medical students report burnout and a third have depressive symptoms (17,18). One in nine report suicidal ideation during medical school (17). Suicide is the second-leading cause of death among resident physicians (19). And things hardly improve after the completion of our training: suicide accounts for 4% of all physician deaths in the United States (20). No matter how many doctors we train, how could we ever truly replace our colleagues who die every year by suicide?

Within this grim picture, there is room for hope. More states’ medical boards are updating their license applications to be consistent with FSMB recommendations, which includes evaluating the need to ask about mental health diagnoses and reframing those questions to focus on current impairment. 1 While these changes may not affect the structural challenges we face in the profession, they can at least make available more resources with which to weather them. Within the culture of medicine, we can work to normalize mental health, decrease stigma, and encourage help-seeking among our peers and colleagues.

In 2020, the American Medical Women’s Association launched the initiative Humans Before Heroes, to address these very issues. When physicians are looked up to as heroes, it can be easy to forget that they are humans, with the same vulnerabilities just like any other person. I encourage you to join AMWA’s Humans Before Heroes initiative and be a part of the movement working to remove the barriers to care that prevent us from healing ourselves.

 

Tegan Clarke is a medical student at the University of New Mexico School of Medicine (Class of 2024). She is passionate about health equity, progressive policy, and political advocacy. When she’s not in the hospital or studying, she can be found drinking coffee and painting in the company of her beloved dog, Sandwich. 

References

1. Saddawi-Konefka D, Brown A, Eisenhart I, Hicks K, Barrett E, Gold JA. Consistency Between State Medical License Applications and Recommendations Regarding Physician Mental Health. JAMA. 2021;325(19):2017–2018. doi:10.1001/jama.2021.2275

2. Taylor NW, Porter C, Rivera-Rodriguez M, Miller ISK, Desmarais N. Mental Health Disclosure Questions on Medical Licensure Applications: Implications for Medical Students, Residents, and Physicians. Acad Med. 2022;97(8):1117-1122. doi:10.1097/ACM.0000000000004682

3. Jones JTR, North CS, Vogel-Scibilia S, Myers MF, Owen RR. Medical Licensure Questions About Mental Illness and Compliance with the Americans With Disabilities Act. J Am Acad Psychiatry Law. 2018;46(4):458-471. doi:10.29158/JAAPL.003789-18

4. Hu YY, Ellis RJ, Hewitt DB, et al. Discrimination, Abuse, Harassment, and Burnout in Surgical Residency Training. N Engl J Med. 2019;381(18):1741-1752. doi:10.1056/NEJMsa1903759

5. Heiderscheit EA, Schlick CJR, Ellis RJ, et al. Experiences of LGBTQ+ Residents in US General Surgery Training Programs. JAMA Surg. 2022;157(1):23-32. doi:10.1001/jamasurg.2021.5246

6. Cheng MY, Neves SL, Rainwater J, et al. Exploration of Mistreatment and Burnout Among Resident Physicians: a Cross-Specialty Observational Study. Med Sci Educ. 2020;30(1):315-321. Published 2020 Jan 7. doi:10.1007/s40670-019-00905-z

7. Fresán A, Guízar-Sánchez D, Yoldi-Negrete M, Robles-García R, Tovilla-Zárate CA, Saracco-Álvarez R. Gender Differences in Professional Adversities and Mental Health Among Surgical and Nonsurgical Medical Trainees: An Internet-Based Survey [published online ahead of print, 2023 Feb 18]. J Surg Educ. 2023;S1931-7204(23)00033-8. doi:10.1016/j.jsurg.2023.01.013

8. Shahriar AA, Puram VV, Miller JM, et al. Socioeconomic Diversity of the Matriculating US Medical Student Body by Race, Ethnicity, and Sex, 2017-2019. JAMA Netw Open. 2022;5(3):e222621. Published 2022 Mar 1. doi:10.1001/jamanetworkopen.2022.2621

9. Choshen-Hillel S, Ishqer A, Mahameed F, et al. Acute and chronic sleep deprivation in residents: Cognition and stress biomarkers. Med Educ. 2021;55(2):174-184. doi:10.1111/medu.14296

10. Zhang S, Ring J, Methot M, Zevin B. Medication Errors in Surgery: A Classification Taxonomy and a Pilot Study in Postcall Residents. J Surg Res. 2021;264:402-407. doi:10.1016/j.jss.2021.03.007

11. Choshen-Hillel S, Ishqer A, Mahameed F, et al. Acute and chronic sleep deprivation in residents: Cognition and stress biomarkers. Med Educ. 2021;55(2):174-184. doi:10.1111/medu.14296

12. Rahman SA, Sullivan JP, Barger LK, et al. Extended Work Shifts and Neurobehavioral Performance in Resident-Physicians. Pediatrics. 2021;147(3):e2020009936. doi:10.1542/peds.2020-009936

13. St Hilaire MA, Anderson C, Anwar J, et al. Brief (<4 hr) sleep episodes are insufficient for restoring performance in first-year resident physicians working overnight extended- duration work shifts. Sleep. 2019;42(5):zsz041. doi:10.1093/sleep/zsz041

14. Fang Y, Lodi S, Hughes TM, Frank E, Sen S, Bohnert ASB. Work Hours and Depression in U.S. First-Year Physicians. N Engl J Med. 2022;387(16):1522-1524. doi:10.1056/NEJMc2210365

15. Fletcher I, Castle M, Scarpa A, Myers O, Lawrence E. An exploration of medical student attitudes towards disclosure of mental illness. Med Educ Online. 2020;25(1):1727713. doi:10.1080/10872981.2020.1727713

16. Coentre R, Góis C. Suicidal ideation in medical students: recent insights. Adv Med Educ Pract. 2018;9:873-880. Published 2018 Nov 29. doi:10.2147/AMEP.S162626

17. Ranasinghe PD, Owusu JT, Bertram A, et al. Depressive Symptoms and Burnout Among Medical Students: a Prospective Study. J Gen Intern Med. 2022;37(1):64-69. doi:10.1007/s11606-021-06765-x

18. Dyrbye LN, Moutier C, Durning SJ, et al. The problems program directors inherit: medical student distress at the time of graduation. Med Teach. 2011;33(9):756-758. doi:10.3109/0142159X.2011.577468

19. Yaghmour NA, Brigham TP, Richter T, et al. Causes of Death of Residents in ACGME- Accredited Programs 2000 Through 2014: Implications for the Learning Environment. Acad Med. 2017;92(7):976-983. doi:10.1097/ACM.0000000000001736

20. Yasgur B. A tragedy of the profession: Medscape physician suicide report 2022. Medscape. March 4, 2022.

Holly Brolsma

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