Being a Doctor is a Health Hazard

Doctors are in trouble. Grueling training schedules have long been considered part of the culture of medicine, but suicide and depression rates are taking their toll, and some are saying enough is enough.

If outdated hospital cultures are making patients worse off, imagine what stale hospital policies are doing to doctors themselves.

Actually, you don't have to think too hard at all. Studies, stories, and first-person accounts detail almost daily the stress that medical residents and physicians are under.

"You don't miss, you don't get sick," Daniel Pacheco, MD, medical director for Arizona Care First Health Plan told me. "Patients come first at all costs."

Before joining Arizona Care First Health Plan, Pacheco was chief medical officer for Banner Behavioral Health Hospital in Scottsdale, AZ. He is trained as an internal medicine physician, but was a therapist for seven years before earning his MD.

Pacheco's experience in helping others helped him cope through the challenges of medical school, but he says it also opened his eyes to residents and physicians who suffer silently. "I could see behind the veneer," he says. "We're instructed to take care of people and yet, we are in trouble."

Suicide
Physicians are in trouble. According the American Foundation for Suicide Prevention (AFSP), 300 to 400 physicians die by suicide each year, and depression rates in medical students are as much as 30% higher than in the general U.S. population.

Earlier this year, in response to the suicides of three residents in 2014, the Accreditation Council for Graduate Medical Education (ACGME) Council of Review Committee Residents (CRCR) published a set of resident wellness suggestions.

The 28-member panel of CRCR members took an introspective approach to determining what kind of resources residents need. Personal relationships with mentors were found to play a significant role in residents' resiliency. That was one of five recommendations the group outlined in March in the Journal of Graduate Medical Education:
               

• Increase awareness of and destigmatize depression
• Provide confidential access to depression treatment
• Formalize peer and faculty mentoring
• Promote supportive culture
• Develop resident wellness opportunities

The ACGME is hosting a two-day, invitation-only symposium in Chicago next month on resident wellness. Spokewoman Emily Vasiliou told me that the primary goal of the event is to start a national dialogue that leads to positive, transformation change.

"From the symposium, we will find out what our next steps are," says Vasiliou.

Around 150 physicians and residents from hospitals and academic programs are among those who were invited. The event will take place in Chicago November 17 – 18.

Safety
Pacheco's medical training has taken place over the last 10 years, after the ACGME reduced duty hours for residents in response to patient safety issues. But, what about the safety issues for physicians?

"You make mistakes when you're mentally exhausted, when you're depressed, and when you're burned out," he says. Pacheco agrees that there is generally more awareness about mental health issues in residency. "But in the real world," he says, "what I find is that no one wants to talk about it publicly because you don't want the hospital thinking you have a problem and looking into your license."

When physicians think about what they have to do to get help for depression, suicide ideation, or a substance abuse problem, not only do they have to overcome the fear of a stigma among peers, but they are often fearful of having the issue documented.

State-run physician health programs are meant to be a safe harbor for physicians in crisis, but some are being criticized and even sued over their heavy-handed practices. Pacheco says he has told physicians to head to a private therapist and pay cash.

"Some people didn't like to hear that, but if you pay cash, it doesn't get coded, it's not in the EMR system that record is between you and your therapist," he says. "Some people don't trust the employee assistance program because it's associated with work. They think, 'What if I see one of my colleagues?' "

Pacheco's solution is practical. It is also an unfortunate testimony to the grip of shame that accompanies mental health issues. Breaking down the barriers to access, payment, insurance and treatment are fundamental steps that can change the way mental and behavioral health issues are viewed.

Stigma
It is no secret that mental and behavioral health issues carry a stigma among patients. The fear stops them from getting treatment. Left to linger, those issues can become acute.

Physicians are in a unique position to challenge that stigma. Unfortunately, the deeply regarded culture of medicine may not have room for such enlightenment. The long hours and exhaustion are part of paying your dues as a doctor, especially if you're a new doctor. It's time to consider shedding those traditions and recognizing them for what they are: dangerous.

"When you have a license, you don't want anybody to know you have a problem," says Pacheco. "So people downplay it, hide it, and try and deal with it themselves. That adds to the stigma."

Strategies
Pacheco uses his unique experience as a therapist and internist to speak up on the importance of doctors recognizing their own mental stress and getting help for it. He's delivered lectures and speeches to physicians and resident groups in the U.S. and China.

"After I do my talk, there's silence," says Pacheco. "But, I will have a line of people who want to talk to me."

What Pacheco and others argue for is not only awareness and treatment but also understanding that depression, OCD and substance abuse, for example, can be treated.

UCLA's David Geffen School of Medicine established a mental health program for its residents that has many of the characteristics the ACGME's CRCR recommends. Called the UCLA Mental Health Services for Physicians in Training (MHSPT), the 24-hour program provides confidential off-campus counseling. No written records are kept and it is autonomous from the dean's office and the hospital.

The American Foundation for Suicide Prevention's program highlighting depression and suicide among physicians is a good resource for help. There are warning signs of suicide:

• Talking about wanting to die
• Looking for a way to kill oneself
• Talking about feeling hopeless or having no purpose
• Talking about feeling trapped or in unbearable pain
• Withdrawing or feeling isolated

There is also help. The national suicide prevention lifeline 800-273-TALK (8255) is a free, 24-hour hotline that provides support, as well as local resources and information for the person and/or families in crisis.