The profession of medicine is an exacting and demanding occupation in the service of helping the physical and mental health of patients at their most vulnerable and sick.
Ironically, the mental health and well-being of physicians themselves may be at risk. A recent report published by Medscape noted the alarmingly high rates of physician suicide in this country, calling it “a public health crisis.” This report had come out in March 2020, before COVID-19 had hit its apex and even before the nation had imagined that this virus would reach pandemic proportions.
The long hours and high-intensity shifts that providers face—especially in acute or emergent settings—can take a serious emotional toll leading to depression, burnout, and even suicide. Yet outdated and archaic stigmas surrounding mental health continue to exist, barring care teams from getting the very care they need most—further threatening the lives of our frontline providers during a large-scale healthcare crisis.
Recognizing and responding to trauma
Studies have shown that physicians represent a higher rate of rate of suicides compared to the general population—with physician suicide rates nearly double that of active duty military members. This jarring statistic becomes clearer when we begin to examine and acknowledge the emotional stresses and trauma that physicians witness daily on the frontlines of a pandemic.
Past work has noted that almost 50% of doctors report some symptoms of being “burned out” or psychologically exhausted. Yet, this statistic captures only part of the story. For many providers, the term burnout connotes a subtle individual level judgement or attribution of blame for not being “tough or resilient” enough to withstand the myriad number of stressors associated with the practice of medicine. In contrast, recent work has begun exploring the idea of moral injury as a driver to the trauma that many providers are experiencing during this pandemic. Moral injury is a term coined to describe the moral and ethical challenges soldiers faced during war. Along that vein, similar challenges are faced by providers daily as equipment and bed and staff shortages mean that there are patients that are unable to receive the levels of care needed. Seeing these patients suffer and knowing—that even after you have done all you can—it’s not enough, opens the doors for lingering guilt and depression.
In a study published in General Hospital Psychiatry, 40 percent of attending physicians, 54 percent of residents or fellows, and 64 percent of nurses and AP providers screened positively for acute stress disorder as a result of the pandemic. Rates of depression were not far behind.
Recognizing the psychological impact of the pandemic early on gives us an opportunity to start now to implement change and work to prevent suicide among our care team members.
It Starts with the Stigma
Studies conducted through Brigham and Women’s Hospital suggest that 28 percent of resident physicians experience depression, or a combination of depressive symptoms, and additional studies show that 74 percent of residents meet the criteria for burnout.
Yet despite the pervasiveness of mental illness, remaining stigmas around mental health require many physicians and other medical professionals to remain silent in the face of stress. According to one study, 56 percent of medical students felt others would respect them less if the student was openly depressed—and one third had resisted seeking treatment for mental health issues due to existing stigmas.
Once these students get onto the floor, those stigmas don’t leave. Physicians who seek help for mental health may fear retaliation, impact of licensure, or loss of respect. As a result, we have physicians who end up turning to suicide, and nurses who are attending random funerals just to be given the opportunity to cry, unjudged.
By allowing physicians to care for the mental health of others but denying them the opportunities to get that help themselves, we create a double standard and it needs to stop. If we want to start addressing the alarmingly high rates of physician suicide, we need to stop the stigmas surrounding physician mental health.
“Healing for the Healers”
While the pandemic has been extraordinarily difficult for patients and providers, there have been moments of beauty and renewal in the spirit of humanity during this historic time. As a physician practicing in New York City, I’ve seen the encouraging signs hung from balconies and the clapping from socially distant windows. The daily cadence of individuals stopping their day to recognize the enormity of the current situation has been profoundly moving. These gestures have been greatly appreciated, and I hope that we will build on this together with the public to highlight the need for continued investment for a robust public health system to sustain us through this pandemic and to prepare us for the ones to come. A growing recognition of some of the unique stressors experienced by healthcare workers during this period will ideally be a catalyst for broad support for system level changes in both the ways providers are protected, in addition to how we can continue to serve our patients safely and effectively.
Our studies have shown that existing resources such as physical exercise, talk therapy, yoga, and faith-based or spirituality practices have been endorsed by physicians (59 percent, 26 percent, 25 percent, and 23 percent, respectively) to help improve mental health. But there is more that can be done on a systemic level to support these individuals.
Providing access to self-guided counseling and therapy, improving supply chain to ensure adequate equipment, and implementing workflows and technology that reduce—instead of increase—alert fatigue are all top-down steps in the right direction that we can take organizationally to better support our care teams. And finally, we need to reevaluate and change policies that reinforce existing stigmas around mental health to ensure our providers are able to get the help they need.
It is estimated that 300 doctors commit suicide each year. Whether that number seems large or small in comparison to the general population—by remembering that each of those individuals had devoted their lives to the service of helping their fellow citizens, and in losing each of these souls, we incrementally diminish our ability to care for the broader population, we begin to realize that the fallout of these tragic losses is something directly effecting the well-being of us all.
When we do finally arrive at the moment of “flattening the curve” of this global pandemic, and the signs are no longer waving, the flags no longer furling, the chants and claps no longer filling the streets, please continue to stand by your healthcare workers. Chances are, they’ll need it now more than ever.
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Bernard Chang, MD, PhD, FACEP is Vice Chair of Research and Associate Professor of Emergency Medicine at Columbia University Irving Medical Center. He has research interests in clinician psychological and physiological health. Dr. Chang has received grant funding at the institutional, state, and federal level for his work on burnout and is currently one of the leading NIH-funded Emergency Medicine Principal Investigators in the United States with 2 active large (R01) federal grants looking at long term cardiovascular and psychological development of burnout in Emergency physicians and nurses.
This article is a collaborative effort with Collective Medical.