Last year, a physician friend began experiencing what she believed was burnout. She felt constantly overwhelmed, had difficulty sleeping and eating, and began to dread going into her office. She worried excessively about patient outcomes, decisions she had made, and whether she was actually a good doctor. She even began to cry unpredictably. Like so many physicians who struggle with these kinds of symptoms, she avoided seeking help until she was nearing a crisis with thoughts of suicide.
The symptoms of burnout are exhaustion, negativism about or mental distance from one’s job, and reduced professional efficacy. While many physicians do have classic burnout, these symptoms are not the only ones some doctors are experiencing when they think they have burnout. Now, consider symptoms of major depressive disorder: depressed mood, which manifests as sadness, emptiness, or hopelessness; appetite change; sleep disturbance; feelings of worthlessness; fatigue; difficulty concentrating; and recurrent thoughts of death or suicide.
I did not evaluate my friend clinically, of course, but her symptoms had a lot more in common with depression than with burnout. We already know that half of attending physicians experience burnout at some point in their careers, rates of depression among resident physicians are two to three times that of the general population, and sucide rates among physicians are higher than among non-physicians – with women physicians at higher risk than men. But rates of depression may be even higher than surveys suggest, as misdiagnosis of depression as burnout among doctors may be more prevalent than recognized.
We infrequently access mental health treatment despite the high prevalence of burnout, depression, anxiety, and alcohol and substance use disorders among physicians. The overall stigma around mental health issues impacts doctors and the general population, and the mental fortitude and grit encouraged in medicine can make it difficult to admit that we are struggling enough to need help. Busy schedules can make counseling seem like a logistical impossibility, even if we are interested.
The most regrettable reason that physicians do not seek professional help for mental health and drug or alcohol problems is the very real possibility of negative consequences for such a disclosure. Too many physicians have self-reported their depression or alcohol abuse to a department or residency chair only to find themselves facing licensing problems, or reduced responsibilities and restrictions that feel punitive instead of helpful. Some have been ignored or told to just get through it. Other doctors have had their treatment or diagnosis exposed to co-workers or patients, even inadvertently, leading to shame, hopelessness, or a withdrawal from care. Health insurance may cover services only in our own system or we may be unaware that other options are available, so a visit to a mental health provider might mean running into our patients in the waiting room or being treated by a colleague. And since health insurance will only cover counseling services with a mental health diagnosis on record, some doctors have discovered that their recorded mental health diagnosis can impact future life and health insurance policies, and treatment may be discoverable by their employer.
The disproportionately high number of physicians who struggle with mental health issues represents a crisis in medicine. Unfortunately, the factors that keep physicians from accessing help are long-standing. Wellness programs and efforts to destigmatize mental illness will eventually help, but change is slow.
In response, some mental health counselors across the country, like myself, have opened private counseling practices specifically for physician clients. These practices have several commonalities: The providers are familiar with the unique concerns of physicians and their careers; they are independent from medical systems that employ physicians, and most are self-pay to eliminate insurance involvement. Some of them even offer more flexible appointment times to accommodate physician’s schedules. Paying out of pocket for counseling offers privacy and confidentiality that is difficult to obtain otherwise. If self-pay is not desired or feasible, or if one of these practices is not available, physicians should at minimum consider a mental health provider that operates outside their medical system, or even outside their geographic area. Many insurers, including HMOs, cover some private practice counselors in addition to their in-system providers.
Finally, attending physicians struggling with a mental health issue should consider contacting a counselor first, rather than a department head or employer resource. A counselor can assess the mental health issue, offer treatment recommendations, and provide therapy that meets the physician’s needs – all while protecting that person’s privacy. Mental health providers are legally obligated to maintain confidentiality except under the most narrow of circumstances. Despite the concerns that licensing boards and employers have about the risk to patients or impairment, there is little evidence that simply having a mental health issue, or receiving treatment for one, imperils patients. We have abundant evidence, however, that avoidance of treatment imperils physicians. Many physicians have successfully undergone counseling while continuing to work without ever notifying their employer or department, imperiling patient care, or incurring licensing consequences.
Until changes occur that mitigate the causes of burnout, depression, anxiety, and substance use disorders among physicians, our priority must be increasing access to and engagement in treatment. Physician-specialized private counseling practices are one way to accomplish that.
Vickie Mulkerin is a family physician and owner, White Coat Counseling, LLC.
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