Long before COVID-19, healthcare providers had high rates of burnout, depression, and suicide, that ... [+]
Over the weekend, inspired by a recent New York Times article about the death of well respected emergency medicine physician, Dr. Lorna Breen to suicide during Covid-19, Dr. Esther Choo, also an emergency medicine physician and a vocal public health advocate, took to her twitter account of nearly 130,000 followers to express her feelings about stoicism in medicine, the dangers of the hero trope, and her own experience with mental health.
What followed was an unprecedented experience in healthcare. A flood of professionals from physicians to nurses to therapists to pharmacists wrote about their own mental health histories, sometimes for the first time, in an attempt to destigmatize mental health and help seeking in the medical profession. They spoke about medication, therapy, coping skills, and the reasons they had not spoken up before.
It was a truly powerful display seeing so many people normalizing mental health and mental health treatment on such a large scale. Dr. Adam Hill, Associate Professor of Clinical Pediatrics at Indiana University School of Medicine and Author of “Long Walk Out of the Woods: A Physician’s Story of Addiction, Depression, Hope and Recovery,” feels that for decades we have “shamed, judged, closeted, and punished seeking mental health treatment in the medical workforce.” However, if these conversations are telling us anything it is that it is time to tell our stories and create a safe space for others to share as well. He says, “Maybe, just maybe, by the simple act of raising our voices – we can save lives with the power of our solidarity. No one is on this road alone, I promise you.”
Dr. Nicole Washington, Chief Medical Officer of Elocin Psychiatric Services and founder of physicianmentalhealth.com hopes that talking about the benefits of treatment will make more healthcare professionals open to engaging with it. She explains, “This is definitely a start and can be a huge shift in the toxic culture of medicine that dictates physicians bury their mental health needs and deal with things internally.” She adds that she feels the people who spoke out are “brave” and it is particularly powerful when the disclosures are done by someone who is well known and respected. However, she does worry that speaking out can still come with negative consequences, like criticism from other physicians and even employers.
She wouldn’t be wrong in this assumption as many have been told not to disclose their mental health status, even when speaking to their peers in an attempt to normalize treatment. For example, one medical student, Jenny, wrote on twitter, “I was on a mental health panel at my medical school. Then a lot of people told me I shouldn’t speak openly about depression, see a therapist, or use my insurance and real name because residency and licensure could be tanked by it. This needs to change.” A resident at UCSF, Dr. Justin Bullock, who has written about and openly discussed his own experiences with Bipolar Disorder, explained that even though people would write him and many thanked him for his story, people always suggested he be careful disclosing his mental health history. He said, “There is a palpable stigma in medicine (and in society in general), and this false notion that physicians are supposed to be superhuman and not suffer from the same diseases as our patients (which I personally think is absurd).”
This superhuman notion is just one of many barriers and why open conversations are just one part of the needed change. Dr. Ariel Brown, founder of the Emotional PPE Project notes, “There are mountains of evidence, from research studies to personal anecdotes, to employer reports, that healthcare workers are both more likely to suffer from mental distress and less likely to seek mental health services.” She cites external barriers like time or work stress as preventing care seeking and internal barriers like stigma and fear of repercussions of seeking help. She says healthcare workers worry how using treatment will be perceived and “the word weak keeps coming up.” Dr. Stephanie Zerwas, psychologist and founder of Project Parachute, adds that she has been surprised “how hard it can be to give away free therapy.” She notes that while they are excited they have been able to provide pro bono care to 225 frontline workers, given the large interest by therapists, they have over 600, and the clearly large stressors and need for care in frontline workers due to Covid-19, they expected more of an uptake. She emphasizes, “It’s been so hard to break through the stigma that healthcare workers feel when asking for help.”
Another significant reason for lack of help seeking? Health professional licensure forms.
Licensing Applications: A Clear Barrier To Help Seeking
Dr. Christian Neal was on antidepressants during medical school and remained on them until he pursued entry into the medical corp of the Army Reserve. There, they asked him about his mental health history, which included any history, including therapy. Even though he knew it could be potentially disqualifying, he chose to be open. That led to a discussion and needing to go to the review board. At that point, he decided to discontinue medications and has been off of them ever since. Now, when he has had to do credentialing for employment and the question, do you have any mental or physical conditions and/or take any medications that might affect your ability to competently and safely perform your job appears on a form, he says, “my initial thought is ‘how am I supposed to answer that?’ and ‘who outside of me can effectively determine what would constitute a condition that would affect my performance’. There’s always the concern of if there were issues at work, could they be dismissed in the context of how I answered? Would I not be able to get privileges? And if the answer is unimportant or doesn’t influence the ability to get a license or get privileges, why ask?”
This is a common back and forth that many health professionals have with themselves when filling out forms for licensing. Some question if they should disclose the truth or if they should lie. Even still, often the conversation occurs before they even decide if they should get help at all. In fact, physicians in states that ask broadly on applications about mental health history and the potential for it to affect competency were 21-22% more likely to be reluctant to seek help.
Dr. Eileen Barrett, Associate Professor of Medicine at the University of New Mexico in Albuquerque; and The Director of GME Wellness Initiatives in the Office of Professional Wellbeing, who worked with her own state to change the licensing questions says, “I hear repeatedly that everyone knows someone who that was a factor in whether they decided to seek mental health care...and, to quote Dumbledore, just because it is in your head doesn’t mean it isn’t real.” She says that while maybe not everyone knows someone who has had an investigation, everyone has heard about it or read about it, and the fear is real because “without having a license we don’t have a livelihood.” That fear prevents care seeking and that could cost them their lives. One study found that among surgeons with recent suicidal ideation, 60% were reluctant to seek mental health care because of concerns it could affect their licensure to practice.
The Federation of State Medical Boards and American Psychiatric Association have previously stated that current impairment and risk to patients cannot be inferred from history of mental illness, diagnosis, and treatment alone. Still, many of these questions remain on applications in violation of the Americans with Disabilities Act (ADA) of 1990, which states these questions can only ask about current impairment. For example in nursing, of the 30 boards that still ask about mental illness, 22 of them violate the ADA rules. What these boards choose to do with the information they receive is additionally worrisome. In a survey of state medical boards, 13/35 states reported that the diagnosis of mental illness by itself was sufficient for sanctioning physicians and that they treat physicians receiving psychiatric care differently than they do physicians receiving medical care. And, similar questions are also found on hospital credentialing applications, malpractice insurance applications, and are asked of peer references. The hesitancy that healthcare workers feel in seeking help when they need it is very real and grounded in potential long lasting career consequences.
It also leads to significantly worsened outcomes for everyone involved. Dr. Lisa Merlo, Director of Wellness for the University of Florida College of Medicine and Director of Research for Professionals Resource Network explains, “These questions discourage physicians from seeking treatment, ironically putting patients at more risk because physicians are more likely to continue practicing even if they are potentially impaired by a mental health condition rather than seeking treatment that would eliminate the risk for impairment.” Also, physicians who are ignoring their symptoms are likely getting worse. It is much harder to help at that stage, than in earlier prevention points.
But, it does not have to be that way. Instead of singling out mental health or historical data, or asking for impossible or untrue predictions, forms can simply ask an expertly recommended broad question like, are you currently suffering from any condition for which you are not being appropriately treated that impairs your judgement or that would otherwise adversely impact your ability to practice medicine in a competent, ethical, or professional manner? Or, they could just get rid of the questions completely.
Ultimately, everyone that needs and wants help, should feel safe to ask for it. Judging from the number of physicians who should be depressed on the basis of epidemiological realities, it seems likely that physicians working in some of the very best academic medical centers in the United States hesitate to ask their colleagues in Psychiatry for a referral for themselves. With Covid-19, and the added mental health strain on frontline providers, problems are only compounding and untreated problems worsening. We need to start removing barriers to help seeking for our healthcare professionals and we need to do it today. Licencing feels like a tangible win and we have, as Dr. Barrett calls it, a “moral imperative to take care of each other right now.”
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Changing medical culture around mental health also does not just help healthcare professionals, it helps everyone. Parity and stigma begin in the medical profession itself. “If physicians feel stigmatized for seeking their own care, it will be natural for patients seeking mental health care to also feel stigmatized by the healthcare system,” according to Dr. Barrett. She feels healthcare professionals inadvertently perpetuate bias and their internalized and externalized mental health stigmas are transferred to patients. Perhaps they might not ask the right questions or they might use words like “addict” and judge people for their mental illnesses. Or, maybe they denigrate psychiatrists and psychiatric treatment, and regularly do not screen or refer patients for mental health care. Ending the stigma of mental health in healthcare might help end it more broadly, especially in how health care is practiced.
If physicians and nurses and therapists finally feel safe asking for help and talking about their own help seeking, perhaps they will finally make patients feel the same. This domino effect is badly needed, now more than ever.
