“On the unofficial start of residency, here’s what I’ve learned about the crisis of mental health and suicide for docs in training. We think about depression as an individual problem, but this is a systems problem. Med students are healthier than their peers. Training makes them sick.”
These words marked the beginning of Dr. Elisabeth Poorman’s recent twitter thread where she wrote about the stigma that keeps medical students and residents from accessing care in a safe, confidential, and effective way. She wrote that even when they ask for help, they often aren’t getting it.
“Sometimes they have to ‘ask their program director for permission,’ are made ‘to work an extra day for leaving for an hour,’ or are told ‘you’re not sick enough to be depressed, because your work is fine,’’ Poorman tweeted. “These are the kinds of barriers that keep people from accessing care and lead to our appalling suicide rate in medicine.”
Dr. Poorman’s complaints are grounded in both personal experience and research. It’s true that physicians begin their medical careers in better health than the general population; they experience lower rates of a variety of issues, ranging from mental health illnesses to cancer to cardiovascular disease. But of course, doctors are humans too, and are not impervious to the mental health and burnout epidemic that plagues us globally, a trend that Thrive Global has been following closely. in fact, a 2014 study found that more than half of U.S. physicians were experiencing burnout. Another study published last year reported that once in practice, the burnout rates nearly doubles for physicians and the risk of suicide becomes 1.4 and 2.3 times higher for male and female physicians, respectively. The Journal of ISAKOS recently revealed that burnout among surgeons is increasing at an alarming rate, with current reports exceeding 50%. Additionally, the divorce rate amongst surgeons is 15% more than the general population.
On a positive note, a study led by researchers at NYU School of Medicine suggests that physicians working in smaller practices may be protected from symptoms of burnout, though the researchers admit the study has its limitations (it’s only representative of small practices in New York City, and they may have underestimated the number of hours worked by physicians — a key contributor to burnout) and does not necessarily propose a resolution. Dr. Donna Shelley, MD, professor in the Departments of Population Health and Medicine at NYU Langone Health, and the study’s senior author, also acknowledged the lack of research relating physician burnout to patient outcomes, which a new study from Stanford Medicine begins to address. In it, researchers found that that “physicians with burnout had more than twice the odds of self-reported medical error.” The study also notes that burnout influences quality of care, patient safety, turnover rates and patient satisfaction. The statistics speak for themselves: Our doctors, whom many people depend on to stay alive, are not in good health.
In speaking with a variety of physicians, in different stages of their career and serving different socio-economic demographics, the reasons behind the epidemic are plenty. “The pressure in some practices to see more and more patients for shorter periods of time, insurance companies often influencing care more than the doctors, the increase [of] electronic records, and decreasing human interactions are some of the factors that I believe are contributing to burnout,” says Patricia Fitzgerald, D.A.O.M., Director and Founder of the Santa Monica Wellness Center. Others echoed her sentiment, focusing in particular on the rise of electronic medical records. This is particularly significant given the larger conversation happening around safe and healthy relationships with technology.
Rena Xu aptly illustrated the conflict in The Atlantic, comparing doctors to chefs. “To understand how burnout arises, imagine a young chef. This chef must document everything she cooks in an electronic record. The requirement sounds reasonable at first but proves to be a hassle of bewildering proportions. She can practically make eggs Benedict in her sleep, but enter ‘egg’ into the computer system? Good luck,” she wrote. “There are separate entries for white and brown eggs; egg whites, yolks, or both; cage-free and non-cage-free; small, medium, large, and jumbo. To log every ingredient, she ends up spending more time documenting her preparation than actually preparing the dish.”
And like Xu suggested in her analogy, doctors are spending less time face-to-face with patients and more time on the computer, which according to Dr. Vijay Vad, MD, may hurt the patient-physician relationship. “Patients will often say to me, You know that doctor that you sent me to? They didn’t even look at me in the eye. They were looking at the computer typing the whole time,” Vad says. Presumably, doctors didn’t enter the profession to be “sophisticated desk workers”, as one medical student called it, but the increasing demands of data inevitably make that their reality. Consider this: For every hour spent with a patient, a physician will spend two hours on clerical/administrative work, according to one study. Doctors are spending less and less time doing the things that brought them to the profession in the first place, and the depersonalization is putting them at risk for losing the heart of medicine. Perhaps more importantly though, the depersonalization is in and of itself an aspect of physician burnout. “Burnout comes from emotional exhaustion and depersonalization — which is treating patients less like people and more like objects,” says Dr. Patricia Normand, MD and Director of Wellness and Integrative health for the Road Home Program at Rush Medical Center. “Burnout is different than stress. Stress is a feeling that is activated, you’re hyper active. [With burnout,] you’re almost immobilized.”
Indeed, it can be difficult to identify what is “normal” stress and exhaustion, and what is an acute cases of burnout. Certainly, there’s a certain amount of work that’s required for a job that holds other people’s health in the palm of its hand, but to what extent? It’s increasingly important for medical students and residents to be fluent in these nuances, considering they are the future of medicine. When I spoke with Jake B., a second-year medical student, about how burnout is discussed among his peers, he said, “People don’t actively talk about it, because people are just tired. So, I don’t hear the word ‘burnout,’ but you can see it in their faces. From what I gather, it’s not just because they’re busy and in the zone. It’s because they’re tired. But it’s hard to differentiate between being tired and burnout just from looking at someone.”
While the burnout epidemic doesn’t discriminate against the medical community, neither does the stigma around discussing it. Dr. Vad, whose healthcare system recently lost one of its doctors to suicide, admitted that the medical profession is known to be tough on the topic. “You know, in training, doctors are brutal on their own kind. There’s the whole, ‘man up’ and ‘toughen up’ mentality,” he says. “When I was in my internship, I took one day off because I was sick as a dog, and I came back and people kind of looked at me like, hm.”
While Dr. Vad says he suspects that trainings and residency are likely better today, there’s reason to believe that’s actually not the case. When asked about whether stigma affects the conversation in the hospital he’s working at, one medical student said he’s noticed people don’t talk about burnout because people just do what they have to do: “It’s more of, this is the reality right now. This is what has to be done. Until policy changes, or resources change, this is what is going to happen.”
When I reached out to Dr. Poorman regarding her Twitter thread, she said she’d be happy to talk but that she avoids the word burnout whenever she can. If a patient is told that their doctor is burnt out, for example, the patient may internalize that the doctor doesn’t care about them, or that the doctor isn’t all that good at their job. “It’s a difficult word to use because of its negative associations,” she continued. “It’s hard to have a productive conversation.”
Dr. Poorman’s advocacy is personal. During her training, she experienced a major depressive episode and while she was able to recognize the symptoms of depression and get help, her peers shrugged it off as “a normal reaction” to training. “In some ways, they were right, because so many of us experienced depression in training,” she said. “But it was a misguided way to handle what was happening, to normalize a disease that was incredibly treatable.”
Perhaps, to Dr. Poorman’s point, if we replaced the word “burnout” with “depression”, doctors and residents who seek help would be met with a different response than the one she received. But given the stigma that still pervades the mental health conversation, a shift in language could still result in the same “this is how it is” response, an age-old cop-out.
At the end of every conversation, I asked what each physician hoped our readers would glean from the piece. Two answers stood out to me. Dr. Normand shared that “leaders set the tone,” pointing to Aetna’s implementation of a Chief Mindfulness Officer as a noteworthy example; and Dr. Vad had a message for physicians themselves. He urged them to take time to laugh with patients, and to pace themselves. If they don’t, he said, the people who will pay “the biggest price” are their patients. His point struck a nerve and led me to this final, harrowing thought: Doctors are rapidly becoming the patients themselves, and in this shift, we are all implicated.