#17 Addressing the Broader Landscape of Physician Mental Health

September 6, 2022 | By Nora Taranto

Building a Culture of Wellness with Dr. Elisabeth Poorman

We’re joined by Dr. Elisabeth Poorman (@DrPoorman) to discuss the impactful and very important topic of mental health in health professionals.  Dr. Poorman reviews the current data regarding prevalence of burnout and mental health conditions, as well as specific and actionable ways we can create a more holistic and healthy environment in the field of medicine.

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Credits

• Producer-Writers: Nora Taranto, MD; Beth Garbitelli, MD  
• Show Notes, Cover Art: Beth Garbitelli, MD
• Infographics: Molly Heublein, MD
• Hosts: Era Kryzhanovskaya, MD; Molly Heublein, MD; Nora Taranto MD 
• Audio Editor: Clair Morgan of nodderly.com
• Guest: Elisabeth Poorman, MD

CME Partner: VCU Health CE

Show Segments

• Intro, disclaimer, guest bio
• Guest one-liner, Picks of the Week
• Case from Kashlak
• Defining Burnout
• Strategies for broaching topic with learners/colleagues
• Signs of depression, burnout
• Statistics, prevalence of depression 
• Practices and mindsets to encourage introspection
• National interventions, racism in medicine
• Fighting barriers to care
• Outro

Physician Wellness Pearls

1. The phrase ‘burnout’ conceals rather than reveals. Let it  raise your awareness and consider asking a bit more to understand the context for your colleague or learner.
2. Inquiring to a colleague about their mental health, wellness, or burnout can be seen as a compassionate action or an incredibly intrusive one.  Be mindful of your existing relationship with the person as well as how (and where) you choose to approach this topic with them. 
3. Dr. Poorman recommends persons in leadership to normalize and model seeking help (including counseling, therapy, and psychiatric care) by example. 
4. Discussing our emotional experiences in medicine can be a helpful framework for building wellness, per Dr. Poorman.  Writing, even if you don’t publish, is a helpful practice and a way to reflect on your daily life. 
5. Check out the Emotional Wellbeing Support Hub from the ACP. The webpage offers a list of free or low cost resources for emotional health, therapy, and counseling. 

This is a sensitive topic. If this is triggering for anyone listening, the national suicide hotline number 1-800-273-8255. Moreover, if anyone needs or wants guidance on available resources, Dr. Elisabeth Poorman has made herself available via email at doctorpoorman@gmail.com, or you may reach out to any of us on Twitter (Era @EraKryzhMD, Nora @Norataranto, Beth @bethgarbitelli) We are happy to talk and see that you get the support you need.

Physician Mental Health – Show Notes

Defining The Terms

The COVID pandemic is unlike anything our healthcare system (or country) has seen in recent memory.  Dr. Poorman believes that when colleagues, especially in leadership roles, are dismissive of the unprecedented nature of the pandemic, it can be hurtful to learners navigating this landscape.  

Burnout is an occupational phenomenon defined by chronic exhaustion and a sense of disconnection from work, due to repeated experiences of helplessness, devaluation, and feeling unheard. It is a coping mechanism for that sort of environment.  It can appear similar to depression but it is distinct. 

The phrase ‘burnout’ conceals rather than reveals. Does this mean the resident had a particularly rough week? Does it mean she is suffering from mild or even severe depression?  Let the phrase raise your awareness and consider asking a bit more to understand the context. 

Checking in with a Colleague or Learner

Inquiring to a colleague about their mental health, wellness, or burnout can be seen as a compassionate action or an incredibly intrusive one.  Be mindful of your existing relationship with the person as well as how (and where) you choose to approach this topic with them.  Try to avoid inquiring about mental health in public areas or prior to busy/stressful times such as while rounding or just prior to rounding.  

Keep the relationship dynamic in mind. If you are someone who is evaluating this learner, the conversation can feel very threatening if it is not initiated in the right way.  Modeling your own vulnerability (ex: open, frank discussions about the challenges you have faced in medicine) as well as working on building an organic relationship with your learner are ways to build a safe space. 

From Dr. Poorman’s personal experience: Wanting to ‘fix’ the situation caused a lot of harm for her, especially if the ‘fixing’ took the form of invalidating her feelings.  One strategy that did work for her was when colleagues made time to meet with her outside of work and validated what she was experiencing. 

Lower the Activation Energy to Access Care

Residents often express distrust regarding the confidentiality around therapy/counseling and/or psychiatric help that is provided by residencies (And sometimes these concerns are valid!) (Aaronson 2018, Gold 2015).  Dr. Poorman recommends persons in leadership to normalize and model seeking help (including counseling, therapy, and psychiatric care) by example. 

Make accessing help easy for residents and emphasize the confidentiality that is offered by various services (as well as its limitations). 

What are Signs of Burnout and Depression?

One of the most common misconceptions about this topic is that burnout and depression are always concomitant with performance impairment.  Per Dr. Poorman’s expert opinion, by the time that mental health concerns are impacting a medical professional’s work, the illness is usually quite severe.  Irritability and conflict escalation are other manifestations of psychological distress.

But, sometimes, there are no signs of suicidal ideation or depression that are visible to colleagues.  We need to change the system so that medical professionals do not feel fear when seeking help.  If we conceptualize mental health as an important aspect of our professional life and prioritize processing the traumatic aspects of our job, this cultural sea change might help save lives. 

Depression by the Numbers

Approximately 1 in 4 medical students screen positive for depression in pre-pandemic studies and more than 10% had contemplated suicide (Rotenstein 2016). Only 1 in 6 of those with symptoms of depression sought care. The most common reason for not seeking care involved fear of career impacts (Rotenstein 2016). Approximately 40% of interns (pre-pandemic!) experience a major depressive episode in their first year  (And some associations with depression symptoms: “Poor faculty feedback and inpatient learning experience, long work hours, and high institutional research rankings” (Peireira-Lima 2019.)) A large swath of attending physicians also report active depression (Outfhoff 2019). Pandemic has increased distance between folks  and worsening depression and anxiety symptoms in pandemic (CDC 2021). Everyone is really struggling.

Encouraging Introspection

Discussing our emotional experiences in medicine can be a helpful framework for building wellness, per Dr. Poorman. Writing, even if you don’t publish, is a helpful practice and a way to reflect on your daily life. 

Dr. Poorman recommends maintaining relationships with persons outside of medicine. Sometimes, we in medicine normalize the situations that we experience and this can cause damage. Getting feedback from friends and family who are not in medicine can be grounding and helpful. 

(Note: If you are a physician treating other physicians, be wary of over-identifying or normalizing experiences. You don’t know exactly what the person went through/is going through just because you are both in medicine. Everyone has their unique experience and this can lead us to miss things or to make the person feel not heard if we assume too much about what they are going through.)

Toolbox for what Training Programs Should Have:

1. Opt-Out Therapy: Consider offering this through independent providers, as because many residents will not trust seeing someone residency or even hospital-affiliated.  Individuals in health care may not self-refer because of fear of stigma or resources and time (Gold 2015; Aaronson 2018).  Opt-out interventions are feasible and improve self-reported wellness (Major 2021). 
2. Appropriate Time for PCP Visits: Residency is physically demanding and we all get sick. Residents need protected time to see a medical professional to address acute and chronic concerns. Consider having protected time during orientation/onboarding if possible.
3. Debriefing Sessions: Regular debriefs can be useful in how residents process traumatic experiences and normalize experiencing and confronting emotional responses.   These should ideally be run by a mental health expert, and someone who is not in an assessment role.

You have to mindfully consider privacy concerns for all of these interventions. 

National Interventions for Physician Mental Health

We need to have a conversation about what kind of doctors we want and ask ourselves: are we training physicians to be that way?  Are we setting up a system that allows wellness in physicians and healthy empathy?  Full-stop: Humiliation as a tool of education should be eliminated.  Dr. Poorman believes we should not emphasize memorization, but emphasize how we work through new information. She also believes we need to teach and guide learners on how to display empathy as well as manage empathy in medical practice.

Racism and Homophobia in the System

There is a lot of racism baked into not only patient care, but how medical professionals interact with each other (Check out some of our other episodes on these topics: #222 Addressing Anti-Black Racism in Medicine Utibe Essien MD, MPH, #6 Anti-Racism in Medical Education, #48: Anti-Racism Series: Foundations with Dr. Ben Danielson).  One example: The persistent lack of diversity in medical schools and the physician workforce.  We should continue focusing on recruiting residents of diverse backgrounds, but we also need to think about how burdens may impact these residents (Ex: Ongoing conversations about anti-black racism will impact Black residents more than non-Black residents.) 

Consider how feedback can be racist.  Implement ways of coaching evaluators on how to give feedback that is less racist.  We could adopt structures where this is a feedback review process before it is given to the individual (and contact the individual who provided racist or sexist feedback before giving it unfiltered to a person). 

Barriers to Care

Many states licensing boards ask about mental health in a way that can be stigmatizing and discriminatory, per Dr. Poorman. Additionally, researchers have found that some of these questions actually violate the Americans with Disabilities Act regulations (Gold 2017). Among states that query about mental health in license applications about half limit their questions to functional impairment and only 6 limit their question to current issues (Gold 2017). Credentialing and licensing concerns are a major barrier to medical workers seeking care (Dyrbye 2017, Arnhart 2019). 

Privacy concerns are another issue. Dr. Poorman advocates programs utilize external therapy and mental health resources as it can generate more trust for their residents. She also recommends that residency programs work actively to walk residents through what to expect with licensing questions and how to answer with confidence. 

A coalition affiliated with The Institute for Health Improvement is working on ways to remove stigmatizing licensing questions. Check out an interview here. For more information contact: Saranya Loehrer, MD, MPH: saranya@c3c.org and Ankita Sagar, MD, MPH, FACP: Ankita.Sagar@commonspirit.org

Resources for more information!

Check out the Emotional Wellbeing Support Hub from the ACP. The webpage offers a list of free or low cost resources for emotional health, therapy, and counseling. 

Take Home Point: Emotional distress (and mental health issues)  are very common in medical school, residency, and medical practice. To be a great clinician requires you to be introspective about how your job affects you. And we need to advocate for humane practices for medical professionals. 

Please check out our episode #4 Learner Mental Health with Dr. Chantal Young for more on this important topic. 

Links

1. Dr Poorman’s recommendation: Ms. Marvel (TV Show) 
2. ShirlywhirlMD (Instagram, Twitter)
3. On Rotation by Shirlene Obuobi
4. Grace Parris (Instagram, Twitter) 
5. Nora’s pick of the week: Ozark (TV Show) 
6. Era’s pick of the week: Esther Perel’s Where Should We Begin? (Podcast) and Where Should We Begin (Card Game)
7. Institute for  The Institute for Health Improvement and Impactinhealthcare.org are advocating for reducing stigmatizing language in health care licensing if you want to get involved.

Goal

Listeners will gain greater insight into the prevalence and scope of mental illness in physicians, how COVID19 has amplified the problem, and how to begin to address it. 

Learning objectives

After listening to this episode listeners will…  

1. Identify the changing rates of depression during medical training
2. List the predictors of burnout and how burnout is different from depression  
3. Recognize the role of systemic barriers to seeking care for mental illness   

Disclosures

Dr. Poorman reports no relevant financial disclosures. The Curbsiders report no relevant financial disclosures. 

Citation

Poorman E, Taranto N, Garbitelli B, Heublein M, Kryzhanovskaya E.. “#16 Addressing the Broader Landscape of Physician Mental Health”. The Curbsiders Teach Podcast. http://thecurbsiders.com/teach.  September 6, 2022.