“As I think about the emotional well-being of our country, I am particularly interested in how to cultivate emotional well-being for healthcare providers. If healthcare providers aren’t well, it’s hard for them to heal the people for whom they are caring for.” – Surgeon General Vivek Murthy, MD, MBA
As physicians, we are entrusted with healing people’s minds and bodies. We hold ourselves to high standards of responsible and accountable behavior. In our profession, we see pain, we feel pain and we try to heal pain. We are not always successful, we sometimes feel culpable for the outcome and the cycle starts again. Long hours, missing family and friends, sleep deprivation and psychological stress in caring for very sick patients have an impact on our own physical and psychological well-being.
Yet, years of medical school and residency training have taught us that we need to be strong. We are hesitant to seek mental health out of the same fear as our patients: STIGMA. We might be concerned about confidentiality and fear of recrimination from our colleagues and the institutions we work for. We may be required to disclose a mental health treatment history when applying for a medical license. Ultimately, we fear that acknowledging we need help translates into being weak.
In the end, we are HUMANS. Without being human, we cannot help our patients. Not recognizing our limitations and weaknesses turns us into machines. Not recognizing and accepting that one might experience burnout, anxiety or depression is unhealthy and dangerous to oneself and one’s patients.
Threats to the well-being of physicians begin early in their career. Studies show that among medical students, more than 20% will suffer from depression within the first two years and up to 9% will have suicidal ideation before graduation.
“The rate of depression in the population of training physicians is remarkably higher than the general population” said senior author Dr. Srijan Sen, associate professor in the Department of Psychiatry at the University of Michigan when discussing the results of a large systematic review and meta-analysis study.
Studies with information on the prevalence of depression or depressive symptoms among resident physicians published between January 1963 and September 2015 were reviewed. The summary of the review of 54 studies involving 17,560 resident physicians estimate the prevalence of depression or depressive symptoms at 28.8%, ranging from 20.9% and 43.2% depending on the instrument used.
Residency Well-Being Questionnaire
These numbers prompted the Internal Medicine Residency Program at SBH to administer the “SBH Resident Well-Being Questionnaire” in March 2016. The questionnaire, assigned to 81 residents from all three levels of PGY training, had an 84% completion rate (68 residents). On the question related to burnout: 22 residents (32.4%) reported no symptoms; 39 residents (57.4%) reported being occasionally under stress but not feeling burnout; and a total of 7 residents (10.4%) responded that they were experiencing few burnout symptoms to feeling complete burnout.
On the question related to feeling depressed in the past 7 days: 47 residents (69.1%) reported they never felt depressed, while 8 residents (11.8%) reported they sometimes or often felt depressed.
While these results are not as alarming as the ones from the article mentioned above, they prompted the residency program’s revision of available resources to address burnout and depression.
Experience does not make us immune to burnout and depression. Having completed residency training and, as we have assumed more professional and personal responsibilities, we remain at risk at developing depression (comparable to that of the general population). A recent study revealed that nearly half of physicians report at least one symptom of burnout. Some of the contributors include: caring for difficult and complex patients, facing ethical dilemmas, coping with patient death (and suicide), meeting deadlines and regulatory requirements, using EMR systems, and balancing professional and personal responsibilities.
Burnout is a triad of emotional exhaustion (emotional overextension and exhaustion), depersonalization (negative, callous, and detached responses to others), and reduced personal accomplishment (feelings of competence and achievement in one’s work) associated with:
- Decreased productivity and decreased job satisfaction
- Physical symptoms including insomnia, appetite changes, fatigue, colds or flu, headaches, and gastrointestinal distress
- Daydreaming while interacting with patients
- Excessive cancellations of appointments or commitments
- Increased alcohol or drug use
When these symptoms are not timely and appropriately addressed, burnout can ultimately lead to depression and suicidal ideation, plans, and attempts.
In physicians, depression can manifest in different ways:
- Severe irritability resulting in interpersonal conflict
- Erratic behavior
- Inappropriate boundaries with patients, peers, staff
- Isolation and withdrawal
- Increased errors in or inattention to the medical record and patients’ calls
- Inappropriate dress or change in hygiene
- Inconsistency in performance and absenteeism
Burned out or depressed physicians limit their performance to focus on only the most necessary tasks. They may also have impaired attention, memory, and concentration that decrease their recall of information and consideration to detail. As burned out physicians become negatively detached from their work, they may develop negative attitudes toward patients, poor communication skills and ultimately an impaired capacity to deal with the dynamic and continuously evolving nature of the current health care system.
With greater recognition of the risks associated with increased rates of burnout and depression in medical students, residents, and physicians has also come a greater understanding that our profession needs to provide adequate care for its members.
What can be done?
On an individual level, a formula to prevent and address burnout and depression is to reduce work-related stress while restoring one’s energy. Consider interventions such as:
- Mindfulness meditation can help us identify those unconscious thoughts, feelings, and behaviors that sabotage our emotional, physical, and spiritual health. The practice has a balancing effect on our body’s response to stress, calming the autonomic nervous system, reducing stress and restoring energy. Tip: between appointments or meetings, while in your office, take five minutes to sit comfortably in a chair, close your eyes and take deep breaths. Focus on the feeling of release and relaxation. Results will not happen on the first attempt, but be consistent!
- Regular physical exercise
- Spiritual activities
- Schedule daily rest, music, massage
- Enjoying nature – walking on our campus grounds, admiring the flowers and sensing their smell can be therapeutic.
On an organizational level, the increased awareness on the topic has provided these various opportunities:
- Developing stress-reduction programs (our institution provides a SBH Walking Group)
- Enhancing support for health professionals treating a challenging population
- Developing mentoring programs for physicians and residents
- Process groups have also been used (especially in psychiatry) to provide a protected setting to address issues that are professional and bordering on personal and to help foster work-related relationships
In recognition of the challenging work that we do as physicians, providing opportunities for self-care and work-life balance, along with having organizational support, is vital. Being a well-balanced human being and physician makes you more patient, caring and available to your patients and family.
‘‘If all of the knowledge and advice about how to beat burnout could be summed up in one word, that word would be balance—balance between giving and getting, balance between stress and calm, balance between work and home.’’- Christina Maslach, 1982 (co-author of Maslach Burnout Inventory)