Stress, distress, and symptoms of depression and anxiety are common among medical students, 1,2 residents, 3 and physicians. 4–6 Physicians are at risk for suicide, with women, nonmajority-identifying individuals, and members of certain specialties being particularly at risk. 7,8 Suicide is a leading cause of death among residents in programs accredited by the Accreditation Council for Graduate Medical Education 9 and is a tragic occurrence in medical students as well. 10,11
The existing well-being crisis in the health professions is now accentuated by a parallel crisis of emotional and physical harm associated with COVID-19. 12 Clinician well-being is thus a growing priority for health care leaders, policymakers, and other decision makers capable of bringing about system-level change. 13 A broad range of strategies exists at the organizational and national levels 12,14,15 for improving well-being within the workforce. However, having physicians share their personal stories about resilience in times of distress has not received much formal attention as a potential method to improve well-being.
We wrote this editorial to examine the potential value of self-disclosure about mental distress and illness. Speaking openly about one’s mental health requires a great deal of courage. We hope to underscore the critical need of cultivating a professional culture in academic medicine that accords a high priority to physicians’ and trainees’ mental health. Many physicians and trainees are living with mental health issues—no one is alone. The propensity to refrain from sharing personal stories regarding mental health is a disadvantage that deserves close attention.
In this issue of the journal, Dr. Kirk J. Brower, 16 chief wellness officer at the University of Michigan Medical School, writes about his mental health challenges. By sharing his story, Dr. Brower hopes to help reduce the stigma of speaking up about mental health issues and obtaining care. Dr. Darrell G. Kirch, 17 former president of the Association of American Medical Colleges, shares his mental health journey and asks all of us in academic medicine—especially struggling learners—to open up about our own mental health challenges to improve lives and potentially to save them. Christopher T. Veal 18 describes how, as a medical student, certain personal stressors brought him very close to ending his life. And an anonymous author 19 shares a personal story of overcoming depression as a medical student.
Breaking the Silence
Journals often publish personal stories related to professional challenges and overcoming them. The column A Piece of My Mind, published in JAMA, allows authors to express their despairs and delights in clinical practice and their experiences of trying to balance medicine with other parts of life. 20
Personal stories across journals have captured our attention over the years. One author 21 questions how she could be so blind to the abusive nature of a relationship, given her training in obstetrics and gynecology, and writes that breaking the silence and allowing others to help is the key to recovery. Another author 22 writes of her sexual assault in the form of a letter to her rapist, describing the physician who cared for her after the event as “the measure of the doctor I compare myself to.”
A middle-aged academic surgeon 23 writes about being involuntarily committed to a psychiatric hospital in the context of a long-standing history of dysthymia and depression. He endured, survived, recovered, lived. Because so many are silent due to the fear of stigma associated with mental illness, he felt compelled to tell his story to make it easier for others. A pediatrician 24 describes losing her medical license and becoming sober, finding herself in support groups with many other doctors overcoming their own challenges. The same author, 25 in another piece, walks us through her “relatively new self-harming disorder,” caught between her own expert, objective medical knowledge, and her own “intolerable emotions.” Bravely, she describes reaching out for help and, ultimately, healing.
A physician 26 describes how his own vulnerability and openness with colleagues reveals their compassion and understanding. After giving a grand rounds lecture telling his story of addiction, depression, and recovery, he received a standing ovation and hundreds of emails that shared others’ strengths and triumphs. Another writer 27 shares her experience with depression in medical school and the “admission of humanness” that is confiding with family, friends, and colleagues. “Depression is not weakness,” she states. “Admitting to depression is not weakness, it is further confirmation of an insidious, life-threatening epidemic in the medical profession.”
Healers are witnesses to death and disease, to vicarious trauma associated with patient care, and to sometimes overwhelming demands of service. Sharing our stories diminishes isolation by fostering connection with peers, 28 reminding us that we are not alone.
Potential Barriers to Disclosure
Stigma encourages the concealment of mental disorders out of fear of unfavorable treatment by others. 29–31 Concerns about medical licensure implications of disclosure and pursuit of treatment persist in many states in the United States. 31 In one survey 32 of program directors, respondents suggested that disclosing a mental illness during the residency application process reduces the chance of obtaining interviews and lowers the overall ranking for a residency interview. Perceived stigma may also influence residents’ willingness to seek health care, given concerns about jeopardizing confidentiality and training status. 33 Residents may be concerned about a director or supervisor learning about their personal health issues. 34 A majority of medical students with burnout probably eschew treatment. 35,36 In addition, medical students might not report severely ill classmates due to fears of breaching confidentiality and bringing adverse educational repercussions upon their ill colleagues. 37
Self-Disclosure and Stigma
When colleagues openly discuss their own mental health issues, they counteract stigma and prejudice. 16,17,38 One small randomized trial of medical students’ attitudes about mental illness compared those who were exposed to a panel of 2 physicians who discussed personal histories of mental illness with those who were not exposed. 39 Attitudes toward mental illness improved significantly in the intervention group but not in the comparison group. Most students across both groups agreed that knowing physicians further along in their careers who overcame mental health issues would make them more likely to access care if needed. In a second interventional study, 40 medical students spoke confidentially to their peers about their experiences with mental illness. Results suggested that the intervention led to a reduction in stigmatizing views toward mental illness.
In this issue, Vaa Stelling and West 41 describe how 3 self-selected faculty members shared their personal experiences with depression and mental health issues during a confidential conference for residents. Almost all of the residents who attended agreed that faculty members’ sharing of personal struggles destigmatizes mental health issues during training. Further studies are required, including those with larger numbers of participants, the provision of controls or comparisons, longitudinal follow-up, and the use of validated methods to assess outcomes.
Dr. Abraham Verghese, 42 when describing the value of JAMA’s A Piece of My Mind column, counseled that we who are physicians now need stories more than ever as instructions for living, to renew faith in the practice of medicine, and to help us to realize that we are not alone in our worries, suffering, and heartbreak. Our work is hard and sometimes exhausting, and our professional standards—in the pursuit of excellence in all of our academic and clinical roles—are demanding. It is easy to fall short of our high standards and ideals, to err, and to think that we have failed. We are vulnerable to becoming unduly self-critical, and a medical culture of shame or blame cannot be a healthy one. The institutional culture should readily enable disclosure and discussion of stress or adversities. 43
Speaking up about personal adversities and mental health challenges empowers others to do the same and mitigates the shame and stigma associated with mental illness. With this in mind, institutional leaders and professional organizations must continue to work to minimize stigma and remove reprisals for self-disclosure at all levels of training and practice. And all of us in academic medicine, Dear Reader, must continue to examine the organizational and cultural factors that promote burnout, distress, and suffering and that limit help-seeking. Lives depend on it.
1. Rotenstein LS, Ramos MA, Torre M, et al. Prevalence of depression, depressive symptoms, and suicidal ideation among medical students: A systematic review and meta-analysis. JAMA. 2016;316:2214–2236.
2. Hope V, Henderson M. Medical student depression, anxiety and distress outside North America: A systematic review. Med Educ. 2014;48:963–979.
3. Mata DA, Ramos MA, Bansal N, et al. Prevalence of depression and depressive symptoms among resident physicians: A systematic review and meta-analysis. JAMA. 2015;314:2373–2383.
4. Shanafelt TD, Boone S, Tan L, et al. Burnout and satisfaction with work-life balance among US physicians relative to the general US population. Arch Intern Med. 2012;172:1377–1385.
5. Shanafelt TD, Hasan O, Dyrbye LN, et al. Changes in burnout and satisfaction with work-life balance in physicians and the general US working population between 2011 and 2014. Mayo Clin Proc. 2015;90:1600–1613.
6. National Academy of Medicine Consensus Study Report. Taking Action Against Clinician Burnout: A Systems Approach to Professional Well-Being. 2019. Washington, DC: National Academies Press; https://pubmed.ncbi.nlm.nih.gov/31940160/
. Accessed January 27, 2021.
7. Dutheil F, Aubert C, Pereira B, et al. Suicide among physicians and health-care workers: A systematic review and meta-analysis. PLoS One. 2019;14:e0226361.
8. Duarte D, El-Hagrassy MM, Couto TCE, Gurgel W, Fregni F, Correa H. Male and female physician suicidality: A systematic review and meta-analysis. JAMA Psychiatry. 2020;77:587–597.
9. Yaghmour NA, Brigham TP, Richter T, et al. Causes of death of residents in ACGME-Accredited Programs 2000 through 2014: Implications for the learning environment. Acad Med. 2017;92:976–983.
10. Cheng J, Kumar S, Nelson E, Harris T, Coverdale J. A national survey of medical student suicides. Acad Psychiatry. 2014;38:542–546.
11. Laitman BM, Muller D. Medical student deaths by suicide: The importance of transparency. Acad Med. 2019;94:466–468.
12. Dzau VJ, Kirch D, Nasca T. Preventing a parallel pandemic—A national strategy to protect clinicians’ well-being. N Engl J Med. 2020;383:513–515.
13. Dzau VJ, Kirch DG, Nasca TJ. To care is human—Collectively confronting the clinician-burnout crisis. N Engl J Med. 2018;378:312–314.
14. Shanafelt TD, Noseworthy JH. Executive leadership and physician well-being: Nine organizational strategies to promote engagement and reduce burnout. Mayo Clin Proc. 2017;92:129–146.
15. Shanafelt TD, Dyrbye LN, West CP. Addressing physician burnout: The way forward. JAMA. 2017;317:901–902.
16. Brower KJ. Professional stigma of mental health issues: Physicians are both the cause and solution. Acad Med. 2021;96:635–640.
17. Kirch DG. Physician mental health: My personal journey and professional plea. Acad Med. 2021;96:618–620.
18. Veal CT. We burn out, we break, we die: Medical schools must change their culture to preserve medical student mental health. Acad Med. 2021;96:629–631.
19. Anonymous. Depression: A medical student’s perspective. Acad Med. 2021;96:765–766.
20. Malani PN, Zylke JW. Forty years of A Piece of My Mind. JAMA. 2020;323:1651–1652.
21. Karp N. Breaking the silence. The Pharos. 2015;78:30–31.
22. Dhaliwal MK. A PIECE OF MY MIND. My body, your crime: The anatomy of a medical note. JAMA. 2016;315:463–464.
23. Weinstein MS. Out of the straitjacket. N Engl J Med. 2018;378:793–795.
24. Fortescue EB. Oblivion. JAMA. 2018;319:1767–1768.
25. Fortescue EB. Mercy. JAMA. 2015;314:1231–1232.
26. Hill AB. Breaking the stigma—A physician’s perspective on self-care and recovery. N Engl J Med. 2017;376:1103–1105.
27. Gupta R. I solemnly share. JAMA. 2020;323:1712–1713.
28. Goldman ML, Shah RN, Bernstein CA. Depression and suicide among physician trainees: Recommendations for a national response. JAMA Psychiatry. 2015;72:411–412.
29. Wahl OF. Mental health consumers’ experience of stigma. Schizophr Bull. 1999;25:467–478.
30. 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.
31. Dyrbye LN, West CP, Sinsky CA, Goeders LE, Satele DV, Shanafelt TD. Medical licensure questions and physician reluctance to seek care for mental health conditions. Mayo Clin Proc. 2017;92:1486–1493.
32. Pheister M, Peters RM, Wrzosek MI. The impact of mental illness disclosure in applying for residency. Acad Psychiatry. 2020;44:554–561.
33. Moutier C, Cornette M, Lehrmann J, et al. When residents need health care: Stigma of the patient role. Acad Psychiatry. 2009;33:431–441.
34. Dunn LB, Green Hammond KA, Roberts LW. Delaying care, avoiding stigma: Residents’ attitudes toward obtaining personal health care. Acad Med. 2009;84:242–250.
35. Chang E, Eddins-Folensbee F, Porter B, Coverdale J. Utilization of counseling services at one medical school. South Med J. 2013;106:449–453.
36. Dyrbye LN, Eacker A, Durning SJ, et al. The impact of stigma and personal experiences on the help-seeking behaviors of medical students with burnout. Acad Med. 2015;90:961–969.
37. Roberts LW, Warner TD, Rogers M, Horwitz R, Redgrave G; Collaborative Research Group on Medical Student Health Care. Medical student illness and impairment: A vignette-based survey study involving 955 students at 9 medical schools. Compr Psychiatry. 2005;46:229–237.
38. Merlo LJ. Healing physicians. JAMA. 2016;316:2489–2490.
39. Martin A, Chilton J, Gothelf D, Amsalem D. Physician self-disclosure of lived experience improves mental health attitudes among medical students: A randomized study. J Med Educ Curric Dev. 2020;7:2382120519889352.
40. Aggarwal AK, Thompson M, Falik R, Shaw A, O’Sullivan P, Lowenstein DH. Mental illness among us: A new curriculum to reduce mental illness stigma among medical students. Acad Psychiatry. 2013;37:385–391.
41. Vaa Stelling BE, West CP. Faculty disclosure of personal mental health history and resident physician perceptions of stigma surrounding mental illness. Acad Med. 2021;96:682–685.
42. Verghese A. Writing medicine. JAMA. 2020;323:1649–1650.
43. Coverdale J, Balon R, Beresin EV, et al. What are some stressful adversities in psychiatry residency training, and how should they be managed professionally? Acad Psychiatry. 2019;43:145–150.