Physician burnout, depression, and suicide are reaching alarming rates but recently several medical organizations and schools are implementing measures to address them. It’s ironic physicians are viewed as healers yet in the process of becoming a physician their own well-being is virtually ignored – a practice that many experts say starts in medical school.
However, there are more physicians publicly sharing their stories of mental health issues and slowly breaking down the stigma that often prevents many from seeking help. Dr. Pamela Wible, who recently published a book, “Physician Suicide Letters,” wrote, “Nobody talks about our doctors jumping from hospital rooftops, overdosing in call rooms, hanging themselves in hospital chapels. It’s medicine’s dirty secret – and it’s covered up by our hospitals, clinics, and medical schools.”
Every year in the U.S., 300 to 400 physicians commit suicide, according to the American Foundation for Suicide Prevention – the equivalent of an entire medical school class. Last year, authors of a JAMA Psychiatry article called for a national response to address the high levels of physician suicide and depression in medical students. The authors’ suggestions included educating the academic community and encouraging mental health screening along with access to care for trainees. “A national commitment to support residents and fellows throughout the challenges of medical training will help ensure the well-being of future generations of physicians and their patients,” the authors wrote.
Similar concerns were voiced more than 10 years ago in 2003 when a consensus statement was published about the lack of attention to physicians’ mental health. The authors recommended "transforming professional attitudes and changing institutional policies to encourage physicians to seek help.” It seems those suggested interventions received little, if any, attention.
A fiercely competitive atmosphere sets the stage
Many experts say physicians’ mental duress begins in medical school with the vast amounts of information they are forced to learn in a short period of time fueled by a fiercely competitive atmosphere. Research has shown students enter medical school with their lowest rates of depression. This rate increases almost threefold by the end of their second year. A recent multi-institute study found almost 12% of medical students experienced suicide ideation in the previous year.
Dr. Geoffrey Young, senior director of student affairs and programs at the Association of American Medical Colleges (AAMC) told Healthcare Dive, “It’s overwhelming for students…and I think for many of them the stakes are high. Many of them have been working towards this goal for years – starting in high school.” He said that a recent study showed 14% of medical school students have moderate to severe depression. Yet, many don't seek help. A study in Academic Medicine found only 22% of medical students who screened positive for depression sought help and only 42% of students with suicidal ideation received treatment. These students said barriers to seeking mental healthcare included:
- Time constraints,
- Confidentiality concerns,
- Costs, and
- Fears their issues would be documented on their academic record.
The AAMC is very active in working with schools and identifying effective practices to enhance students’ mental health. “I think on a national level, we’re very aware of the need for schools, or medical education in general, to think about the way in which learners learn. The learning environment is not just about students, but also residents, faculty – anyone involved in a learning environment that may impact the learner. We do emphasize that it’s important for institutions to think about how stress and burnout may impact a student’s ability to function,” said Young.
In fact, the association's Council of Deans developed a statement in 2014 on the shared accountability for creating an optimal learning environment in medical education that promotes respect, resilience, integrity, and excellence. “The learning environment plays such a key role in student formation. Medical education is dependent upon an inclusive curriculum and an environment designed to promote student learning and maturation,” said Dr. John Prescott, AAMC chief academic officer in a press release. Online resources are available on the AAMC website for medical schools interested in enhancing their learning environment.
A little change can go a long way
Saint Louis University School of Medicine has been ahead of the curve and implemented their own paradigm for improving students’ mental health by a curricular change program in 2009. Dr. Stuart Slavin, associate dean for curriculum, Office of Curricular Affairs, and professor of pediatrics at the school, spearheaded those changes after a depression and anxiety survey in 2009 showed 30% of students reported moderate to severe depression and 60% had moderate to severe anxiety at the end of the first year of medical school.
Slavin published his curriculum changes, which include changes to course content, contact hours, scheduling, grading, electives, learning communities, and required resilience/mindfulness experiences. These changes were associated with “significantly lower levels of depression symptoms, anxiety symptoms, and stress, and significantly higher levels of community cohesion in medical students who participated in the expanded wellness program compared with those who preceded its implementation,” he concluded.
The numbers back up his claim. The most recent survey showed a significant drop in both depression and anxiety among medical students at 4% and 14% respectively.
Yet, Slavin said in an email, “No question that stigma is still a major problem for medical students, residents, and practicing physicians,” adding, “continued education is needed across the medical education continuum of the importance of seeking mental healthcare and that depression is not something that indicates weakness or should cause shame.”
Medical colleges are not required to report suicides to outside external sources, which many experts agree is important data that could be used to implement changes. When Healthcare Dive asked why medical student suicides aren’t tracked, Slavin replied, “It’s very difficult for me to say why it’s not being done except that the topic of suicide itself makes people very uncomfortable and it may feel safer and easier for organizations and institutions to keep these events as quiet as possible.”
Pending Missouri legislation could help provide a national assist
Missouri is the first state in the U.S. to have a bill that addresses depression and suicide in medical schools. The “Show Me Compassionate Medical Education Act,” (H.B. 1658) sponsored by Rep. Keith Frederick (R-Rolla), would establish a committee to study mental health issues, depression, and suicide in the state’s six medical schools and prohibit any medical school from restricting such a study. The collected data would be used to “implement practices to minimize stress and reduce the risk of depression and suicide for medical students in this state,” the bill states.
The Missouri House of Representatives passed the bill earlier this month. Missouri House Speaker Todd Richardson (R-Poplar Bluff) told the Missouri Times he hoped the legislation would garner support from Gov. Jay Nixon. “It’s important that if we’re going to work collaboratively we’re going to not only have to do our part, but I think the Governor will have to follow through on his part, and I think that means not holding money from these critical services.”
Steps to alleviate physician burnout
Physician burnout (defined as a combination of emotional burnout, depersonalization, and low personal accomplishment) has been increasing and a recent study found now more than half of physicians suffer from burnout with a decrease in work satisfaction across all specialties and age categories. Another study presented at the American Psychiatric Association annual meeting last year by Dr. Emily Holmes, a psychiatry resident at the University of North Carolina Healthcare (UNC Healthcare), found 70% of residents suffered from burnout, 17% suffered from depression and eight residents reported suicide ideation. “There is abundant evidence that burnout contributes to increased medical errors, decreased patient satisfaction and decreased productivity and employee retention. Hospitals and practice administrators should be very interested in improving the well-being of their physicians for all these reasons,” Holmes told Healthcare Dive in an email.
The American Medical Association (AMA) recently launched its STEPS Forward series to address resident and fellow burnout. This includes five steps to create a wellness culture:
- Create a framework with a team of wellness advocates;
- Develop a program;
- Foster individuals;
- Empower faculty and trainees to confront burnout; and
- Create a sustainable culture of wellness and resiliency.
Holmes applauded the AMA for their “excellent recommendation that medical practices establish wellness as a quality indicator." However, she opined some of the STEPS Forward recommendations to improve physician resiliency “are admirable but unrealistic for resident physicians practicing within the current training system," citing residents' unpredictable work schedule. In addition, Holmes said her research has convinced her the problem of burnout is not just related to the number of hours worked. She points to increased computer time for EHR tasks and a lack of life-work balance. “I feel that interventions that bridge life and work including on-site childcare and exercise facilities, and a flexible coverage system that allows residents to reliably attend to their own medical and mental health appointments are crucial.” She supports the use of scribes, discharge planners, and case managers to provide assistant to residents.
There are increasing efforts to address physicians’ mental health starting in medical school and continuing through residency and into their professional careers. It’s being discussed more in the media and physicians like Wible are shining a light on physician suicide. The AMA plans to launch a STEPS Forward program for physician suicide and if Missouri passes its medical education bill, perhaps other states will follow.
It seems as if the practice of healing is at a tipping point. “If we simply maintain the status quo, our profession will suffer. We will be unable to recruit bright young adults to the field, and we will continue to tragically lose our colleagues to suicide,” Holmes concluded.