We are facing a mental health crisis among doctors. According to research, more than one in five physicians report feeling depressed. Even more concerning, male physicians are nearly one and a half times more likely to commit suicide than the general male population and female physicians are nearly two and a half times more likely than the general female population.
It’s not just attending physicians who are struggling either. It is estimated that nearly half of all medical students suffer from anxiety and nearly a third from depression. Moreover, according to the American Foundation for Suicide Prevention, 28% of residents experience a major depressive episode during training compared to only 7-8% of similar-aged individuals in the U.S. population.
As alarming as these statistics are, what is perhaps even more concerning is that the true prevalence of mental health issues among medical students, residents, and attending physicians is likely much higher as underreporting has been a huge barrier to addressing the mental health needs of doctors. There are many reasons why a physician may not feel comfortable coming forward about their mental health issues, but let’s start with the culture of medicine.
1 | The Culture of Medicine
The stigma surrounding physician mental health starts early in medical training. Despite having similar rates of depression to their nonmedical peers when they enter medical school, research has shown that, on average, medical students’ mental health worsens over the course of their careers. Why is that?
To start, getting into medical school and becoming a doctor is highly competitive. Everyone is trying to achieve the highest grades, the best test scores, and the most research to match into their desired specialty. This immense pressure to perform can often lead to feelings of inadequacy and impostor syndrome which can quickly turn into anxiety, depression, and more serious mental health issues.
Next, there’s the workload. Becoming a doctor requires countless hours of studying and hard work. Aspiring physicians must endure sleep deprivation, long nights, weekends, and work after hours and on days off – and the workload doesn’t necessarily decrease when you become an attending physician either.
The average attending physician works around 52 hours per week; however, there are many specialties where working 60, 70, or even 80 hours per week is not uncommon. When medicine is the primary focus of your life and you’re working these types of schedules, it’s common for self-care and hobbies to take a back seat to your career.
Despite the prevalence of mental health issues among doctors, few seek medical treatment due to the potential consequences of disclosing mental illness. One study from the University of Michigan found that medical students with moderate to severe depression frequently agreed that “if I were depressed, fellow medical students would respect my opinions less” and that “faculty members would view me as being unable to handle my responsibilities.” Mental illness is often perceived as a sign of weakness and, as a result, many students keep their feelings to themselves and suffer in silence.
By the time a student completes medical school, goes through residency, and becomes an attending physician, these beliefs are deeply ingrained. Instead of not wanting to appear weak to their peers and instructors, now it’s their colleagues and administrators.
When you’re the one that’s supposed to be taking care of others, it can be difficult to admit that you’re struggling yourself.
2 | Medical Licensure & Hospital Privileges
The next reason physicians don’t seek help for mental illness is the fear that it will impact their ability to gain licensure. According to a 2016 study published in the Mayo Clinic Proceedings, approximately 40% of physicians reported that they would avoid getting mental health care for this exact reason.
Although it is actually against the law – specifically the Americans with Disability Act – to restrict a physician’s right to practice on the basis of mental illness, there is still a gray area that exists that can discourage physicians from seeking help.
To start, many state licensing boards ask questions regarding a doctor’s history of mental illness, addiction, or substance abuse on applications for medical licensure and renewal. Those that disclose this information may be asked to provide medical records outlining their treatment and be granted only “conditional licensure.” The intended purpose of these questions is to help protect patients by ensuring doctors are “fit” to practice; however, an unintended consequence is that they can also discourage physicians from seeking help.
The irony is that by deterring doctors from seeking mental health treatment, these questions ultimately put patients at even greater risk as physicians who are struggling with mental illness are more likely to make medical errors that they ordinarily wouldn’t make.
Lack of energy, trouble concentrating, difficulty making decisions, anger, and irritability are all symptoms of depression that can negatively impact a physician’s ability to practice. According to Medscape’s 2022 Physician Burnout & Depression Report, 23% of depressed doctors reported feeling less motivated to be careful when taking patient notes, 14% reported expressing their frustration in front of patients, and 11% reported making errors that they might not ordinarily make.
Although you may hear this and think it is justification for including these mental health screening questions, the reality is that they are causing more doctors to suffer in silence and allow their mental health to reach the point where it is affecting their work.
With mental health, like most things in medicine, an ounce of prevention is worth a pound of cure. It is much better to address mental health issues at the first signs of trouble instead of letting them progress to much more severe issues.
Doctors need to be able to get help before it impacts their ability to do their job.
To address this issue, the Federation of State Medical Boards came out with new recommendations in 2018 that urge state medical boards to omit these questions and instead rephrase them to focus only on current impairment – which is more meaningful in the context of a physician’s ability to provide safe care to patients in the immediate future. Many state licensing boards have since omitted some of these questions from their licensing applications; however, few have adopted them fully. As such, some medical license applications continue to deter physicians from seeking mental health treatment.
Even if we can get more states to adopt these recommendations, many hospital privileging applications continue to ask questions regarding mental health history as well, so there is a great deal of work that must be done before physicians can feel safe seeking mental health care.
3 | How to Decrease Stigma
If we are to make significant progress toward improving the mental health of our physicians, we must start by normalizing mental illness. According to the CDC, approximately one in five Americans will experience a mental illness in a given year and more than 50% of Americans will be diagnosed with a mental illness or disorder at some point in their lifetime. Despite this, we often treat mental illness like it only affects a small percentage of us.
Furthermore, we don’t often have stigmas for other organ systems, so why is there such a strong stigma associated with mental health? If you break your leg, nobody judges you for going to the hospital and getting it taken care of. But if you’re struggling with your mental health it’s viewed as a reflection of your character and you’re seen as weak. Does it make sense? I don’t think so. Part of the reason is that brain function and mental health are not nearly as well understood as many organ systems, and this opacity results in us attributing certain issues to character flaws rather than biochemical or pathophysiologic origins.
This stigma doesn’t just harm doctors either — it harms patients too.
Despite being victims of mental health discrimination themselves, these deeply ingrained views towards mental health can negatively affect the care that doctors deliver to patients with mental illness. When it’s ingrained in you that mental health is synonymous with weakness, it doesn’t just affect how you perceive yourself but also how you perceive others.
These implicit biases towards patients with mental health issues have been shown to negatively impact the care that these patients receive. Studies have demonstrated that people living with mental illness commonly report feeling that their symptoms are not taken seriously when seeking care for non-mental health concerns. They have also demonstrated that people treated for mental health often receive poorer care for physical health problems – likely due to physical symptoms being misattributed to a patient’s mental illness. This, in turn, creates delays in diagnosis and treatment which ultimately negatively impacts care.
As you can see, the mental health stigma among physicians is an issue that impacts all of us. This is not an issue that will be fixed overnight but one that we will have to consistently work at. We need to take a good hard look at the issue of mental health among physicians and start making strides to break down these barriers to seeking treatment. Only then will we be able to make meaningful progress towards happier and healthier physicians.