In 2014, an emergency medicine resident opened a personal email and was shocked to see it briefly mention the death of another resident physician from a different training program. Unofficial group chats ensued amongst her co-residents, discussing the vague email. Suspicion arose that the resident has died of suicide. His particular death was never addressed outright in a formal or public manner at the hospital, department, or residency level. All agreed with the protection of privacy, but the unexpected death of a fellow trainee haunted those left behind. Not long after, an NYU medical student tragically died of suicide. While some official emails were sent with this case, they seemed muted and incomplete.

The truth is that many physicians have died by suicide. This is devastating, and sadly all too common. We often see these deaths superficially mentioned via email, on social media, or discussed in the hospital halls. We sense a lack of comfort speaking openly about our own crisis. We can’t ask, “What happened to that person? What was the system failure that could have prevented this death?” Without these questions being asked and discussed openly, there is no hope for answers given that could perhaps help us to understand how to better protect ourselves and each other.

We are given perfunctory reminders to “seek support” and encouraged to meditate, do yoga, or sleep well. Days or even hours later, though, providers are expected to return to work as normal, allowing the broken system to creak forward.

Now, we all face another crisis in COVID-19, which is adding to the already untenable mental health toll on providers. Doctors worry about caring for increasingly ill patients while inadequately protected from exposures, resource allocation, and health disparities, bringing the virus home to their families, and more. We witnessed a tragic example just this week of the devastating combination of COVID and inadequate mental health support, as our community mourned the loss of an emergency medicine colleague to suicide. We worry that more avoidable deaths will follow unless something changes.

How did this happen? Our government and health care system has failed to prepare for COVID-19.

As a medical profession, we also failed to create a system that protects the mental health of doctors and other clinicians, who now face one of the toughest experiences in their careers. This pandemic could result in a catastrophic exacerbation of what is already a mental health crisis for doctors.

Three mental health syndromes frequently reported in doctors and other health care clinicians are burnout, post-traumatic stress disorder (PTSD), and depression.

Burnout for doctors has been described in academic medical literature as well as the mainstream press. Burnout is the feeling of emotional exhaustion, depersonalization, and work inefficiency. Forty-two percent of surveyed doctors in the United States reported burnout. Some stressors for doctors are the electronic medical record, increasing administrative burden, long shifts, and lack of control. A pandemic likely further exacerbates several of these risk factors and may cause additional unique stressors – though there is less literature around this.

PTSD is described as a condition that can be caused by witnessing or experiencing a traumatic event.” Being an emergency medicine doctor is a risk factor. Approximately 15% of emergency medicine doctors meet diagnostic criteria for PTSD, versus 3% of people in the general U.S. population.

Most concerning, doctors are at high risk of depression and suicide. An estimated 40% of all doctors screen positive for depression – five times the national average for all adults over age 20 (8%, per the CDC). Approximately 14% of doctors have considered suicide, and the rate of completed suicide for doctors is double the national average for adults.

Doctors struggle to detect mental illness in themselves or colleagues. For generations, the culture of medicine has also normalized high stress, physical exhaustion, and emotional fatigue as acceptable and expected aspects of training and practice. Suffering is viewed as a badge of honor and makes us legitimate, despite its often-malignant nature.

Doctors in training still regularly work over 24 hours without sleep. Sleep-deprived humans function similarly to those who are intoxicated with alcohol, and struggle to perform even basic, low-stakes tasks. Unfortunately, the practice of medicine regularly involves very high stakes, with human lives hanging in the balance. Residents will often speak up about the difficulties of their training and be met with a response from senior physicians themed around, “I had it worse.” Residents are then left feeling completely unsupported.

So why don’t doctors just get help? Well, it’s complicated. Many do not feel comfortable disclosing mental health concerns to others, given fear of shame and concern for confidentiality. This can lead to isolation and increase risk of outcomes such as substance abuse, self-medication, and suicide. Formal reporting requirements and invasive questions about mental illness can affect a doctor’s ability to obtain or renew a medical license. Documented diagnosis and treatment can also challenge the ability to obtain life and/or disability insurance.

But there are working solutions.

In 2014, “Project Safe Space” was born as an initiative to give emergency medicine residents access to small group therapy led by psychiatrists who were experts in burnout, PTSD, and depression. The program aimed to provide direct access to mental health care and normalize the need, value, and desire for therapy. The small groups were paired with the same therapists over all four years of training to create a longitudinal relationship. The same psychiatrists were also available for individual therapy, as needed. The initial “Project Safe Space” was started at the NYU emergency medicine residency program. Last year, we started the same program at the Harvard Affiliated Emergency Medicine Residency, and other residencies here in Boston are looking to launch their own “Safe Space” programs for trainees.

“Project Safe Space” and similar endeavors are a start. Barriers to diagnosis and treatment need to be lifted. Stigma and punishment for seeking care need to be erased.

Doctors need therapy and other mental health services — both their lives and their patients’ lives depend on it.

Jason Bowman and Adaira Landry are emergency physicians.

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