Why physician-specialized private counseling practices are important [PODCAST]

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“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.

She shares her story and discusses her KevinMD article, “Why physician-specialized private counseling practices are important.”

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Hosted by Kevin Pho, MD, The Podcast by KevinMD shares the stories of the many who intersect with our health care system but are rarely heard from.

Transcript

Kevin Pho: Hi, and welcome to the show, where we share the stories of the many who intersect with our health care system but are rarely heard from. My name is Kevin Pho, founder and editor of KevinMD. Today on the show, we have Vickie Mulkerin. She is a family physician and counselor, and she wrote the KevinMD article “Why physician-specialized private counseling practices are important.” Vickie, welcome to the show.

Vickie Mulkerin: Thank you, Kevin. It’s great to be here.

Kevin Pho: Thanks. We’ll get into the article in a little bit, but first off, can you share your story and journey to where you are today?

Vickie Mulkerin: I am a family medicine doctor. I went right from college to medical school and residency. I practiced family medicine for about a decade and then developed a completely debilitating illness out of the blue. I ended up being completely disabled, had to stop work, and spent a few years not being able to function. I ended up being put, with very good intentions, by my own rheumatologist, on OxyContin, and became addicted to opiates during all of that. So I spent a few years not practicing, being in trouble with drugs, and finally ended up getting sober with a lot of help from people around me.

After that, I really had to think about what I wanted to do for a career. I was concerned that family medicine was not the right path for me moving forward, and I discovered that emotional and mental health was so much more critical to my well-being than physical health was, because I still have my illness. Because of that, I ended up going back to school. I got a master’s in counseling psychology and have been working as a mental health and drug and alcohol therapist since then.

About nine months ago or so, we had switched to online counseling, obviously, and with the pandemic, I was hearing from some of my own physician clients that I had at the time, but also a lot of friends and former co-workers, about the tremendous stresses that were going on. I mean, we all know the pandemic has upended a lot of people’s lives and really put a lot of undue stresses on us, but physicians feel like they are bearing a tremendous burden of what’s going on. Because of that, I thought that it would be good to actually do a physician-client-specific mental health and AODA practice, and so I opened one earlier this year. I specifically provide counseling to other physicians, and so far, it feels like it’s been a really meaningful endeavor.

Kevin Pho: So give some of the reasons, from the physicians that you’re talking to, why specifically they are undergoing so much stress. Without going into too much detail, share some stories, symptoms, case studies that you’re seeing in your counseling practice with the physicians today.

Vickie Mulkerin: So physicians have always struggled with mental health and alcohol and drug issues more than the average person. Other professions don’t have nearly as much depression, anxiety, burnout, and drug and alcohol use as doctors do. There’s also been kind of this quiet epidemic of suicide among physicians. Physicians commit suicide at higher rates than people in other professions do. So all of those things have already been kind of the steady state for living and existing as a physician.

But in the past year or so, with the pandemic, I’ve been seeing more depression. I’ve been seeing more people who have what they say is burnout, but the burnout, to me, feels not like what we describe as classic burnout but feels much more like depression. I’ve also been hearing from doctors who have been working unbelievably demanding schedules. I mean, we all know that physicians can work 60-80 hours a week; sometimes some people might do a 100-hour week. But the level of stress on doctors, as far as hours worked and days worked, is incredible. I’ve recently heard from somebody who has worked 28 consecutive days. That is unsustainable, and, I mean, it’s not surprising that this person is struggling.

I’ve been hearing more doctors having what I call passive suicidal thoughts, so thoughts of, “It would be OK if I died of COVID, because then my partner would have a life insurance policy.” That’s not active suicidality, but that’s a concerning thing to me, when someone’s having these passive thoughts, “Things might be easier if I wasn’t here.” I’m hearing so much more of that, and I think that, again, doctors often attribute it to, “I’m just burned out.” But to me, that really speaks to this person having depression. We’re so good as doctors at pushing through. We really don’t like to admit that we’re struggling. We’re perfectionists. And so I think part of what I see is, for people, burnout sounds like a safer thing. It sounds less threatening. It sounds less stigmatizing to say, “I’m burned out in my job.” But what I’m seeing from a lot of doctors is they’re labeling it burnout, but what I’m seeing is actually depression.

I’m also seeing stuff that I think revolves around grief. I’ve been really thinking a lot about grief in the past probably 9-12 months. I think our nation is going to have some grieving to do once this is all settled that I think we’re not really acknowledging. But I think physicians have this very strange place where they exist in their jobs, not really being connected to patients. They don’t know their story. They don’t know who they are as people. And when they’re providing the kind of care that’s being required for people with COVID, they get so intensely invested in that person’s outcome. They get very intimately aware of an aspect of that person, their body, their function.

I think that when COVID patients die, there’s this odd disenfranchisement around grief. Doctors don’t feel like they can grieve for somebody that they didn’t really know, and yet they’ve invested so much time and energy and heartache into COVID patients that there is some grief. Doctors and nurses and other people who are involved in medical care in the hospital are sometimes the only people that these patients are able to connect with, so that builds another layer in which it feels like the doctor is crossing into a different role. They’re the support person; the family can’t visit. So I’ve been seeing a lot of what I think is disenfranchised grief. Doctors are experiencing so much loss, and there’s really no discussion about it. There’s no formal forum for processing that. So that’s something that I think I’m seeing a lot of, too.

Kevin Pho: And you talk more about those issues in your KevinMD article titled “Why physician-specialized private counseling practices are important.” Now, for those who didn’t get a chance to read that article, can you just walk my audience through it and share the story of why you decided to write it?

Vickie Mulkerin: Sure. I have a very good friend who’s a family medicine physician. She and I go way back. She was visiting this past summer and described that she had experienced, she called it a breakdown. She’d experienced terrible burnout, and she kept labeling it burnout. She was exhausted, but the symptoms she was talking about didn’t just feel like burnout. Burnout is exhaustion, negativism about your job, sometimes some depersonalization, and definitely reduced efficacy at your job. But she was describing crying and hopelessness, fears that she was incapable of doing her job. She was having some of those passive thoughts of suicide.

And so she ended up, fortunately, finding a counselor who specialized in treating physicians, and she and I had a lot of discussion about whether what she had was really burnout or depression. We really got into why she had so much trouble accessing help, why she had a difficult time seeking assistance for this, and a lot of it boiled down to, first of all, doctors not really recognizing when they’re struggling. We’re so efficient, we’re such perfectionists, we’re so driven, we have so much grit, that I think we continue to function and put any concerns aside until things are really, really bad and we’re in really severe distress. So I think that had happened with her. Part of it is kind of inherently what physicians are, what’s selected for in physicians.

But part of it also was around not feeling safe to access services as a doctor. First of all, there’s stigma around mental health challenges and drug and alcohol use issues. We all know it. Everybody has heard demeaning stories about people who have drug or alcohol problems. There’s certainly been a lot of stigma around seeking mental health counseling, because then you’re labeled as having a mental illness. That’s true for everyone. Physicians are humans, so we all also experience that stigma.

But above that, physicians have a lot at stake when they access mental health treatment. There are stories of physicians approaching their chairs, their residency heads, revealing something about struggles with depression, struggles with alcohol use, and suddenly they’re being disciplined. Suddenly they’re being taken out of some of their roles; their hours are being cut. There have been stories of people reporting, “Yeah, I’m having a problem with alcohol. It’s not when I’m at work. It’s not impacting my work.” But then suddenly those physicians are in front of their licensing board, and they’re being put through professional assistance programs when their work wasn’t impaired at all by their use. So doctors do not access treatment, because there are a lot of negative things that can happen when they do.

I have another physician friend who wanted to get treatment for anxiety. She was funneled to the behavioral health clinic that’s attached to the hospital she works at. She actually called, and the person who was taking her information said, “Oh, hi, Doctor. I’m one of your patients.” She actually hung up and didn’t access treatment because of that. So when doctors go for counseling, they might run into patients. They might end up being treated by a colleague, which gets very complicated. One of your colleagues at the large medical organization that you’re at may be your provider. So I think there are a lot of barriers for physicians seeking treatment, which are real. There really have been negative consequences for people.

Part of my practice is based around self-pay. I am not taking insurance, and I thought a lot about whether or not I should take insurance. I have in the past, but I have heard from a lot of physicians about negatives from accessing insurance in order to pay for mental health counseling. I heard from a doctor who had higher life and disability insurance rates quoted to him because those insurers had dug up a 17-year-old diagnosis of depression from when he had sought counseling in the past. Seventeen years. So when you go through insurance to get mental health treatment, the mental health provider must provide a mental health or drug-and-alcohol-related diagnosis to the insurance company, and that diagnosis can follow you. If I don’t have to use insurance, then I don’t have to put that diagnosis in a physician’s file somewhere that might follow them.

Kevin Pho: So it sounds like a private counseling service like the one that you offer can alleviate some of the stigma and barriers that you described. Can you contrast the treatment that you give as a private counselor to a traditional form of behavioral health treatment a physician may be offered?

Vickie Mulkerin: At the core, I provide mental health and drug and alcohol counseling that’s similar to other providers, other therapists who provide mental health counseling. I trained the same way other mental health providers did. I have the same licensing. However, as a physician, I’m fairly unique. There are not a lot of physicians who have become mental health counselors, and as a physician, I understand what it means to be a physician. I understand some of the particular stresses that are on physicians, and I also understand some of the kind of deeply embedded stigmas and beliefs that physicians have that can be different than what other people in other professions have.

The perfectionism is something that’s not universal to all doctors but is fairly common, and that’s not necessarily something a lot of people come into counseling with, perfectionism on top of struggling. And so with physicians, there really is a different path that I take in order to, first of all, alleviate some of the stigma and address the shame that’s tied in with admitting that you have a mental health challenge or a drug and alcohol issue. There’s so much shame for physicians, and that’s something that I really have to address with them before they’re able to start to heal and to actually improve.

So there’s definitely an understanding that I have when people talk about, I mean, it’s funny, physicians can talk about some horrible, traumatic thing that happened at work and a comment from a nurse may have made them feel bad. You can tell that story to somebody who’s not a physician, and the person who’s not a physician gets freaked out about the blood and the coding that was happening. But physicians are like, “Oh, yeah, it was a code.” The thing that really bothered the doctor is actually the comment from the nurse. And so kind of weeding through the things that I know physicians feel are important and the things that are not important is also something that I think I’m able to do.

I think physicians also feel more comfortable talking with a physician. I think there’s something, and I include myself in this group: I think physicians, we have big egos. I think that we’re highly educated, highly intelligent people, and sometimes it can feel a little concerning to go to a person that doesn’t have that level of education and may not be as smart as you. And so I think me having the background I have, having the education that I have, helps physicians feel more comfortable that I can keep up with them, I can help them, I can address their problems, and I can understand what’s going on.

Kevin Pho: We’re talking to Vickie Mulkerin. She is a family physician and counselor, and she wrote the KevinMD article “Why physician-specialized private counseling practices are important.” Vickie, I have a lot of physician coaches on my blog and on this podcast. Can you contrast physician coaches versus counseling?

Vickie Mulkerin: Yeah, that is such an excellent question, because I think a lot of us don’t understand the difference between coaching and counseling. Coaching tends to focus more on what changes you can make in your life. What are the changes that you can make to the external? There are a lot of physicians who do coaching around career choices, changing, doing non-clinical work. There are a lot of physician coaches who help people with relationship issues or attaining goals that they’ve set. People who are coaches, especially physician coaches, do go through a training program, and it’s a training program that’s focused mostly on behavioral adaptation. So how can people organize? How can they change? Some of it’s about thought changes, challenging dysfunctional thoughts that they have, but a lot of it is about taking action to change something external.

Professional counselors look more at the internal. Professional counselors have a completely different training than professional coaches do. It’s a lot of psychology. It’s a lot of understanding. It’s a lot of looking at formation of beliefs, formation of false and true self-beliefs. A lot of counseling is about, “Where did this thing I believe about myself come from? Why did I adopt it? And what’s a healthier belief I can start to grow into?” So I really help people with emotional health. I help people look at who they are and why they are that way, and what might be a healthier and happier place for them to be. What are things that they can do differently in their emotional reactions? How can they address relationships from the standpoint of, “Who am I in this relationship? How can I interact from a place of love and not fear?” So professional counselors address a lot more of the internal and the emotional and the shame parts, and coaches address a lot more behavioral and external things.

So professional coaches are incredibly helpful. I work with people who actually have been seeing coaches, and sometimes they end up coming to me because the coach has been able to help them with some aspects of their life or their professional work, and there’s still something that they’re struggling with. A lot of times, what I’ve been experiencing is people have seen a coach because they’ve told themselves, “I have burnout. I need to change something about my job. I need to stand up to the hours I’m being asked to work. Maybe I can switch to a different area of the practice that I’m in. Maybe I can go more to administration.” But I think I’m seeing the people who are addressing burnout with a coach and discovering that it’s not just burnout, that there’s actually depression there. Professional coaches aren’t trained to treat depression or anxiety, and professional counselors are. So I’m really able to help people look at and explore the depression, and discover and make changes that will help them with those mental health issues.

Kevin Pho: And my final question: What’s your take-home message that you want to leave with the KevinMD audience?

Vickie Mulkerin: My take-home message would be, if part of you believes that you’re struggling with depression or anxiety, if part of you believes that you have burnout but the burnout is so severe that you’re having some of these passive thoughts of suicide, please access a counselor, and look for a private counselor. I’m concerned about people going to their department chairs. I’m concerned about people accessing their wellness programs at their work, because then you’re kept in that system, and there can be negative consequences around your job. Please access a professional counselor outside of your system. Consider paying cash so that your insurance isn’t involved. But you deserve, just like you refer your patients to mental health counseling, you deserve to have that same care directed at you. You deserve that same level of attention that you give to your patients.

Kevin Pho: And how can people reach you?

Vickie Mulkerin: People can reach me by going to my website. It’s www.whitecoatcounseling.com. They can email me, they can call me, they can fill out the contact form. I can provide professional counseling for anyone in Wisconsin, and many states are also still allowing some professional counseling for people licensed outside of their state. I am treating people in several states because legally I’m allowed to. But if you have any questions, if you have any concerns, and you don’t live in the state of Wisconsin, still reach out to me. I can help you. If I can’t provide counseling for you, I can help you find somebody who can. That’s one of the things that I’ve been doing a lot of: People contact me, I can’t provide counseling for them, but I help them find somebody who will be able to.

Kevin Pho: Vickie, thank you so much for sharing your time and insight, and thanks again for being on the show.

Vickie Mulkerin: Thank you very much, Kevin. It’s great being here.

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