Prioritizing physician mental health

By Emily Margosian, Assistant Editor, January 1, 2022

On Oct. 28, 2012, life changed for Pamela Wible, MD, a family practice physician in Eugene, Oregon. “I found myself in the second row of a memorial service for the third doctor we lost to suicide in my small town,” said Dr. Wible, now an advocate for physician suicide prevention. “I started counting how many doctors in my life I had lost to suicide. I put the pieces together and realized the issue was much greater than this one man. It captivated my interest as a healer. My job description is to ease human suffering and prevent death, and I wanted to figure out what was going on. I’ve never lost a patient to suicide, I’ve only lost physicians.” 

According to the National Institute of Mental Health (NIMH), approximately one in five adults in the U.S. experienced a mental illness in the past year, with an increase in observed prevalence over the last decade. However, studies of physicians, including medical students, residents, and fellows often show a higher prevalence of mental illness, with a higher suicide rate than that of the general population. Despite this, the idealized image of the physician as a caregiver rather than a care receiver, along with the stigma associated with mental illness, often dissuades many physicians from seeking care. “We’re helpers, not people who ask for help. That’s our whole identity, so it’s really hard for physicians to admit they’re struggling,” said Dr. Wible. 

This month, DermWorld speaks with physicians and mental health advocates from across the house of medicine to discuss available mental health resources for physicians, the importance of prioritizing mental health and wellbeing, and proposed changes regarding mental health, licensing, and credentialing.

Factors impacting physician mental health

From the start of their careers, physicians must undergo the stressors of medical training, and from there, navigate long hours, high expectations, and heavy administrative burdens, as well as the need to adapt to a rapidly changing health care environment. These factors, along with a tendency toward perfectionism, can significantly impact mental health. “High-achieving people tend to gravitate toward medicine. They set a high bar for themselves in all areas of life. We know that people who are perfectionists tend to shame themselves much more than others for their weaknesses,” explained Smita Gautam, MD, a child and adolescent psychiatrist at Northwestern University. 

High internal expectations, combined with the external pressures of a profession notorious for never taking sick days, can produce burnout and even lead to depression or other long-term mental health consequences. Daniel Saddawi-Konefka, MD, MBA, an anesthesiologist-intensivist at Massachusetts General Hospital, works in a department that takes a positive approach to provider mental health. However, in medicine in general, he argues that “there’s definitely an ingrained stigma where there’s the idea that you just keep working. If you cough up a lung, you shove it back in, and you get back to work. It’s a really destructive mentality, but it certainly is something that seems to be propagated.” 

“There’s definitely an ingrained stigma where there’s the idea that you just keep working. If you cough up a lung, you shove it back in, and you get back to work. It’s a really destructive mentality.”

However, while physicians may be disinclined to address mental health concerns out of fear of personal and professional repercussions, failing to do so not only compromises their own health and wellbeing, but also potentially that of their patients. “As physicians, whether in training or in practice, we are sort of notorious for putting our patients and our work first, which in the end is actually in nobody’s best interest,” said Jonathan Ripp, MD, MPH, dean for well-being and resilience and chief wellness officer at the Icahn School of Medicine at Mount Sinai. “If you as a trainee or a practicing physician are suffering from a mental health condition and are not addressing it, you’re not only doing a disservice to yourself, but you’re also probably not doing your job very well.” 

With the introduction of COVID-19, the stress of caring for patients amid an ongoing global health crisis has produced what has been dubbed a ‘parallel pandemic’ of extreme burnout among medical providers. “Physicians have a very strong work ethic, and typically we’re masters of disguise in the sense that we’re not allowed to admit we have mental health issues, or we could lose the career we’ve worked decades for,” said Dr. Wible. “The pandemic has given the public a window into the souls of physicians. There is this incredible level of relatability they have now to a group of people who have historically been rather stoic and emotionally inaccessible.”

Institution-based resources 

As physician mental health has begun to gain more traction in the public eye, an increasing number of health care institutions have turned their attention to the mental health and wellbeing of their workforces. “Three years ago, I was maybe the fourth or fifth chief wellness officer in the country, and now there are about 35. The role has come about largely because of the recognition that burnout is associated with a lot of concerning outcomes, both on the individual level, and quite frankly, on the optimal functioning of a health care system. All the outcomes that health systems focus on, such as quality of care and patient satisfaction, are influenced by the wellbeing of the workforce,” said Dr. Ripp. 

In 2020, Mount Sinai opened its Center for Stress, Resilience, and Personal Growth, where all health system employees can access a range of mental health services for free, including screening and treatment. According to Dr. Ripp, the center was launched in response to the significant mental health and psychological consequences health care workers had experienced due to COVID. “Effectively, everyone within the Mount Sinai Health System — medical students, graduate students, postdoctoral fellows, resident physicians, clinical fellows, faculty, and employees — can access free mental health care,” he explained. 

Often, health care workers can be reluctant to seek help due to perceived stigma and professional retaliation. According to Dr. Ripp, Mount Sinai has taken steps to build trust and a sense of confidentiality among employees who opt to utilize mental health resources provided by the institution. “There are a number of things we do, including a fair bit of communication to de-stigmatize mental health,” he said. “October was Depression Awareness Month, and we held a panel of speakers, including leaders throughout the health system, who shared their personal stories dealing with mental health. We believe this is an incredibly powerful tool to show people that their colleagues have also dealt with mental health issues, have received treatment, and are doing better. Not only are people speaking up, but they’re showing it hasn’t interfered with their career — in fact, they’re highly successful.” 

Seeking professional mental health care

Depending on their individual needs, physicians may want to speak with a professional mental health provider. This can be a potentially daunting task, regardless of one’s familiarity with the health care system. In the aftermath of COVID-19, several physician-facing directories and hotlines have emerged that promise streamlined and anonymous mental health services. 

One such option is the Emotional PPE Project, an online directory that connects health care workers with mental health professionals free of charge. Established in March 2020, “The idea was that the real shortage was not PPE and ventilators, but the mental health and resilience of the health care workforce,” explained Saddawi-Konefka, MD, MBA, co-founder of the Emotional PPE Project. “One of the things we wanted to be sensitive to is all the barriers that come with accessing mental health care — everything, from cost, to decision-paralysis, to insurance concerns. For providers, there are also concerns around malpractice insurance, licensing, and credentialing. So, we wanted to make sure we were setting up something that was free and confidential.” 

Site visitors select what state they’re from to ensure they connect with a therapist licensed to practice in their state. The therapist then directs treatment without fees or insurance. “We have profiles for each of the volunteer therapists along with their contact information, so we aren’t collecting any information from health care workers. We do ask our therapists if they’re being used and have heard different anecdotes. Some users have seen their therapists regularly for weeks, if not months, and others just needed someone to talk to once or twice,” said Dr. Saddawi-Konefka.

Another available option is the Physician Support Line, a free, national support line established by a group of psychiatrists in March 2020, also in response to COVID-19. “This was around the time when no one could get PPE and physicians were wearing the same masks for seven days at stretch. It was something that this generation of physicians, and even the generation before us, had never experienced,” said Dr. Gautam, co-founder of the Physician Support Line. “It felt like many of my colleagues on the front lines were in a war zone, and I had immense bystander guilt because I was able to shift to telehealth right away due to my outpatient work as a psychiatrist.” 

According to Dr. Gautam, since its inception, the Physician Support Line has fielded roughly 2,500 calls from physicians and is staffed by roughly 250 volunteer licensed psychiatrists. “Since then, we’ve been ongoing. Physician mental health has always been a problem, but COVID was sort of the straw that broke the camel’s back.”

To mitigate any privacy concerns, the process is fully anonymous; callers do not have to share their name, state, or specialty. “A lot of times, physicians don’t have anyone to talk to, and they may not want to utilize employee assistance programs or talk to anyone in their state because there’s a risk it will somehow be reported,” explained Dr. Gautam. “Because this is a national helpline, a doctor from Florida could be talking to a psychiatrist in Washington. So, there’s anonymity and confidentiality that opens the door for physicians to call.” 

Legal considerations 

For many physicians, the decision of whether to seek mental health care involves additional legal consideration. From a statistical standpoint, nearly 40% of physicians say they’d be reluctant to get mental health care out of concern over receiving or renewing their license (https://doi.org/10.1016/j.mayocp.2017.06.020). 

In many states, applications for medical licensure and renewal involve questions pertaining to mental health that could potentially threaten or complicate one’s ability to practice. Dr. Saddawi-Konefka has seen these challenges play out among his medical residents. “On top of stigma, there are all these other barriers. If you apply for licensing, there are many states that will ask you about any mental health conditions, whether they’re related to impairment at all,” he said. “If you have a leave of absence, they’ll ask you questions about it. I’ve had residents, who for very reasonable circumstances with no impairment of practice, have had to go and sit in front of the board; they’ve had to get lawyers to go with them just to try to get limited licenses. Even that’s just one element. There’s credentialing at the hospital level or trying to get malpractice insurance. We’re at a place where people were burdened even before COVID, and there are all sorts of inappropriate barriers to accessing mental health care due to stigma and real repercussions of seeking help.” 

As far as ongoing reform efforts regarding licensing procedures, in 2018, the Federation of State Medical Boards (FSMB) released recommendations for updating licensing applications. Per these new guidelines, questions about physicians’ mental health diagnoses violate the Americans with Disabilities Act (ADA). However, action from state boards has been mixed. 

“Nobody should ever fear losing their career because they admit they have occupationally induced anxiety, depression or PTSD.”

“More than half of state medical boards have made changes to their licensing applications, often adopting our recommended language verbatim, removing questions about mental health and substance use altogether, and adopting ‘safe haven non-reporting’ language which allows applicants for licensure to not report current or previous involvement with state physician health programs or other appropriate treatment pathways,” said Joe Knickrehm, vice president of communications at the Federation of State Medical Boards. “While many state licensing boards are able to make changes to their licensing applications without seeking legislative change, in some instances legislative change or approval from oversight bodies is required.”

A 2021 JAMA report authored by Dr. Saddawi-Konefka and others from the Emotional PPE Project found that only one state, North Carolina, followed all the FSMB’s medical licensing recommendations regarding mental health. The report also found five states — Alaska, Florida, Idaho, Kansas, and Wyoming — were not consistent with any of the FSMB’s recommendations for medical license applications (325(19):2017-2018).

“Medical boards have a lot of stigmatizing language in applications for licensure. It’s discriminatory and shouldn’t be there. In many states, each time you apply to renew, you’ll have to disclose any mental health issues. Certainly, that’s not the case for any other job, but it happens here,” said Dr. Gautam. 

Dr. Wible agrees. “Nobody should ever fear losing their career because they admit they have occupationally induced anxiety, depression, or PTSD. These questions should be reformatted as competence questions. It’s a breach of privacy and should be illegal to pry into somebody’s mental health issues on a job application.” 

According to Knickrehm, the FSMB continues to work with state medical boards and partner organizations to support the adoption of their policy recommendations at the state level. “We have been promoting a model started by the North Carolina Medical Board that involves removing questions about health — including mental, physical, and substance use — and replacing them with an attestation that the applicant acknowledges the importance of safeguarding their own health and will seek treatment if it becomes necessary. This model has recently been adopted by additional states,” Knickrehm said. 

Peer-to-peer support  

Among resources available to physicians, many mental health advocates emphasize the value of peer-to-peer support both in reducing stigma and raising awareness within medicine. 

According to Dr. Gautam, this was a driving factor behind the launch of the Physician Support Line. “We are all psychiatrists, and we also went through medical school, residency, and fellowship. We’ve been in the same boat. If you’re talking to a therapist or a social worker, they may have no clue what goes on in an ICU. Our interventions are usually drawn from different therapeutic techniques, but we’re not providing therapy. It’s pure peer-to-peer support,” she said. “Part of the reason why we only accept calls from physicians as opposed to all medical providers is because physicians have a hard time asking for help unless it’s specifically designated for them. This gives them implicit permission to say, ‘this is for me.’” 

Since 2012, Dr. Wible has operated her own suicide hotline for physicians, something she says she never planned to do. “I don’t have any staff. People can contact me through my website, and I call them back. I try to call everyone back the same day, and if I sense any crisis at all, I try to call them back within a few minutes,” she explained. “I’ve spent thousands of hours on the phone with physicians telling me things they’ve never told anyone else in their lives. So, I have a unique under-the-radar view of the dark side of our profession.” 

Dr. Saddawi-Konefka offered his own advice for physicians struggling to maintain their mental health. “I think physicians tend to not seek help until things really feel like they’re broken. I don’t have a good dermatology-specific analogy, but if someone’s blood pressure is 160 over 90, they’re probably going to be okay acutely, but long-term that’s going to have consequences,” he said. “The idea that we have to wait until the fuel tank is completely empty before we seek help has to change. For me personally, I noticed last year I was running at about 85%. I was getting more irritable with my kids, and I knew I could do better. So, I went and started seeing someone, and it’s been tremendously helpful. I just want to encourage people that even if you’re feeling only 85%, that’s a good trigger to try to see someone, you don’t have to wait until you’re totally broken.”

Additional DermWorld Resources