Monday, December 26, 2016

Helping Doctors Get Help

Every year, roughly 400 doctors and medical students die from suicide.  To put this in perspective, there are roughly 100 medical students in a medical school class, and schooling takes four years: each year in the United States, we lose an entire school worth of doctors to suicide.  For more perspective: there are 141 medical schools and 31 osteopathic schools in the country; educating students takes time, money, and a tremendous amount of resources, and we have a doctor shortage.  Losing a school worth of physicians each year is an awful thing.  Furthermore, surveys have shown that about 30% of medical students have significant symptoms of depression, a percentage notably higher than the general population.

This seems a bit odd: medicine is still a profession that is held in esteem.  People work for years to get into medical school and it's a very competitive process.  Those who have made it are, for the most part, lucky.  Academically, they are the cream of the crop: motivated, hardworking, organized, driven, and among the few who get the privilege of working in a field where you help people and earn good money.  And as someone who treats patients, I will tell you that it truly is an honor to be a doctor and a psychiatrist; I am grateful for the career I've been able to have and for the flexibility and diversity it has afforded me as both a healer and writer. 

So why the high rates of suicide and depression?  The blame has been put on the rigors of training, the demoralization of doctoring, the disappointments and the tremendous stress.  And doctors are people, they  get psychiatric illnesses for the same reasons others do: genetic predispositions, personal losses, stress and a fear of failure, sleep deprivation, or devastation over a bad personal or professional event.  We still don't know why some people are resilient in the face of difficulties and others are not.

And doctors hesitate to get help: after all, mental illness is stigmatized and doctors may be asked about their mental health issues for licensing and for jobs.  I knew one medical student who took Prozac-- it helped with anxiety and irritability, though she never had a full blown episode of disabling depression-- and said so on health forms when she started residency. She had to explain and get documentation that she was capable of working.  Obviously, we don't want someone in the throes of a disabling psychiatric episode treating patients, but we also don't want people to avoid getting care because they might be called out on it, or even lose their license when they have treatable conditions.  It seems it might be better to encourage people with psychiatric and substance abuse disorders to get help rather than to have them treating patients when they aren't at their best or to have them die from suicide. It's a mixed bag, because many psychiatric and substance abuse problems can be hidden, especially by someone who is able to show up at work and function reasonably everyday, and treatment is generally available to this group of professionals in that they have insurance and resources.

The 'stigma' of quiet mental illness is still a bit odd to me.  As a medical student in New York City in the 1980's, psychiatry wasn't just about being mentally ill, it was, to some extent, about self-examination.  Psychiatrists who did psychotherapy were expected to have psychotherapy, and psychoanalysts were required to undergo an analysis.  

As students, we were told that the school had a mental health service which provided an evaluation and 10 visits with a private practice psychiatrist (and then the student could pay for more if they wanted), or treatment with a psychiatry resident for very low fees.  Many of my classmates were very open about being in treatment, and people went because they were stressed, disturbed about relationships, or having more serious psychiatric issues.  During my psychiatry rotation, the chief resident wrote his analytic hours on the board in the nursing station so he would not be disrupted, and I sat in a class where one resident said to another, "Hey Bob's not here because he's starting therapy today."  One of my classmates had a serious suicide attempt and was treated in the ICU.  It wasn't someone I knew very well and I know none of the details.  What I do know is that this classmate graduated and went on to a prestigious residency program.  Google let me learn that my classmate is now, over 25 years later, a physician at a top academic institution.  Today, I'm not sure if that outcome could happen.  

This month, I saw an article in one of the psychiatric newspapers calling on licensing boards not to require doctors to report past episodes of psychiatric illness, only present episodes, in an effort to encourage doctors to get treatment.  Really? Why single out psychiatric disorders?  Shouldn't reporting requirements encompass all disabling disorders?  Do you want your surgeon seizing while he's operating on you?  Or having his blood sugar drop?  Do we really care about the fact of an illness?  Shouldn't we care more about whether it impairs a physician?

So I was pleased to read this month's newsletter from the Maryland Board of Physicians: there was a specific discussion on mental health/substance abuse treatment that noted that Maryland's licensing board asks only about current conditions (including physical conditions) that impair a physician's ability to practice.  It lists some resources for getting care, and notes that this is not the same as mandated treatment in the case where it's come to the attention of the Board that someone has a health issue which obviously impairs them-- one that has been reported by a third party to the Board as being a risk to patient safety.  

So Maryland docs, if you are quietly depressed, anxious, suicidal, or wonder if those happy blips in your mood mean you have bipolar tendencies -- go for it and get help.  Tell who you want, and don't tell who you don't want.  Will decreasing stigma or reporting requirements lower suicide rates?  I hope so.  And finally, if you're in Maryland and need a private practice psychiatrist to see you quickly, don't forget our resource at where psychiatrists with availability within two weeks may list their practice.  It's a free service for both shrinks and patients.


R said...

I don't see Pamela Whibble's blog on your blogroll, she's one of the few voices in the blogoshpere frequently writing about physician suicide and mental health. She's definitely worth a read.

Unknown said...

The main agenda of Asset health in ca is to develop illness prevention strategies to eradicate or decrease health risk factors and promote health.

Dinah said...

R -- thank you, I added her blog to our blogroll. ~Dinah

clairesmum said...

As a nurse who has taken antidepressant medications for 30 years, and is sometimes open with individual colleagues, I would not have been able to function as a nurse (or wife, mother, or other adult human roles) without medication..and a lot of psychotherapy.
BUT I have never had emergency psychiatric care, I do not have some of the chronic health conditions that are often adult sequelae of traumatic childhoods that include sexual abuse, I have never attempted suicide.
I started treatment in the mid a state where acknowledgement of mental health issues was not a totally taboo subject, where I had good insurance and supportive husband.
Now, I don't know how the same situation would play out...but I do know that we need fewer barriers to treatment, not more of them. Early treatment is much more effective...with any chronic illness, the longer it progresses without interventions aimed at stabilization of the patient and control of progression the higher the cost to the patient and to society.

Joel Hassman, MD said...

What happens if and when Trump gets Universal Health Care as the substitute for ACA?

Think more doctors will be happy and invested?

Politicians setting health care standards, so sad to read and watch.

Independence and autonomy, crushed and dumped into the sewage system of what is forced on us as popular, easy, and convenient.

I'm sure the May APA meetings will address this issue...

Joel Hassman, MD