Mental Health & Physicians
Cut me up, open my insides, and in between the gobbets and gunk, the goo and giblets, you’ll find out that I want to be a doctor.
It’s a little dream sometimes blocked by the hurdles of my tongue and other times swallowed in bits to be digested by my stomach, if only partially. Then it’s excreted, and the cycle continues with another mouthful of words, and here it is again, the unfettered, unclean, and slimy truth that sticks to anything I touch: I desire to be a physician.
But such honesty leaves me bare and vulnerable like a baby torn from the womb. This is not an idle metaphor. My experiences, significant moments, and possible accomplishments can be viewed under a suspicious, ever-magnifying microscope, just as a baby is. Moreover, I’m scared. The truth is terrifying. When I waddle, it makes me poop my pants. When I try to speak, it makes me gurgle. And there in front of me as I write it out in full, one letter kicked off shaky fingers followed by another, it screams for its life.
Why? I’m afraid of what it means to be a doctor, that I’ll never figure out anyways because how could I if not for shadowing another physician, and even that shows only the outline, never the light itself, and everything is changing so fast, and how will I keep up, and what about all those other wonderful potential applicants, and they look so calm and collective, and I need to be like them, I need to be anything but myself – and so on until somehow, maybe, I make it into the chaotic future and I transcend the barriers and hoops and manage to swim through current that I can neither control nor influence directly, only to find out that I don’t like being a physician.
Worst yet is the possible realization that I’m a mediocre caregiver and I do more harm than good.
These howling doubts and uncertainties define most futures. Yet physicians and those wishing to be them seem to deny such gnawing human emotions. They swallow their anxiety, which only makes them more anxious. Of course, I’m no different. The honest sentence I began this piece with took weeks to write correctly.
But physicians have an unspoken darker world that is hardly sterile and transparent. Simply said: while a student may be killing themselves in their studies to become a doctor, it turns out they may be setting themselves to do the same as a physician later.
Male physician suicide rates are more than twice than the regular population (1). Female physicians rates are three times as high. Among medical students, suicide is the second leading cause of death, after vehicular accidents (2). Depression is stratospherically high in the medical profession, affecting approximately 12% of males and 18% of females.
The reasons for these high incidences of mental health and suicide ideation – note that doctors are also 1.4-3.2 times more likely to actually be successful in their suicide attempt – are many (3, 4). Compared to all careers – except possibly soldiers – physicians, nurses, and other healthcare positions carry the weight and responsibility of other lives. While each uniquely deal with certain aspects of care, it is the physicians who often shoulder the gravity of a life as a primary caregiver. Should something go wrong, it is often they who independently face the professional, moral, and legal consequences (5). These worries are only exacerbated by the elements of stressful training – from the long hours, dealing with death and dying, estrangement from possible support networks such as family, and financial worries (the approximate average debt for medical students was $175,000 in 2012) (6).
Yet, equanimity – a term used by William Osler in 1889 to describe the ideal physician (7) – is stressed in spite of these pressures. As a result, a culture of chronic helplessness is fostered. Study after study show that while there is an alarming frequency of mental health concerns among doctors, little is offered in way of support (8, 9, 10). Instead, there is a constant fear of being withdrawn from practice, a general worry about the confidentiality of admitting any form of anxiety and health-related issue, and the possibility of stigma in a community that should, it seems, be weary of the illness that such stigma may cause.
These worries aren’t just born from paranoia, however. Physicians who have reported their depressive symptoms have consistently observed the consequences, some of which included license limitations, discriminatory employment practice, and further cycles into depression (8, 10). In many instances there has also been loss of hospital privilege and prestige, and a significant stake of one’s professional advancement (11). And this altogether forgets the numerous complex difficulties and consequent stressors female physicians have in trying to balance their career and a potential family life; that is, the time necessary to take maternity leave, possible daycare services, and wonders about trying to nurture a child (12).
These tied ends – the emotional and psychological trauma coupled with the inability to voice it – are not only detrimental to the physician. The patient suffers similarly. A physician who is clouded by depression or is exhausted by burnout will be more probable to make erroneous judgments on care (9, 10).
Perhaps, similarly, my worries caused me to erroneously allow them to manifest themselves here. In a way, I worry about that. And doing so makes me worry more.
This cyclic realization is key. What is forgotten in the hoopla of medicine is that as doctors, physicians are teaching themselves how to be patients. In treating death, they see it in themselves. It is no coincidence then that when checking for a pulse, doctors often feel their own before the patient’s.
Yet if they cannot have time or space to grasp the weight of such a realization, if they cannot experience the intersubjectivity of healthcare for what it is – a recognition that they will die and that so will others, even if they try to prevent it – then they will lose the chance to know what it means to live. That is, they will only see death in themselves and others, not the life before it.
Current research does not leave room for this possibility. It is cold and pedagogical. It hints at an anesthetized world when really it’s a bloody messy out there. Worse yet is that while the academic papers noted here often illustrated higher incidences of suicide ideation, depression, mental illness, and burnout than the regular population, they became experiments in disappointment. Each paper I read offered suggestion after suggestion, recommendation after another. But as the years passed, the studies compounded, and the reviews were done because some researcher had to be kept busy somewhere and somehow, I discovered that nothing has changed. Treatment wasn’t being supported. Doctors were still dying. And no one could answer the question: who heals the healers?
Admitting one’s human frailty, in recognizing the very real difficulties of navigating either the aspiration or already achieved goal of being a physician, is what I believe is the first step in answering such a question. Sharing one’s narrative, from one’s failures to one’s successes, one’s happiness to one’s sadness, allows connectivity between all those undergoing a similar journey. Such vulnerability is not a weakness. It is one’s only strength against sickness that is often random, stress that is unyielding, and a life where one can’t help but wonder what the heck is going on anyways.
By Kacper Niburski
- Lindeman S; Larra E; Hakko H; Lonngbist J. A systematic review on gender-specific suicide mortality in medical doctors. Journal Psychiatry. 1996. 169.
- Andrew L; Brenner B. Physician suicide. Medscape. July, 2014.
- Frank E; Dingle AD. Self-reported depression and suicide attempts among U.S. women physicians. Am Journal Psychiatry. 1999. 156: 1887-94.
- Schernhammer ES; Colditz GA. Suicide rates among physicians: a quantitative and gender assessment (meta-analysis). American Journal Psychiatry. 2004. 161: 2295-302.
- Balch CM; Oreskovich MR; Dyrbye LN. Personal consequences of malpractice lawsuits on American surgeons. Journal of American College Surgery. 2011. 213: 657-67.
- How do I pay for medical school. Association of American Medical Colleges. < https://www.aamc.org/students/aspiring/paying/283080/pay-med-school.html>
- Sinha P. Why do doctors commit suicide. The New York Times. < http://www.nytimes.com/2014/09/05/opinion/why-do-doctors-commit-suicide.html?_r=0>
- Givens JL; Tjia J. Depressed medical students’ use of mental health services and barriers to use. Academic Medicine. 2002. 77: 918-21.
- Guille C; Speller H. Laff R. Epperson N; Sen S. Utilization and barriers to mental health services among depressed medical interns: A prospective multisite studi. Journal of Graduate Medical Education. 2010. 2: 210-14.
- Center C et al. Confronting depression and suicide in physicians: A consensus statement. Journal of Americam Medical Association. 2003. 18: 3161-6.
- Shanafelt TD et al. Suicidal ideation among American surgeons. Archives of Surgery. 2011. 146: 54-62.
- Verlander G. Female physicians: Balancing career and family. Academic Psychiatry. 2004. 28: 331-36.
Image taken from http://well.blogs.nytimes.com/2010/10/07/when-doctors-get-depressed/