COVID-19 has shed light on a pre-existing condition in medicine – our health care system has failed to tend to its workforce’s well-being. While generally privileged, physicians are an underserved population about their own mental health care.
Numerous articles and countless interviews have focused on the pandemic’s deleterious impact on physicians’ mental health and well-being. But this is not a new problem, nor is it caused by a lack of resilience. Rather, many health care institutions and training environments are oppressive, limit autonomy, and systematically wear down the hard-fought resilience and stamina of its finest. When a physician finally considers mental health care, the barriers to accessing that care, both external and internalized, are even worse. For example, medical license applications in most U.S. states ask questions about mental health impairment in the past five years, lifetime history of mental health diagnosis and treatment, or ask invasive questions about mental health and substance use. Fewer than half the states ask either no or only a few questions limited to current impairment. Beyond the license application, intrusive hospital credentialing requirements are another hurdle physicians face where any history of mental health care is subject to extreme scrutiny.
Couple this with the insidious messaging in medicine that needing “help” is a sign of weakness. It should not surprise anyone that over 400 physicians die by suicide every year and over 50 percent of physicians report burnout and emotional distress was before the pandemic. This implicit message is a double whammy – you, doctor, should be impervious to needing mental health care, but should you succumb to such distress, your career will be in jeopardy if you seek help.
Notably, the vast majority of physicians endorse their work as meaningful. This highlights one of the pervasive problems in medicine wearing down physicians’ vitality. Caring for patients is not the problem. Physicians are buoyed by caring for patients, and this is what keeps them in clinical medicine long after their mental, physical, and social health starts to suffer. Being expected to care for more patients in a single shift or a single week than one feels they can do safely is the problem. Limitless boxes to click in the electronic record to generate revenue and relentless administrative work are the problem. Practicing primary care in a manner that feels superficial and unbearably time-constrained, so that the root causes of suffering and disease can’t be addressed, is the problem.
Physicians trying to be resilient in the face of these chronic stressors, coupled with a mindset of perfectionism which was inculcated during training, allows the voice of self-criticism to flourish. Many physicians achieve excellence by repeatedly bowing at the altar of self-criticism and demanding more and better for themselves. This behavior is rewarded throughout training, but once training ends, this well-oiled mechanism is extremely hard to turn off. It doesn’t stop simply because the evaluations, feedback, and grading has stopped. The cognitive and behavioral habit loops of the self-critical voice have been formed. My clinical practice has been exclusively caring for physicians for the past few years, and the most pernicious threat I work to defuse is a negative internalized voice – the voice of not being, doing, enough.
A fortuitous side effect of COVID-19 is the writings, videos, and social media outcries by health care professionals coalescing into one common message: Pay attention to our needs. So how can we pay attention to the mental health needs of physicians?
Health care organizations need to provide physicians access to high quality, private, flexible, low barrier, and expert mental health care. Employee Assistance Programs (EAPs) cannot provide this as they are almost always staffed by the lowest licensible clinicians, without expertise working in medical settings or familiarity with the culture of medicine, and offer limited flexibility in scheduling. Mental health clinicians have been in short supply due to overwhelming demand during the pandemic, making finding a clinician through insurance a formidable task. Furthermore, insurance requires a diagnosis to cover mental health services (see point above about license and credentialing applications and the risks of having a diagnosis documented).
I applaud many internal efforts in health care organizations to stand up for peer support programs and/or develop their internal own mental health supports, often through psychiatry departments. However, many physicians – especially anyone with leadership aspirations or leadership roles – do not want to broadcast vulnerability inside their own organizations. Internal programs often minimize or overlook potential conflicts of interest and the extant needs of their own mental health workforce. No one is immune.
The recent and massive rollout of digital mental health tools also fall short of a solution. While low cost and highly scalable, digital solutions are potentially good for improving early detection and overall emotional intelligence, these tools are not specific enough to physicians’ unique occupational exposures and hazards in their day-to-day work. Moreover, physicians who dedicate their time, attention, and presence, day in and day out to patients, also want to be seen, to be heard, to feel cared for and to be understood, especially during times of distress. They do not want their emotional toil and potential solutions to be distilled into a 5-minute video or guided meditations on an app.
Ideally, we would appreciate medicine as an occupation that is both an extreme privilege and one with known occupational exposures that can be mitigated through trauma-informed models of education, assiduous attention to the workforce’s well-being highly specialized, flexible, low barrier, and private mental health care.
Christine N. Runyan is a psychologist.
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