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Physician Wellness

December 2009

By Bonnie Darves, a Seattle-based freelance health care writer.

Career Resources Editor’s Note: Physicians are not immune to health problems. In a practice environment that is increasingly challenging and complex, dealing ineffectively with anticipated and unanticipated stressors can lead to depression and maladaptive coping strategies, such as disruptive behavior and psychoactive substance-use disorders. Aligning professional activities with personal core values and entering into mentorship and trusting collegial relationships early in one’s career can be instrumental in successfully dealing with stress, achieving work-family balance, and appreciating the joys of practicing medicine.

— John A. Fromson, M.D., Associate Director of Postgraduate Medical Education at the Massachusetts General Hospital

Challenges to personal health and work-life balance abound, and resources to address them are becoming more plentiful and accessible.

Because of their experiences in practice and changing societal attitudes about illness prevention, physicians today are more cognizant about the importance of achieving and maintaining general personal wellness than their older colleagues might have been. Younger physicians are more inclined to take care of the physical aspect of wellness by exercising and eating well than their counterparts of 20 years ago. Increasingly, many older physicians are “seeing the light” and recognizing the importance of being attentive to physical well-being, if only as a means of preserving stamina.

Unfortunately, neither trend is any assurance that doctors – regardless of age or career stage – will be as attentive to personal well-being as they are to their patients’ health. By and large, physicians still operate in the “patient first, self last” mode, even if that means spending less time caring for themselves, pursuing once cherished avocations, or connecting with family and friends. In large part, this is because that’s what they’ve been taught or what their models have exhibited.

A growing body of research indicates that medical professionals are especially prone to burnout, which is simply defined as emotional exhaustion and depersonalization. And physicians often ignore or overlook unhealthy behaviors or signs of depression.

A recent survey of more than 7,000 U.S. surgeons, whose results were published in the Annals of Surgery in September 2009, found that 40 percent of surgeons had symptoms of burnout, and 30 percent screened positive for depression. Other studies of physicians and residents have also found high rates of burnout and substance-use disorders, often attended by an unwillingness to seek help.

The sad supporting statistic in this regard is that suicide rates among physicians are higher than those of the population in general. Between 300 and 400 U.S. physicians take their lives each year. Noted Mick OreskovichOreskovich, MD, director and CEO of Washington Physicians Health Program in Seattle, “One third of all physician deaths are by their own hands. The highest incidence of suicide is in the first year after retirement, and the second highest incidence occurs in the first year after training.” Male physicians take their lives at twice the rate of their nonphysician counterparts in the general population, and for female physicians, the rate is four times that of nonphysicians. That is thought to be attributable in some part to the extra parenting pressures that women assume and the untenable situations they find themselves in when trying to meet the needs of patients and children.

“I think that the last person in the room to recognize depression is the depressed physician,” said Dr. Oreskovich, a general and addiction psychiatrist. “They think they’re OK because they’re coming to work every day and doing their jobs. Unfortunately, even if their colleagues and peers were concerned that something was up, no one approached them.” Those colleagues, understanding well that a diagnosis of mental illness could have potentially serious repercussions for practicing physicians, turn a blind eye. Although the same “don’t tell” situation is less likely to happen with substance abuse than it once was, the so-called conspiracy of silence and the “good ol’ boy network” still persists in that regard.

“It’s really instigated by what physicians see on the applications. Many ask: ‘Have you ever suffered from a mental illness or received substance abuse treatment?’” said psychiatrist Luis Sanchez, MD, director of Physician Health Services, a subsidiary of the Massachusetts Medical Society. “Physicians are afraid to tell the truth because they’re afraid it will have repercussions.”

That’s what prevented one Southern anesthesiologist (whose name was withheld by his request for anonymity) from seeking treatment “before I was forced into it,” he said. “I thought I had my substance use ‘under control,’ but those around me suspected otherwise. And when I was approached by colleagues, my first thought was: ‘What about my license?’”

Today, three years after treatment, the anesthesiologist is “nothing but grateful. I have my life and my future back, and I confronted some ghosts,” he said. The forced treatment made him look squarely at his addictive behaviors across the board and recognize that the roots of his substance abuse went back well into his past. “I used alcohol to ‘escape’ and to deal with stress – even as a teen. I compensated by becoming a workaholic, and on many levels, I now realize I didn’t like myself.”

Physician and novelist Michael Palmer, MD, who practices addiction medicine and was an associate director of Massachusetts’ physician health program, has seen that pattern play out in many physicians. “Lack of self-esteem lies at the bottom of many addictive behaviors such as overwork, overeating, promiscuity, [and] risk-taking behavior… as well as alcohol and drug use. Each excess brings some relief from their sense of disease, but only temporarily,” he observed. “Those with a genetic predisposition to alcoholism get in trouble once they start drinking because of a loss of self-control.”

Recognizing Physician Distress; Resources to Address it Improving

Unfortunately, fears about the ramifications of divulging problems or seeking help remains “a very big issue,” Dr. Sanchez conceded. That’s the bad news, but there is an emerging upside — in the big picture, at least. At the hospital and community level and in academic centers, physician wellness resources are becoming more plentiful. “Every state now operates a physician health program, and we’re all getting better at offering the full range of services,” Dr. Sanchez said, beyond only working with physicians referred for behavior or substance issues. “We have to, because the stress or complaint may have nothing to do with what the issues are. In our program, we want anybody who needs help to come in the door because we want to know what’s going on out there.”

Dr. Oreskovich also sees positive developments. He thinks that the 85-hour work-duty requirements placed on residents and other related initiatives have brought the issue of burnout to the forefront. “The younger physicians are already demonstrating some good boundary rules. They can say no a lot easier than their older colleagues,” he said. “There’s a positive effect on them because they can say, ‘I want my patients to have the best possible care, but I need to take care of myself, too.’”

Of course, that may not translate into positive behavior later, and physicians who end up in work-life imbalances often do so unwittingly. Most physicians who come to physician wellness programs – involuntarily or voluntarily – aren’t the “bad docs” the media portrays, Dr. Sanchez contended. They’re mostly struggling with balance and boundary issues.

“The majority of physicians we see referred for disruptive behaviors are very good doctors. They’re very committed physicians who want to do the best they can. But they haven’t learned the tools or developed the skill sets to learn how to address conflict and make changes,” he said. “In the doctors we see – young and old – the commonality is that they probably have the personality characteristics that they’re not very resilient and don’t know when to back off.”

Fortunately, national-scale resources for physicians struggling with career dissatisfaction or burnout, though once rare, are on the rise as well. The Vanderbilt University Center for Professional Health in Nashville, for example, offers a three-day CME program for distressed physicians once every three weeks. It’s always full, noted the center’s co-director, Charlene Dewey, MD, MEd, and although the majority of participants have been referred to the program by employers or licensing entities, “self-referrals” are increasing.

“We see a whole range of issues, from workplace conflict or burnout to stresses due to finances or debt,” Dr. Dewey observed. “And there are a lot of participants struggling with that ‘can’t take a break’ issue, that altruistic, sometimes narcissistic behavior that says they must do it all.”

It was encroaching burnout in tandem with behavioral problems that brought one young emergency medicine physician to the Vanderbilt program. She had a history of snapping at fellow staff members and making inappropriate – and sometimes angry – remarks to and about patients. When she made a disparaging comment one day when a patient’s family was within earshot, the hospital told her that she would have to get help if she wanted to keep her job.

“At first, I thought it was unfair. After all, there were times that I worked 12 out of 14 days, and there were a few night shifts in that mix,” she recalled. “And everyone kept telling me to ‘do better’ and control myself, but no one told me how.” The course was a real eye-opener for her. “It changed everything. It’s actually helped me more with my whole life [and not] just my job.” She realized, for example, that she had no buffer zone between her feelings and her actions, and her perception of the situations she encountered wasn’t “necessarily real.” She also discovered that her own history set her up for certain behaviors. As a child, she was discouraged from telling her parents she was not feeling well unless it was serious. And in either case, she didn’t receive any special attention for being ill. She realized she was expecting the same from patients and had little sympathy for those who came in with minor issues.

“One thing the course taught us was to look at what the rules were when we were growing up and how that affects our responses. When I realized that patients were breaking ‘my rules,’ not theirs, it changed my approach,” she said. “Even though I went unwillingly, I see how the course makes our profession better one physician at a time. I think that physicians who have issues should consider this kind of course before they get into trouble and have to clean up the past, because that doesn’t feel good.”

Outside of the academic setting, a growing number of health care institutions and medical practices are implementing targeted physician wellness services and employee assistance programs, offered through companies such as Affinity Health and Physician Wellness Services. On the community level, physician support groups are becoming more prevalent, including groups created to support doctors who are struggling with workplace or career issues other than substance dependency. The Massachusetts Medical Society, for example, runs three support groups a week, one of which is devoted entirely to workplace stress. The website of the Federation of State Physician Health Programs (www.fsphp.org) is a resource for contact information for state physician health programs and the services they provide.

“Our groups are very popular, but I admit that it’s hard to get those groups going because of both confidentiality issues and time-priority issues,” Dr. Sanchez said. For physicians who end up in serious straits and don’t have local resources readily available, organizations like Doctors With Depression are trying to bridge the gap. The organization’s “Struggling in Silence” campaign is part of a nationwide outreach that aims to explore policies and the culture of stigma that prevent physicians and medical school students from seeking help for treatable mood disorders.

“Medical students and young physicians are much more inclined to take advantage of services now, especially since many institutions are offering free counseling,” observed Laurie Raymond, MD, director of the Office of Advising Resources at Harvard Medical School in Boston. “But they’re still concerned about stigma issues, so we need cultural shifts in that regard.”

Stressors: Many Are Age-Old. Some Are New.

Some of the issues that challenge physician wellness are as old as the profession itself. The quest for and personal expectation of perfection — that mistakes and failures of any magnitude are not acceptable — tops that list, all sources agreed. The perfection ethic starts early on and is effectively supported by the culture of medicine, which exacerbates the problem.

“Individuals who make it to medical school are already clearly trained high achievers, and a lot of physicians come to the field with the motivation of ‘mastering’ healing,” explained Dr. Raymond. “So if they experience failure or run up against personal or life limitations, it’s a shock to them.”

Increasingly, societal expectations of perfection in medical care and physician performance in particular may be making that particular stressor worse now than it once was, Dr. Oreskovich contended. The more public nature of error reporting and wider dissemination of such incidents, while beneficial in quality improvement, can be an obstacle to wellness and work-life balance, he said, because physicians face perfection pressures in all quarters.

“The inability to provide perfect care is definitely a stressor, especially for young physicians. When something happens, it’s devastating to them because they will find fault in any crack or crevice,” Dr. Oreskovich said. “A lot of ‘perfect children’ become health care practitioners.”

John-Henry Pfifferling, PhD, founder of the Center for Professional Well-Being in Durham, North Carolina, identified another dimension – lack of reward.

“Physicians’ expectations of what the world is and what it expects of you – from colleagues to lawyers to patients and insurers – always hovers on the unrealistic,” he observed. “So if you happen to be perfectionism-oriented, reality shock sets in.” That in turn causes what Dr. Pfifferling describes as a “clash of expectations” when physicians leave training and head into practice. “The physician expects appreciation and praise from colleagues, staff, and patients, but often they don’t get that, even if they work longer and harder.”

That then leads to erosion of engagement and cynicism, he observed, and ultimately to burnout, which Dr. Pfifferling describes as a facet of grief largely attributable to “mismatch between the spirit and the core passion and purposes of an individual.” When there is no outlet for discussing those feelings, physicians (who by nature think they should be invulnerable and stoic) and caregivers first and foremost, may suffer more and yet be more isolated than their counterparts in the general population, he added.

“I think that unfulfilled expectations of what medicine is all about is a common stressor in young doctors,” Dr. Palmer added.

In Dr. Sanchez’s view, the lack of rewards may be compounded by an inability to talk about troubling workplace experiences or encounters. Both frequently emerge as issues in the workshops his organization offers, and they’re often at the root of behaviors that get physicians in trouble. “One thing we talk about is the importance of timely feedback and how to give it,” he said. “You might want to wait 24 hours before you give feedback — whether it’s negative or positive — but don’t put it off indefinitely. Unfortunately, it’s not something we as physicians are trained to do. Making shifts in how we communicate and relate is an essential part of being a doctor, but it’s not often emphasized.”

The push for efficiency, the corporate influence on the practice of medicine, and reduced control in the delivery of care are relatively new stressors. While mid- and late-career physicians may find these difficult to deal with, physicians just entering the profession have had early exposure to these issues and can better deal with them as anticipated stressors. Mentorship and building trusting, collegial relationships early in a physician’s career can be instrumental in effectively dealing with unanticipated stress and achieving work-family balance, as well as appreciating the joys of practicing medicine.

The American Foundation for Suicide Prevention operates a hotline that responds to troubled individuals and links callers to local resources [(800) 273-8255]. (One needn’t be suicidal to call.)

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