The Physicians as Humans Project was launched by Niresha Velmurugiah last week to much acclaim. More than a handful of physicians have already responded indicating their willingness to share the story of their struggles with the CanadiEM community. Today Bruce Fage, a psychiatry resident from the University of Toronto, kicks off our series of true stories with a fictional one. We hope that it, and its supporting text, resonate with you and help us all to realize how important this conversation is. -CanadiEM Editors @WeAreCanadiEM
Kate is a 22-year-old woman from the Greater Toronto Area. She is desperate to get into medical school.
She grew up quickly after her parents’ divorce, but has many happy memories of spending time after school at her dad’s busy downtown ophthalmology practice, playing with the equipment when he wasn’t looking. As Kate grew up, she became enamored with the notions of ‘helping people’ and becoming ‘a lifelong learner’ like her father. Kate knew she was destined for a career in medicine.
After successfully completing a competitive four-year life sciences thrill ride, Kate was shocked and dismayed by her nationwide medical rejection tour. Gathering her broken dreams, she resolved to rewrite the MCAT and pursue a Master’s degree in epidemiology to improve her chances during next year’s application cycle.
Rejoice! Midway through her graduate degree, Kate was finally accepted to the distributed site of her first-choice medical school. For the first five months, Kate is happy, but then her constant self-comparisons to her colleagues start to bring her down. Why hadn’t her half-finished Master’s degree been more productive? Why hadn’t she run a marathon, or saved a small African nation from a terrifying epidemic? Was she the only human being who hadn’t yet been to Thailand? Discouraged but not yet broken, she once again picked up the pieces and set out to become the most researchiest, well-travelled, superiorly-athletic, and accomplished medical student there ever was, for as her father frequently texted, “never give up.”
As the years fly by moments of absolute terror periodically punctuate Kate’s existence which she fears will define her career and personhood: securing the right summer research grant, picking the right clerkship stream, and schmoozing with the right elective supervisors are the tasks of the day. Each success confers a brief reprieve before self-doubt claws its way back into the forefront.
Jealousy courses through Kate’s veins when Match Day comes for the class before her, but she knows that when she matches, she will finally be happy. The CaRMS tour brings weekly panic attacks, but she perseveres through the late-night anxiety and polar vortex/interview season with the help of some Ativan from the local walk-in clinic. Ultimately, she matches to her first-choice discipline in her second-choice location.
Life is perfect. Kate finishes her exams, books her parents separate hotels for graduation, and heads off for a month in Croatia with her BFFs. She knows she will be happy forever, ignoring that nobody in her specialty has been hired in the past two years.
You know Kate, or you are Kate.
Kate’s stress is familiar; we’re all a bit guilty of wishing for the next milestone to arrive sooner. We believe that the next hit of external success will placate our internal need for fulfillment, if only for a short-lived moment.
But what happens when things go wrong? Despite our best intentions, sometimes our actions result in a patient’s bad outcome. Sometimes our storybook lives take a turn for the mediocre.
The Stigma of Mental Illness in Medicine
In the competitive and paradoxically-isolating era of modern medicine and social media, we must reduce the stigma of not only mental illness, but also of occasionally being less than stellar. Improvements in work environment and lifestyle balance are key to improving the physician condition, but we must also endeavor to support each other with empathy and compassion for the benefit of our patients and our health care system.
Physicians kill themselves at a greater rate than do the general public and are more successful in completing the act.1,2 Women are particularly affected. Surveys show that stress reaches a fever pitch in medical school, and dissatisfaction and burnout take hold early in residency.3,4 External pressure makes itself felt well before medical school even begins; the 2014 Ontario medical school application season saw 954 successful applicants of out 6593 hopefuls.7 Contemporary doctors are coming of age in a time when physician engagement is low, burnout is high, financial pressures are increasing, and patient contact is decreasing along with practitioner autonomy.6
I have heard older-school physicians lament the modern infantilization of medical students. They tell tales of 30-hour workdays and performing appendectomies with naught but a pinecone and a bottle of whiskey (on the first day, no less). To be sure, medical education should not be without rigour or struggle, provided that empathic support is readily available. A systematic review of psychological distress in American and Canadian medical students suggested high levels of depression and anxiety, particularly among students with maladaptive or socially-prescribed perfectionism.9 A survey of 505 American medical students estimated the prevalence of moderate to severe depression at 14.3%, with the presence of suicidal ideation rising to 7.9% among fourth-year students.5 It is one thing to yearn for the shame-based days of yore, but when people are dying, it’s just not okay anymore. We cannot allow the formative process of medical education to result in summative tragedies.
A large-scale study of violent death in the United States found that physicians who completed suicide were significantly more likely to have experienced recent “job problems” (disagreement with a coworker, poor performance reviews, increased pressure, feared layoff, or joblessness) than their counterparts in the general public, despite similar rates of mental health disorders in the two groups. Physicians were no more likely to use antidepressant medications but were much more likely to have used benzodiazepines, antipsychotics, or barbituates, illustrating selective (and suboptimal) access to care.2 A 2008 national study of Canadian physicians reported that 26.5% of respondents felt that mental health concerns had had an impact on their ability to handle workload at some point during the past month. Further, 23.2% reported feeling depressed for more than two weeks.8 Regrettably, 14.5% of respondents were not aware of resources they would feel comfortable accessing for mental health. Stigma remains prevalent in our profession, and is a barrier to living well.
Poor physician wellness and mental health distress is unfortunate and damaging. It’s also prevalent, and adversely affects physician recruitment, retention, workplace productivity, quality of care, and patient safety.10 When self worth hinges on the approval of others, as it often is for physicians and physician-hopefuls, any public failure is devastating. Professional errors are inevitable and can feel damning. Doctors often internalize shame. A study analyzing medical student’s experience of medical error found that exposure to significant errors was common and could lead to severe distress that persisted and often went unaddressed. Some students who attempted to discuss errors were discouraged from doing so by their seniors.13
Physician Mental Health: Back to Kate
What if, instead of turning to Ativan and self-doubt, Kate felt comfortable voicing her concerns and fear of failure to her classmates? Support from co-workers correlates with well-being, even in the face of increased work stress. It is hypothesized that this support helps to provide a buffer against the negative effects of stress,12 suggesting we need more than a much-contended reduction in work hours. Help-seeking behaviours are stigmatized in medicine, however, and we consequently do poorly at providing mutual support.10 There is something within our character and culture, something engendered by the hypercompetitive world in which we learn and practice, which drives us toward accomplishment and shames us when we fail.
Medicine is full of well-meaning overachievers who strive for perfection but fail to recognize the futility of that quest.11 After investing so much of ourselves in achieving a singular goal, we realize that there are ever more accomplishments to reach for. A central conflict in the life of a medical learner is understanding how to be intrinsically happy and satisfied without the approval of others, and maintaining that happiness in the certainty of future error.
In the era of competency-based education, let’s move our profession forward by adding resilience and empathy for our colleagues to the list of professional activities. Medicine is a stressful path, and medical education can be particularly trying. The Canadian public deserves thoroughly trained – and healthy – physicians. The challenges we face are too great, too overwhelming, for us to abandon each other in stigma.
We are both powerful and fragile, and that’s okay.
- Schernhammer, E.S. Colditz, G.A. (2004) Suicide Rates Among Physicians: A Quantitative and Gender Assessment (Meta-Analysis). American Journal of Psychiatry, Vol. 12 (161).
- Gold, K.J. Sen, A. Schwenk, T.L. (2013) Details on suicide among US physicians: data from the National Violent Death Reporting System. General Hospital Psychiatry, Vol. 35(1).
- Cohen, J.S. Patten, S. (2005) Well-being in residency training: a survey examining resident physician satisfaction both within and outside of residency training and mental health in Alberta. BMC Medical Education, Vol. 5(21).
- MacLean, L. Booza, J. Balon, R. (2015) The impact of Medical School of Student Mental Health. Academic Psychiatry, DOI: 1007/s40596-015-0301-5
- Schwenk, T. Davis, L. Wimsatt, L. (2010) Depression, stigma, and suicidal ideation in medical students. JAMA, 304(11), 1181-1190.
- Lister, E. Ledbetter, T. Warren, A. (2015) The Engaged Physician. Mayo Clinic Proceedings, 90(4), 425-427
- OUAC Application Statistics Website, Medical School Applications Statistics. http://www.ouac.on.ca/statistics/med_app_stats/
- Compton, M. Frank, E. (2011) Mental Health Concerns among Canadian physicians: results from the 2007-2008 Canadian Physician Health Study. Comprehensive Psychiatry, 52(5), 542-547.
- Drybye, L. Thomas, M. Shanfelt, T. (2006). Systematic Review of Depression, Anxiety, and other indicators of psychological distress among U.S. and Canadian Medical Students. Academic Medicine, 81(4), 354-373.
- Wallace, J. (2009). Physician Wellness: A missing quality indicator. Lancet, 374(9702), 1714-1721
- McManus, I. Keeling, A. Paice, E. (2004). Stress, Burnout, and doctors’ attitudes to work are determined by personality and learning style: a twelve year longitudinal study of UK medical graduates. BMC Medicine, 2(1), 29.
- Wallace, J. Lemaire, J. (2007). On physician well being – you’ll get by with a little help from your friends. Social Science and Medicine, 64(12), 2565-2577.
- Martinez, W., & Lo, B. (2008). Medical students’ experiences with medical errors: an analysis of medical student essays. Medical education, 42(7), 733-741.