Stigma in Healthcare: Empowering Physicians and Trainees to Seek Help

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In the wake of the coronavirus pandemic 2019, physicians and trainees are facing new types of stressors. In a profession where burnout and depression are already commonplace, these additional stressors and traumas can prove overwhelming. Many physicians may need and want to seek psychiatric care but feel unable to do so due to fear of professional repercussions.

The consequences are tragic. The story of Lorna Breen, MD, the New York City physician who died by suicide at the start of the pandemic is, lamentably, not unique.¹ Only a month into 2021, there are already multiple reports of physicians and medical students dying by suicide. Approximately 300 to 400 physicians die by suicide each year, more than twice the rate of the general population.² Almost 20% of physicians have thought about suicide.³

Suicide is largely associated with untreated or undertreated psychiatric illness.² In the general population, treatment for psychiatric disorders is generally low due to various barriers to care, including inadequate access, self-denial of symptoms, and stigma.⁴ Physician populations seeking treatment face additional barriers to care. Fear of the potential professional repercussions if they are known to be receiving psychiatric care can play a major role in their avoidance of care.⁵

Although stigma toward psychiatric conditions in medicine has decreased, it remains a real problem. A recent study confirms the fears of those who worry about revealing their illnesses.⁶ When residency applications disclosed a common psychiatric illness (major depressive disorder), they were at a notable disadvantage when compared to applicants who disclosed non-psychiatric illness (diabetes mellitus type 1). This is just a single example of the many systems within medicine that still perpetuate stigma surrounding psychiatric disorders. Given the very real, often punitive impacts to receiving psychiatric care, it is not surprising that so many physicians chose to stay silent, which can have dire consequences.

For medical licensing, one-third of states do not ask about mental health conditions, or only ask about current impairment.⁷ But other states inquire into applicants’ psychiatric history, asking questions related to current functioning and competency-irrelevant questions about diagnoses or treatments in the past.⁸ Furthermore, disclosure of treatable and common conditions such as anxiety or depression may result in a range of professional consequences.⁹ Physicians working in states with more in-depth questions about psychiatric diagnoses are 20% less likely to seek treatment.⁸ This silence can lead to deadly consequences, quite literally putting the physicians’ life in jeopardy.²

This fear of seeking help begins early in training despite current attempts to improve trainee wellness.¹⁰ Medical schools and residency programs now make explicit efforts to ensure mental wellbeing of their students.^11,12 When students enter medical school the administration does its due diligence by providing links to resources for mental health care and advising students to seek help when needed.¹³ Regrettably, even now after all of these positive changes, medical students are still 3 times more likely than their peers to die by suicide and almost 10% of students report having suicidal thoughts in the past 2 weeks.^14,15

The process of seeking help for a psychiatric issue can be daunting for anyone. For potential patients, there are often guides online providing step-by-step information about what the process of seeking help looks like. Unfortunately, this process can be different for those in the medical profession. They learn about psychiatric care through rumors or whisper networks. Fear motivates most to stay quiet, and this silence continues after medical school. Recent studies across different groups of physicians have found that almost 50% believe they met DSM criteria for a psychiatric diagnosis but refuse to seek treatment, largely due to concerns relating to stigma and repercussions of licensing boards.^8,9 A poll of emergency physicians released in October 2020 showed that many physicians still do not feel comfortable seeking mental health treatment, even in light of the additional stress of COVID-19. More than half (57%) reported concerns for their jobs if they were to seek help, and 73% believed that there was still significant stigma in the workplace towards those with psychiatric disorders, stating that this stigma played a role in their avoidance of the care they believed they needed.¹⁶

It is clear that the current system leads physicians and trainees to avoid treatment.¹⁷ While the system may prevent some from seeking care, the benefits from seeking treatment do outweigh these risks in a majority of cases. Last year, hundreds of physicians spoke out on social media about their own pathways to treatment, many stating that they wished they had sought treatment earlier.⁷ These testimonials prove that although seeking treatment for a psychiatric condition may be more professionally burdensome than it should be, it does not end careers—for most. In fact, by seeking treatment many of these physicians stated that it improved their ability as physicians.

Physicians should never be penalized for seeking help. Nonetheless, while we work to further improve the system it is important that medical training also includes education about how and when to get treatment. Both trainees and their supervisors should understand this process. Physicians who do not need to seek psychiatric help are often not aware of these processes and their implications; however, trainees are all taught about the importance of reporting physicians who appeared impaired. Providing clear information on how to seek treatment and demystifying concerns surrounding the professional impacts of treatment allows individuals to seek help early, rather than creating a situation where we must wait to catch our colleagues at their lowest points before they submit to treatment.

There is no doubt that more physicians would seek psychiatric care if non-punitive, non-stigmatizing policies were in place. Fortunately, many are already working towards policy improvements.⁷ The medical licensing board questionnaires remain state-dependent, but a 2017 study found there have been changes in questions related to mental health, especially after it was evident that many of these intrusive questions violated the ADA.¹⁸ Additionally, the Dr Lorna Breen Health Care Provider Protection Act (S. 4249; HR 8094) has been introduced in the House and the Senate and is supported by multiple medical associations including the AMA and APA.^19,20

Even if we cannot remove all aspects of these problems today, we can advocate for systemic change that supports physicians and trainees, such as the Dr Lorna Breen Act, by contacting our senators and representatives to show our support. Through awareness of the process, those who need help will feel able to regain some control of their situation; this knowledge can empower physicians and trainees to feel comfortable to seek treatment as soon as they realize they need it.

Tabitha Moses is currently pursuing an MD/PhD in Neuroscience at Wayne State University School of Medicine. May Chammaa is a third-year medical student at Wayne State University School of Medicine.

References

1. Knoll C, Watkins A, Rothfeld M. ‘I couldn’t do anything’: the virus and an ER doctor’s suicide. New York Times. July 11, 2020. https://www.nytimes.com/2020/07/11/nyregion/lorna-breen-suicide-coronavirus.html 

2. Anderson P. Physicians experience highest suicide rate of any profession. Medscape. May 7, 2018. https://www.medscape.com/viewarticle/896257?src=soc_fb_share#vp_1

3. Dong M, Zhou F, Xu S, et al. Prevalence of suicide‐related behaviors among physicians: A systematic review and meta‐analysis. Suicide Life-Threatening Behav. 2020;50(6):1264-1275.

4. National Institute of Mental Health. Mental Illness. Accessed February 1, 2021. https://www.nimh.nih.gov/health/statistics/mental-illness.shtml 

5. Center C, Davis M, Detre T, et al. Confronting depression and suicide in physicians: a consensus statement. JAMA. 2003;289(23):3161-3166.

6. Pheister M, Peters RM, Wrzosek MI. The impact of mental illness disclosure in applying for residency. Acad Psychiatry. 2020;44(5):554-561.

7. Dyrbye LN, West CP, Sinsky CA, et al. Medical licensure questions and physician reluctance to seek care for mental health conditions. Mayo Clin Proc. 2017;92(10):1486-1493.

8. Gold J. It is time to stop stigmatizing mental health among healthcare workers. Forbes. July 13, 2020. https://www.forbes.com/sites/jessicagold/2020/07/13/it-is-time-to-stop-stigmatizing-mental-health-among-healthcare-workers/?__twitter_impression=true&sh=1314f1997709

9. Gold KJ, Andrew LB, Goldman EB, Schwenk TL. “I would never want to have a mental health diagnosis on my record”: A survey of female physicians on mental health diagnosis, treatment, and reporting. Gen Hosp Psychiatry. 2016;43:51-57.

10. Mehta SS, Edwards ML. Suffering in silence: mental health stigma and physicians’ licensing fears. Am J Psychiatry Resid J. 2018;13(11):2-4.

11. Association of American Medical Colleges. Recommendations regarding health services for medical students. Accessed February 1, 2021. https://www.aamc.org/professional-development/affinity-groups/gsa/health-services-recommendations 

12. Batra M, McPhillips H, Shugerman R. Improving resident use of mental health resources: it’s time for an opt-out strategy to address physician burnout and depression (commentary). J Grad Med Educ. 2018;10(1):67-69.

13. Staff News Writer. Medical school burnout: How to take care of yourself. Am Med Assoc. February 1, 2019. https://www.ama-assn.org/residents-students/resident-student-health/medical-school-burnout-how-take-care-yourself

14. Goebert D, Thompson D, Takeshita J, et al. Depressive symptoms in medical students and residents: A multischool study. Acad Med. 2009;84(2):236-241.

15. Paturel A. Healing the very youngest healers. AAMCNews. January 21, 2020. https://www.aamc.org/news-insights/healing-very-youngest-healers 

16. American College of Emergency Physicians. Poll: Workplace stigma, fear of professional consequences prevent emergency physicians from seeking mental health care. EmergencyPhysicians.org. Updated October 2020. https://www.emergencyphysicians.org/article/mental-health/poll-workplace-stigma-fear-of-professional-consequences-prevent-emergency-physicians-from-seeking-mental-health-care 

17. Berg S. 5 reasons physicians are less likely to seek support. AMA Physician Health. July 30, 2018. https://www.ama-assn.org/practice-management/physician-health/5-reasons-physicians-are-less-likely-seek-support 

18. Jones JTR, North CS, Vogel-Scibilia S, et al. Medical licensure questions about mental illness and compliance with the americans with disabilities act. J Am Acad Psychiatry Law. 2018;46(4):458-471.

19. O’Reilly KB. Federal legislation’s message to doctors: It’s OK to ask for help. AMA Physician Health. October 7, 2020. https://www.ama-assn.org/practice-management/physician-health/federal-legislation-s-message-doctors-it-s-ok-ask-help 

20. Dr Lorna Breen Heroes Foundation. The Legislation: The Dr Lorna BreeHealth Care Provider Protection Act. Accessed February 1, 2021. https://drlornabreen.org/about-the-legislation/