Doctors face a dilemma when seeking mental health assistance for themselves

by Ellen Goldbaum, University at Buffalo

Credit: CC0 Public Domain

It's no secret that physicians have stressful jobs. Figuring out how to mitigate and deal with that stress can be a key part of a successful medical career. But while individual physicians seek and find help for their mental health issues privately, the prevailing public perception among physicians is that it just isn't done.

26 april 2019--Sourav Sengupta, a University at Buffalo faculty member, knows all about it. An assistant professor of psychiatry and pediatrics in the Jacobs School of Medicine and Biomedical Sciences at UB, who also treats patients, he reached a point a few years back where he knew that escalating professional and personal demands were impacting his effectiveness.

Last month, JAMA Network online published his essay, "Rebuilding more of me," about how he worked through his issues with the help of a therapist. He wasn't sure how it would be received, but in the few weeks since its publication, he has received personal email messages from dozens of physicians from across the U.S. who reached out to share perspectives and their experiences.

Since publication, Altmetric rated the essay in the top 5% of publications; it has been viewed more than 6,500 times and downloaded more than 500 times. Sengupta has received emails from physicians at every career stage, who tell him it was a relief to read it, to know that others have also gone through this and have succeeded.

'I am an attending physician in the field from which I seek support'

The essay describes the difficulty Sengupta felt in figuring out how to access the help he needed. "I am an attending physician in the field from which I need support," he wrote. "Many of the best clinicians and treatment setting are not options. I know them too well."

Once he found a psychotherapist he could work with confidentially, who wasn't a colleague, he began to open up. Sengupta wrote: "His willingness to acknowledge that clinical work is stressful and can become toxic establishes a life raft upon which I can hoist myself, build new strategies, and shape a different perspective."

That struggle is behind Sengupta now and he was ready to move on. Besides occasionally discussing his experience with others who might be going through something similar, he didn't consider sharing it more widely.

He changed his mind this past winter, when the Jacobs School held an event on National Physician Suicide Awareness Day. Faculty members who direct UB residencies decided to screen a provocative documentary called "Do No Harm: Exposing the Hippocratic Hoax." The movie and a panel discussion that followed took on the issue of physician mental health and suicide. Alarming statistics were discussed, for example, that among physicians ages 25 to 39, suicide accounts for 26% of deaths compared to 11% in the same age group in the general population.

The event struck a chord. More than 200 of UB's 800-plus medical residents and fellows attended. As Sengupta listened to the discussion that followed the screening, he realized he needed to share his story.

"One of the most distressing themes in the discussion afterwards was how scared or resistant or hesitant the trainees were about seeking any therapeutic support," he recalled. "I had the chance to share a little of my experience and a number of residents wondered aloud if it might be helpful for more attendings and medical education leaders to open up a bit more about these kinds of things.

"I wrote the essay for a very particular reason," he said. "There were hundreds of trainees in the room but the vibe around seeking support was quite negative. It wasn't that people thought physicians shouldn't get help, but that there were lots of factors that would probably keep them from seeking help, such as stigma, having enough time, concern for how it might impact their careers.

"I wrote the essay in the hope that I could convey to other physicians what actually happens when you work with a therapist, that it's a collaborative process that can lead to really positive outcomes."

Sengupta, who directs UB's child and adolescent psychiatry fellowship program, also has a close-up view of the difficulties that students and especially medical residents undergo.

"I do see them struggling sometimes," said Sengupta. "Medicine is such a challenging field to be in in this day and age. Trainees are such a critical part of the system and at the same time, they probably need far more support than they are getting. It can be a tough system to work in. You can lose track of what brought you into the field."

Self-stigmatization

Among the factors contributing to physicians' reluctance to seek help are the traits that led them to medicine in the first place, Sengupta said.

"Who is the type of person that ends up wanting to be a physician and then succeeding?" Sengupta asked. "We are pretty intelligent and we're hard-working but we are probably not talking about the struggles we're having. We're internalizers."

At the same time, the nature of medical training itself also contributes. "The training values toughness and grit and perseverance. That shouldn't be to the exclusion of getting help and support but somehow it can be translated into that. Taking care of oneself can seem to represent weakness or incompetence. Sometimes it's the message that is given or sometimes it's a message that trainees perceive.

"Doctors are supposed to be larger than life figures, take in everything, be wise and be helpful," he continued. "We do a really good job of stigmatizing ourselves. When really, getting support when needed could help us get back on track to finding meaning in helping others."

He knows, however, that the challenges to changing the culture are significant. For one thing, he said, trying to find someone who can help is complicated and sensitive. "How interesting would it be if we created some sort of way for physicians who are struggling to communicate with each other… a support group of sorts?"

In the essay, he describes how he shared his experience with his trainees; it came up in the context of a broader conversation about self-care. Afterward, he noticed a change in the way they interacted with him. "I sense a subtle shift in the way some of them approach me. A bit more willing to discuss challenges and vulnerabilities. More open to reflection and self-improvement. A few clinicians even ask for help in finding therapists for themselves, allowing me to transform my process of seeking help into a way to help others."

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More information: Sourav Sengupta. Rebuilding More of Me, JAMA (2019). DOI: 10.1001/jama.2019.2137

Journal information: Journal of the American Medical Association 

Provided by University at Buffalo 

Training for 21st century doctors: medicine, business, and leadership development

Given the complex and rapidly evolving health care system in the United States, medical schools must focus their efforts on training more physician leaders to master the diverse skills needed to navigate emerging challenges in the field, urge leaders from the Perelman School of Medicine at the University of Pennsylvania in a new Perspective piece published today in the New England Journal of Medicine.

17 may 2018--"Academic medicine has been somewhat complacent in the face of the disruptive forces in health care, and as a result, the gap between the physician-leader workforce and the needs of our system has only widened," said J. Larry Jameson, MD, Ph.D., executive vice president of the University of Pennsylvania for the Health System and dean of Penn's Perelman School of Medicine. "Health care systems need a new prescription to close this leadership gap. Given the societal impact of health care, we need to accelerate the development of skills that are not typically acquired during traditional medical training."
Historically, physician leaders have been chosen based on their national prominence and excellence as master clinicians, star researchers, and revered educators. While these credentials remain important, they aren't sufficient in the current health care climate, the authors write.
Today's physicians practice in an era of changing payment models, rising costs, IT advances, and emerging technologies and therapies that are reshaping the delivery of patient care. Dynamic changes have also come with ongoing health system mergers and market consolidation. To lead effectively in this environment, doctors need not only sharp clinical expertise, but also opportunities to hone their communication, team building, and decision making skills, and gain knowledge of finance and business.
Jameson and co-author Caryn Lerman, Ph.D., vice dean for Strategic Initiatives and the John H. Glick, MD Professor in Cancer Research in the department of Psychiatry in the Perelman School of Medicine, suggest health systems focus on three strategies to create this new wave of leaders: rigorous mining of diverse talent pools to identify the most promising emerging physician leaders; building pipelines of future leaders with targeted leadership development to enable progressively increasing responsibility; and deliberate onboarding processes to integrate new leaders and assure alignment across missions and with the institutional culture.
Training in finance and business planning and personnel management should be central to professional development, as many physician leaders may manage budgets similar to those of medium-sized businesses, for example, and work in organizations which are among the largest employers in their community.
"Given the high rate of turnover among physician leaders, such as department chairs and deans, we can no longer afford to neglect the skills that are essential for leaders to succeed," they wrote. "We believe there is a need for a new generation of leaders who can promote strategic and cultural alignment in the face of rapid change."
At Penn, the Perelman School of Medicine has joined with the Wharton School to create an executive education program which will launch in 2019 for health care and academic medical leaders from across the nation and world. The program will provide targeted leadership development experiences and practical skills to enable today's and tomorrow's leaders of health systems and academic medical centers to adapt to a rapidly changing environment.
The new endeavor joins the Penn-Wharton MD/Master of Business Administration (MD/MBA) program, which is designed for medical students interested in integrating their medical course work with training in managerial, financial, and technical expertise in the health care field.
Another example is Penn Medicine's Healthcare Leadership for Quality Residency Track. This two-year training pathway for future physician leaders is one of only a few in the country to offer a pathway for residents aspiring to be leaders in health care quality, patient safety, or informatics. So far, more than one hundred residents have participated in the program.
To help meet the challenges of an increasingly complex landscape, the authors say, health systems should make leadership development an organizational priority—an emphasis which will also pay off in improved patient satisfaction and clinical outcomes.
"The 21st century physician leader must be equipped with a new tool kit of skills for the leadership agility necessary for them to respond proactively to rapidly changing environments," Lerman said. "Leadership development should be an organizational priority, preparing today's medical students and physicians to thrive in a continuously evolving era of health care."


Provided by Perelman School of Medicine at the University of Pennsylvania

Older Physicians Unhappy and Looking to Bail Out of Medicine

IRVING, Tex., Oct. 25 -- Half of physicians from ages 50 to 65 are frustrated with their practices and plan to sharply cut back or abandon patient care within the next three years, according to a survey.
Fifty-two percent of these older physicians said they find medicine has become less satisfying over the past five years, according to a survey by Merritt Hawkins & Associates, a national physician search and consulting firm.
Only 10% of nearly 1,200 responding physicians said the practice of medicine is "very satisfying," down from 20% in earlier surveys.
What's more, 44% of the surveyed physicians said they wouldn't choose medicine as a career if they were starting out today and 57% would discourage their children or other young people from doing so.
These doctors don't intend to remain unhappy for much longer, though. Almost half of survey respondents said they will retire over the next three years, seek nonclinical jobs, work part time, close their practices to new patients (18% have already done so), or significantly reduce the number of patients they see.
If that trend continues, patient access to health care could be severely jeopardized. "Almost half the physicians in the United States are 50 years old or older," said Mark Smith, executive vice-president of Merritt Hawkins. "An exodus of older doctors from medicine would be a disaster for patient care in this country."
The Council on Graduate Medical Education (COGME), a panel of health care authorities, has endorsed a study predicting a shortage of 96,000 physicians by the year 2020. If only 20% of physicians in the 50 to 65 age bracket opt for retirement or nonclinical roles in the next three years, nearly 60,000 physicians would be removed from the clinical workforce, the survey noted.
"The tens of millions of patient encounters these physicians handle would have to be absorbed by younger physicians or by those older physicians remaining in clinical practice."
Why do physicians claim to be so disgruntled? Reimbursement issues were cited by 33% of doctors as their greatest single source of professional frustration, followed by malpractice worries (18%) and long hours (15%).
That represents a significant shift. In the 2004 Merritt Hawkins survey, malpractice worries were the main source of frustration (28%). Reimbursement issues were cited by only 16%.
"When Baby Boom doctors entered medicine, they had control over how they practiced and the fees they charged," noted Smith. "But the rules changed on them in midstream and now many are looking for a ticket out."
These older physicians don't have much regard for the work ethic of their younger counterparts. More than two-thirds of respondents said physicians being trained today are less dedicated and hard-working than they are.
Recently trained physicians may put a higher premium on "quality of life" issues than senior physicians often do. "We find that younger physicians today generally prefer and expect fixed hours, a good call schedule with reliable coverage, and regular vacation time," the survey report noted.
A much higher percentage of young physicians today are female than was the case in the past, and female physicians work 18% fewer hours per week than male physicians, according to the AMA. For these reasons, it may take two younger physicians to replace a more senior doctor.
On a more positive note, six in 10 older physicians said patient relationships are their single greatest source of professional satisfaction.
Also, 48% of physicians indicated that the quality of health care in the United States has generally improved over the last 20 years, compared with 33% who indicated it has generally declined.
So, the survey authors concluded, although the practice of medicine may have become problematic for many older physicians, patient care has generally improved.
The survey was mailed to 10,000 physicians across the nation and 1,175 participated, a 12% response rate. Surgical and internal medicine subspecialists comprised 47% of respondents, followed by primary care physicians (36%) and hospital-based doctors (17%).