Representative image Photograph:( Zee News Network )
The culture of medicine means no crying, no sleeping, no making mistakes. And no getting help.
Certain memories are seared into physicians’ psyches. The chirp of the pager. Driving home half asleep in a postcall haze. The strangest objects found in human orifices (cockroach in the ear). The most hours we continuously stayed awake. Delivering our first baby, watching our first patient die. These are all rites of passage. I’ve found it’s easy to discuss the funny memories, but the disturbing ones are harder. Even with the closest of friends, recounting the tough moments feels like passing on a burden.
My shifts in the pediatric emergency room during my three-year residency training were a tour of human heartbreak for me: A 15-year-old needed a sexual assault kit. A 3-year-old tested positive for the dad’s meth. A man dipped his 6-year-old’s feet in boiling oil. I once had two children die within six hours of each other. After each death, I choked back the welling tears, picked up the next patient’s chart and soldiered into the next room. The culture of medicine discourages doctors like me from crying, sleeping or making mistakes. Worse, we can even be punished for seeking mental health care.
Even before the Covid pandemic, mental health issues were an occupational hazard for physicians. A systematic review and meta-analysis published in 2015 in The Journal of the American Medical Association found that roughly 29 percent of resident physicians experienced depression or depressive symptoms. For context, from 2013 to 2016, 8 percent of Americans age 20 or older had depression in any given two weeks. In a study published in August 2019, 16 percent of emergency physicians met the criteria for a post-traumatic stress disorder diagnosis. The pandemic seems to have made things worse: A survey conducted in the fall of 2020 and presented at the American Psychiatric Association suggested that as many as 36 percent of frontline physicians suffered from PTSD.
Doctors also have a high risk of death by suicide compared to many other professions. An estimated 300 to 400 physicians die by suicide in the United States every year — about a doctor a day. Last year officials at a hospital in New York confirmed that two doctors in its residency program killed themselves within months of each other.
Residency can consist of sleep deprivation, hunger, constantly being told you are not a good enough doctor and working a torturous 100-hour week, all while six figures in debt. Resident physicians routinely work on weekends and holidays, often with only four days off per month. Accreditation Council for Graduate Medical Education regulations generally do not allow resident physicians to work more than 80 hours a week averaged over four weeks, but some residents feel that they must lie on their time sheets to avoid scrutiny.
The merciless culture of medical education can revel in publicly shaming students; the practice of peppering residents or medical students with rapid-fire questions in front of colleagues and patients is called pimping.
Despite the grueling experiences, the medical profession often stigmatizes physicians who seek mental health care and erects barriers to such care. As of last spring, medical boards in 37 U.S. states and territories asked questions that could require a doctor seeking licensure to disclose any mental health treatments or conditions. These questions can be intrusive and overly general.
Ticking those boxes can feel like risking everything we have worked toward over years. It could result in the medical board reviewing our personal medical records, possibly in psychiatric and drug testing and perhaps even in having our medical license reviewed, suspended or revoked, all under the guise of establishing our professional competence. The questions have a chilling effect on doctors. In a 2017 paper, nearly 40 percent of physicians reported being reluctant to seek mental health care because they worried it would jeopardize their chances of getting or renewing their medical licenses. In a 2016 survey of female physicians, close to half said they believed they had met the criteria for a mental illness but avoided care, in part for fear of licensing boards.
When physicians summon the courage to seek help, they might have to do so at the very hospital where they work and could be recognized by patients and colleagues.
Dr. Glen Gabbard, a clinical professor of psychiatry at Baylor College of Medicine, has dedicated much of his career to treating physicians. He explained why his physician patients struggle to admit that they need care: “You’re supposed to know everything in a life-threatening crisis. There isn’t room for self-doubt,” he said.
Dr. Gabbard noted that one way doctors reach out for help is through a “curbside consult.” A friend can stop you in the hospital cafeteria and ask for a quick prescription for Prozac. Not only are doctors terrible patients, but we are often crunched for time and can give fellow physicians awful care, too. According to Dr. Gabbard, these consults can be rushed, and some psychiatrists are too quick to rely on their colleagues’ medical knowledge.
This all has helped create an underground market of sorts for physician mental health care. An often unspoken rule: If you must seek mental health care, do it quietly. Find a therapist outside your city who documents only the bare minimum in your chart, pay with cash only, don’t let it be billed to your insurance company. Make sure there’s no paper trail.
As we enter the third year of the pandemic and creep toward one million dead Americans, it’s time for American health care to recognize the toll on its doctors and what it owes. The past two years have been characterized by violent attacks against doctors, accompanied by even longer hours, sicker patients, limited hazard pay and family sacrifices. A survey conducted in the second half of 2020 found that around one in five doctors was considering leaving their practice within two years. Perhaps the saddest part is that the doctors we are often losing are the very ones we need: the gentle ones who you want holding your mother’s hand, the thoughtful, meticulous ones who call you on their day off.
The quickest and easiest remedy to this problem is to eliminate the questions about physician mental health from state licensing applications and hospital credentialing forms. This would require a fundamental shift in paradigm for the medical community. Other solutions include more physician time off, comprehensive parental leave policies and adequate hazard pay.
A former colleague has told me it is ill advised for me to even write this essay. I can feel my palms sweating as I type. But I’d rather be the doctor who confesses all instead of the one who buries the memories of dead children in bottles of bourbon or syringes of fentanyl. This essay is not brave; it is foolish but necessary. It is time we collectively agree that physicians are worthy of the same compassion we give our patients.
We, as doctors, bear witness to humanity’s ugliest and most glorious moments, so it is only natural that we are deeply moved and sometimes disturbed by it all. Acknowledging this vulnerability isn’t weakness. It makes me a better doctor. It is what allows me to hold a patient’s hand under the fluorescent lighting of a sterile hospital in the middle of the night or stroke the congealed blood out of an infant’s lock of hair.
I do not have all the answers, but I can no longer watch my colleagues suffer. Doctors’ audacity to be human must outshine the medical institution’s cold, indifferent check box.