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Invited Commentaries

Physician Mental Health: My Personal Journey and Professional Plea

Kirch, Darrell G. MD

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doi: 10.1097/ACM.0000000000003942
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Abstract

While my own mental health journey has been very personal, as described below, it has occurred in the larger context of health trends in the United States and globally. A key feature of that context is the research documenting mental disorders to be highly prevalent among the population. Survey data for 2019 reported by the Substance Abuse and Mental Health Services Administration (SAMHSA) indicated that 20.6% of all U.S. adults ages 18 or older experienced a mental illness in the prior year (an increase from 17.7% in 2008). 1 These 51.5 million adults had mental disorders across the full diagnostic spectrum, ranging from anxiety and mood disorders, to substance use disorders, to schizophrenia and bipolar disorder. Likewise, the degree of impairment experienced by those affected ranged from mild to severe. Virtually all of us personally have experienced or know someone who has or had a mental disorder.

In the SAMHSA study, women overall had a higher prevalence of mental disorders than men (24.5% vs 16.3%), a finding of importance to the practice of medicine given the growing percentage of women entering medical school and the physician workforce. 1 In terms of age, the cohort with the highest prevalence of mental disorders (29.4%) was those ages 18 to 25 (the group into which most premedical and many medical students fall), decreasing to 25.0% for those ages 26 to 49 and 14.1% for adults ages 50 and older.

While data from rigorous, large-scale, longitudinal epidemiologic surveys, such as the findings in the SAMHSA report 1 cited above, are not available for physicians as a specific profession, there is no reason to assume that somehow physicians are spared from experiencing mental illness, just as they are susceptible to most other medical disorders. In fact, the unique stressors of medical training and patient care demands, including long hours, might in and of themselves be factors that can threaten the mental health of physicians and other health professionals. Medical students have been one cohort frequently studied for the prevalence of mental disorders, especially depression and suicidal ideation. A recent systematic review and meta-analysis showed an overall crude pooled prevalence of 27.2% for depression and depressive symptoms and 11.1% for suicidal ideation among medical students. 2 Notably, this same report showed that only 15.7% of students who screened positive for depression sought psychiatric treatment.

The challenges to improving physician mental health have become painfully apparent in the course of the current COVID-19 pandemic. On a daily basis, media reports have highlighted the stress on and distress experienced by all health professionals on the front lines of caring for infected patients. This “parallel pandemic” of workplace burnout and a wide range of mental disorders, as well as tragic cases of suicide, experienced by clinicians during the COVID-19 pandemic may very well long outlast the challenge of fighting the coronavirus, having a negative impact on physicians and other health professionals for years to come. 3

All these epidemiologic facts make it exceedingly timely for Academic Medicine to focus on mental health in physicians and those training for careers in medicine. The simple reality is that becoming a physician in no way removes one’s shared human vulnerability to mental disorders. There are likely multiple social and cultural factors, including art and literature, that contribute to an indelible image of the “idealized” physician that many individuals bring to their career in medicine, even before their first day in medical school. In the simplest terms, this physician is one who confidently and unfailingly gives care, not one who needs care—especially mental health services. When this idealized image of the care giver is combined with the ongoing all too common stigmatization of mental disorders, the net result often is that a medical student, resident, or physician who is experiencing the distress of a mental disorder does not seek help, even when their level of distress represents a major threat to their well-being and possibly to their training and career. At such a point, it may be extremely hard for the physician to recognize that their caring instincts, as well as vulnerabilities and need for care, are quintessentially human. 4

My Personal Journey

The simple fact that to care is human, and the acknowledgment that every physician is vulnerable to mental illness, just like any other medical problem, only recently has become something I personally have been willing to talk and write about publicly. While I have progressed through a long, gratifying, and arguably successful career in medicine, I am (and for decades have been) one of those adults who lives with mental illness.

My story began long before medical school. After learning more about my family medical history, it now seems clear that there very likely is a genetic predisposition to both anxiety and depressive disorders in my family. My mother experienced what appears to have been a severe postpartum depression shortly after I was born. While beyond the reach of my memory, there is no doubt for me that our normal maternal–child bonding process was seriously disrupted. Not surprisingly, from my earliest memories I experienced symptoms and showed signs of disabling anxiety and social phobia. My problems were greatly exacerbated when I also experienced childhood abuse by a “trusted” adult in my life. Nevertheless, while suffering from significant psychiatric symptoms as a child and adolescent, I was fortunate to find some degree of refuge as a high-achieving student.

I never spoke about these early struggles, and they certainly were not something I shared with teachers or others who might have helped. Subsequently, I experienced another major trauma during college. One summer, while working on a surveying crew high in the Rocky Mountains, I witnessed and was first on the scene of the fiery crash of a chartered passenger aircraft that hit a mountain near the timberline at the Continental Divide. Thirty-one people died, some of them after my fellow surveyors and I carried their badly burned bodies down the mountainside. There was no critical incident debriefing or counseling made available to those of us who witnessed the crash. My life went on, and I decided to become a premedical student on my return to college.

I learned that the trauma of that plane crash had not left me; it returned with a vengeance during my first year of medical school while I was working with a cadaver in the gross anatomy lab. I experienced the onset of a severe panic disorder that made me seriously consider abandoning the idea of a career in medicine. What kept me in medical school was the thoughtful support of an attentive student affairs dean. He encouraged me to remain in school, and his advice resulted in my being referred to a psychiatrist who, for the first time, recognized and appropriately medicated my intense anxiety and the comorbid depression that had developed.

To this day, more than 4 decades later, I continue treatment for my chronic anxiety disorder, depressive episodes, and related psychological challenges. That treatment has allowed me to have a long and productive career in academic medicine. But it is only now that I am publicly sharing my lifelong struggle with mental disorders with the same openness with which I have routinely discussed my professional work.

Why did it take me so long to reveal this dimension of my personal journey? I confess that, despite my struggles as a child with both anxiety and depression, I was among those who entered medicine with that idealized image of the doctor as one who gives care but who is somehow beyond needing care. I think I actually believed that becoming a physician would somehow “protect” me from further mental distress. Even when that image was shattered by a surge of panic attacks and then depression during my first year of medical school, and even when I was able to remain in school only with the help of a capable psychiatrist, I kept my struggles scrupulously private. In hindsight, I fell victim to the dangerous belief that in any way acknowledging my own challenges with mental illness would somehow lessen me in the eyes of colleagues, patients, and even friends and family. Rather than pushing back on the stigma of seeking mental health treatment, I succumbed to it.

I served as the dean at 2 medical schools for a total of 13 years. Tragically, on more than one occasion, I received a phone call informing me of the terrible news that one of my students had died from suicide. I now wonder what the impact would have been if, as part of my greeting to the new medical students each year, I had shared the story of my own mental health crisis and successful treatment as a first-year student. I have to believe that seeing their dean share such a story might have been remembered by those students who died and might have led them to seek treatment rather than take their own lives. This brings me to my plea.

A Professional Plea

At the risk of falling back on a tired aphorism, I truly hope that the phrase “better late than never” aptly captures my speaking out in this manner at this time. My long delayed, but deeply felt, plea to my fellow physicians is that more of us share our personal stories of meeting the challenge of mental illness. The epidemiology is clear. Mental disorders of all types are highly prevalent among adults, and there is no reason to believe that being a physician somehow exempts us from that prevalence. The research findings regarding mental health issues in medical students, residents, and physicians bear that out. If more of us are willing to describe our own journeys through mental disorders and, most importantly, how we have benefitted from treatment and been able to thrive in our careers, eventually we will reach a tipping point of destigmatization. The salutary result could be fewer of our colleagues suffering in silence and more taking advantage of the steadily improving treatments that are available.

Recent medical research, as well as the popular media, has shown an unprecedented level of awareness regarding the issue of burnout in clinicians, as well as the challenges of mental disorders and even suicidality among health professionals. The National Academy of Medicine has created an action collaborative on clinician well-being and produced a consensus study on how health care organizations can take a systems approach to promote that well-being. 5 General awareness of these issues has increased, and professional organizations and health care systems are taking active steps to improve the well-being of physicians and other clinicians.

But beyond these steps, I believe the personal narratives of physicians who describe their own mental health journeys can be an incredibly powerful tool. 6 Sharing that personal narrative with colleagues, and especially with struggling students or residents, may actually be lifesaving. Especially at a time when medical students, residents, and physicians are fighting a global pandemic and facing stressors unprecedented in our lifetime, there never has been a better time to share our stories.

References

1. Substance Abuse and Mental Health Services Administration. Key Substance Use and Mental Health Indicators in the United States: Results from the 2019 National Survey on Drug Use and Health (HHS Publication No. PEP20-07-01-001). 2020.Rockville, MD: Center for Behavioral Health Statistics and Quality, Substance Abuse and Mental Health Services Administration;
2. 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.
3. 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.
4. Dzau VJ, Kirch DG, Nasca TJ. To care is human—Collectively confronting the clinician-burnout crisis. N Engl J Med. 2018;378:312–314.
5. National Academies of Sciences, Engineering, and Medicine. Taking Action Against Clinician Burnout: A Systems Approach to Professional Well-Being. 2019.Washington, DC: National Academies Press;
6. Charon R. The patient-physician relationship. Narrative medicine: A model for empathy, reflection, profession, and trust. JAMA. 2001;286:1897–1902.
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