Latest / Off the Chart: A Business of Medicine Podcast / S1 Ep103: Physician mental health: A silent crisis, with Daniel Saddawi-Konefka, M.D., MBA, and Christine Yu Moutier, M.D.
Transcript
- 0:00 30% of physicians have depression, 10% of physicians have had suicidal ideation, and one to two and a half percent have attempted suicide. Relative to how big it is, we don't hear about it all that much. 0:22 Well, welcome to off the chart of business and medicine podcast featuring lively and informative conversations with healthcare experts, opinion leaders and practicing physicians about the challenges facing doctors and medical practices. My name is Austin Luttrell. I'm the Assistant Editor of medical economics, and I'd like to thank you for joining us today. In today's episode medical economics, senior editor Richard pearton speaks with Dr Daniel sadawi knevka, an anesthesiologist, co founder and president of the emotional PvE project, and Dr Christine yumuchi, a psychiatrist and Chief Medical Officer of the American Foundation for Suicide Prevention. They're co authors of a recent JAMA paper on reducing barriers to mental health care for physicians. In this conversation, they're going to discuss why stigma culture and outdated licensing practices still keep many physicians from getting the help that they need. They'll also talk about what meaningful change looks like, from reforming credentialing questions to improving mental health education in medical school. Dr sadawi ganefka and Dr Moute. Thank you both so much for joining us, and now let's get into the episode. 1:24 Thank you both for joining us today. 1:25 Pleasure to be here. Thank you for having us. Regarding 1:29 the article with the special communication, it was a great summary I thought of, like I said, challenges and resources. Can you talk a little bit about how that came about and why it was important to bring this to public attention yet again? 1:43 Yeah, absolutely, I guess on a on a personal note, I serve as the program director for the anesthesiology residency at Mass General and I've seen firsthand how mental health conditions get ignored or sort of framed as just a phase, something that'll pass. I see how it gets in this in the way of performance and well being, and then more personally, I've lost colleagues and mentees to suicide. And seeing these barriers and this treatment gap became something that was very personal and something that I felt we really ought to be able to improve. 2:28 Yeah, very similar for me, just, you know, many, many years in academic medicine of experiencing a disconnect between the real struggles and real human issues physicians and trainees face, and kind of the environment and how that was being addressed at the time, and a lot of lot has been changing over the years, but I think this we felt this subject was timely, because a lot of efforts are ongoing, maybe a bit fractured and and that it was time for kind of a summing up of where is the sort of state of things at this present time, and certainly in this kind of post covid era, the mental health of physicians and other health workers as well could not be of more importance. Still, it's we're not over. And we always had said during covid that the effects of this pandemic are going to be felt in terms of a mental health kind of repercussion for a long time to come. And I, and I think we're, you know, whether you frame it in terms of covid or other things, we're still definitely in the thick of it. 3:47 You know, that's a great segue. And to continue along, maybe with that thought both of you would, you take a moment and in your own words, how would you describe the current state of mental health among physicians and other clinicians in the United States. 4:02 What strikes me about the data is how hidden the mental health struggles are. It's around 30% of physicians have depression, 10% with 10% of physicians have had suicidal ideation, and one to two and a half percent have attempted suicide. Those numbers are incredibly high amongst trainees in the US. Suicide is the leading cause of death, but we, relative to how big it is, we don't hear about it all that much. And I think the silence around the statistics really underscores how deeply embedded the stigma is and the barriers to help seeking our overall it's fewer than 1/3 of physicians will actually seek help for for bonafide mental health conditions that could really benefit from help. 4:49 Yeah, and I'll just add to that, that that that silence around these issues is particularly. Be vexing when, as a field, most organizations and leaders are trying to do something about it and actually care a great deal, and yet, the culture, the pressures, the policies, any number of real, you know, complicated issues that we we try to break down in terms of the solutions, potentially to these barriers, they're still creating that tremendous gap between suffering and the ability to access treatment and care and support like we would for any other type of health issue. So yeah, we're very we're very pleased that that our kind of summing up of this was, was was put forth by Jama. 5:54 And you know what doctor in our earlier conversation? This goes back to a couple years ago, and I remember the point well, because you made a distinction between mental health conditions and workplace burnout, and even in that special communication, you wrote that critically differentiating burnout from diagnosable mental health conditions is essential for appropriately addressing physician mental health. Can you discuss that distinction and why appropriate recognition is so important. 6:23 Yeah, and you know, my I'm coming at this, you know, I've devoted my life and my career now to suicide prevention. So of course, I'm coming at this through the lens of the issues that elevate risk for suicide and the things that we can do about that. And the biggest concern, I would say that I have around any conflating between burnout, which is its own serious issue, and experience, and clinical depression, is that there has been, I think, a sort of well, they can co occur first of all, and there is some overlap In the symptoms and the experience. But when burnout is more normalized and acceptable to talk about, then we might miss the opportunity to actually have treatment that could make a huge difference for the person's life, and actually could be life saving. So there is data now that is a little bit more clear and helps us to understand that amongst, for example, in a UCSD study that I was a part of, amongst a sample of more than 2000 health workers, it included more than just physicians, but health workers Overall, about 52% met screening criteria for burnout, and About 48% met criteria for depression, and there was quite a bit of overlap. 33% had both, again by screening criteria. But what's, what was, the most important kind of compelling finding is that it was only the health workers who had the depression, whether or not burnout was present alongside it or not, who were at greater risk for suicidal ideation and other risk factors for suicide like hopelessness and very dire, extreme emotional states and anxiety and desperation. So it burnout had been discussed in some parts of the literature as a risk factor for suicide, but, and it could be for some, it could be along their path of risk, but on its own, is probably not strong enough that I would consider it a strong risk factor for suicide. So again, the most important thing being that recognizing a treatable health condition that's potentially life threatening is, is an essential thing to do and to not get that conflated with burnout. 8:48 I'll add just a quick thing, just in talking with my residents, other physicians these days, it's, it's almost as though burnout hasn't come to mean burnout, any form of distress is is just called burned out. Oh, I'm feeling a little burnt out. And really what they mean to be saying is that they're feeling distressed. And to Dr mots point, if we call all of it burnout, well, burnout requires organizational and systemic solutions, whereas mental health conditions, the treatments individual, it's psychotherapy and medications at times. And so if everything gets relegated to all forms of distress or just called burnout, then then we have physicians who are foregoing or delaying really critical therapies that could not only help prevent suicide, but dramatically improve their quality of life. 9:41 I think it's a great point and and hopefully we'll have a few minutes to touch on both some of those systemic conditions and some of the individual ones that may make have an influence. So far in our conversation, I think you touched on this and the article also meant. Questions about the culture of medicine. Definitely wanted to ask, how does the culture of medicine, including those long hours, perfectionism and reluctance to show vulnerability, contribute to clinician mental health struggles? 10:15 So we have a culture in medicine that's long rewarded stoicism and stress endurance and really has discouraged any acknowledgement of personal vulnerabilities. In fact, it's not even just that inadequate care is normalized. It's almost historically been celebrated. It's a badge of honor to work through illness. I know a mantra that I heard not, and I think I was of a vintage that it wasn't really like pushed, pushed on me, but I definitely heard the the saying, you know, if you cough up a lung, you shove it back in and you get back to work. And that, that being sort of the things that people would say with pride. So this, this culture creates this, this hero narrative, this invincibility complex, that unfortunately gets in the way of of physicians being able to show vulnerabilities and and follow that up with seeking help for conditions that would benefit from help. 11:15 I'll just add that in the broader societal culture we already are dealing with a bit of a challenge in terms of the stigma and misunderstanding of mental health and mental health conditions. You know, when you look at just the staggering sort of statistics that that one in four Americans will have a mental health condition, it's just these are matters of human health, whether it's genetics, early childhood, trauma, you know, any number of biological, psychological, social and environmental forces at play, just like for any health issue. So we as physicians are human beings, and then we come into an environment where that culture of toughness and stoicism had driven people with, you know, and look and while also we're going to medical school and training right during those years when the onset of mental health conditions, 75% of those those mental health conditions will have their onset by Age 24 and we're not recognizing the majority of them because we're writing them off to stress and other things. So you you kind of have a convergence of just human factors along with an environment in training and in practice that was really misconstruing reality, I would say, and I'll just point to an interesting part of our history that had driven so much of mental health suffering and conditions underground, that by the time they showed up and and the field of medicine had developed more specific pathways for physicians who were dealing with substance abuse and addiction problems, but again, by the time they surfaced, they were like stage four and required, you know, intervention and there was impairment going on. And so I think there was actually a learned, kind of a learned experience in the environment that taught some very incorrect assumptions about mental health conditions, which is that the large majority of physicians don't have them if they're in our environment. I've even, I was even asked the question when I started the education program with that was part of the hear program, a suicide prevention program at UCSD, asked the question, well, if these distress indicators are true, then our emissions process must not be doing their job. So there was an assumption that we could sort of screen out these these problems. So it was a really like stigmatized view of of these human health matters, of mental health conditions. The truth is, in terms of impairment, the vast majority of people with mental health conditions do not have a form of work impairment, just like that would be true for, you know, people with diabetes or hypertension, and the earlier you address it, of course, the more likely it is not it will not interfere with work. As far as big eye impairment, of course, it affects, you know, more subtle aspects of of performance. 14:25 You know what? Another really great segue to something that I wanted to ask about, because clearly, there are workplace conditions there, or I should, I want to phrase this the right way, I guess. But there are, there are. There's recognition, for example, for some physicians who may be in the workplace, but to take it a step back even earlier, so to speak, medical schools and their instructors are responsible for training new doctors and hold them to a high standard, to be sure, but there's also passing on those elements of that culture for medical schools and instructors. Question, what should be that role in addressing mental health, wellness and well being for physicians? 15:06 Well, there is a requirement for American medical schools to actually address well being and issues of mental health and have a supportive culture and policies and very specific requirements around faculty who have evaluative roles to not be treating clinically, treating medical students with mental health conditions. So so there are very specific sort of a framework that's that's required in order for medical schools to keep their accreditation? 15:44 I'll add, it's a really good question, Richard, because we know that fear of stigma, the desire for confidentiality, increases substantially even during med school. Med students come in with only about 30% of them being worried about the fear of stigma. It becomes over half of them by the time they finish training. So it is a really important thing. I think a lot of med schools, thankfully, are focused on improving the well being of their students. I think, I think a lot of the focus Lisa is my impression, not not working in um, me. But a lot of a lot of it does seem to focus on decreasing the discomforts associated with training, and then that's critically important. I think if we were to consider well being more holistically, it should also include curricula around the as Dr motier was saying, the commonality of these conditions, and also in those curricula the importance and the benefits of seeking help for these things, and probably also just as important training on how to recognize distress in yourself that might benefit from from help. So I think med schools have a have a significant focus on on well being, and I think they're I think a lot of them are doing exceptional things, and I think there's still an opportunity to elevate nationally the curricula around mental health and med students. 17:15 Yeah, and if you make it part of the curriculum, rather than kind of a side topic. I think you really normalize and elevate the importance that this is part of professional development and training, to recognize these as serious matters, to become proactive about it for ourselves as well as for our colleagues, and to really learn how to be a support to others. And you know, it's an interesting thing to start, you know, because I was a dean in a medical school to realize that modeling a level of human vulnerability does not lower your your reputation or your your ability to be effective. In fact, I think that's a very powerful way for educators and clinical leaders to actually move the needle and create psychologically safe environments so that all the people who work and learn under their their unit leadership can see that it's okay to be fully human and to address your health needs, to address your family's needs, and that there's a way to do that even with the busyness of, you know, a physician's life. 18:35 And one point in the article really caught my eye also, when you wrote that many physicians overestimate their ability to manage their health independently. Self medicating behavior is common. How frequently does that occur, and what risks does that create? You know, for the physician, for their occupational status and for patient care, 18:57 in terms of how common it is, the published reports show that between nine and 15% of physicians report having self prescribed antidepressants at some point. And that's not a sample of physicians with depression. That's that's a general sample of physicians. An additional 7% report getting anti person prescriptions informally from colleagues who are not in treatment roles. You know, I'll talk about maybe some of the risks there. I think Dr Mattia will probably have more to add. I see some significant ones for personal health, in terms of bypassing proper diagnostic evaluation, treating the wrong conditions, approach to medication management, those sorts of things. There's also, because of state medical board regulations, some potential legal vulnerabilities from self prescribing these medications as well. 19:50 The suicide literature for physician suicide decedents versus the general population decedents shows that. That physicians are who die by suicide are as likely to have been suffering from a mental health condition but are less likely to have been in any kind of formal treatment. And in fact, the self prescribing may may sort of thwart and divert from getting actual treatment. Because what we might do in the short term is try to treat the short term symptoms of insomnia or anxiety, and that may really actually prohibit the ability to have that full assessment to understand what is actually going on. And you know, there's still stigma amongst physicians to see a psychiatrist and to get a full assessment, just like you would if you were what you know, you weren't sure if it was a physical health matter, a serious one, you would go to a specialist, and you would find the one that you trust and and work with them and and so the other thing in the suicide literature that's very concerning is that the method of death is much, much higher in terms of toxic substances being there in the toxicity reports for Physician suicide decedents. So I actually view it as something that that is an is an issue of of of a high importance, that can present dangers for individuals, because when you're not well and you're trying to self manage, that, that can really, you know, lead to not only ineffective treatment, but But it actually increasing the dangers and the risks. 21:45 One of the things that that I definitely wanted to ask about, and you had noted in the in the article, the doctor Lorna Breen, heroes foundation and other organizations have pushed for substantial change toward limiting disclosure of mental health treatment for licensing and credentialing purposes. You've already touched on stigma in our conversation. How important are those efforts and what needs to continue to happen for additional success on that in the future? 22:14 I really think this is one of the linchpins of that is changing, thankfully, and must change in order for stigma to actually have a chance at at really coming down more dramatically. Now, the law is changing, and the questions that physicians and nurses are being asked on on licensure forms and recertification forms are really critically important to treat mental health just like physical health, not make assumptions of impairment. The questions should either not be there at all or they shouldn't function. They should center around impairment related to any health cause, and rather than singling out mental health, because there's really some loaded assumptions built in there. I think the thing is that that effort is important and must continue to full to get to all of the state's hospitals. Also need to change their privileging questions along those same lines, and that's kind of a separate advocacy effort that, again, the Lorna green heroes Foundation has been very effective at creating a toolkit that's simple enough to actually make those changes happen. I think the next stage that really needs to happen is a communication strategy so that physicians who are in various hospitals and states understand what their conditions are, and if they are in an environment where it will not even be probed if you, if you go into treatment. And of course, that's back to the self prescribing and the informal curbside stuff that is, in part because of this great fear. So we do need to know that that era is over, and we, you know, so, so we have some ways to go with that yet, but it's a very, very critically important part of this work. 24:10 Yeah, couldn't. Couldn't agree more, the one of the sort of landmark articles, as I see it, that came out in 2018 ish, was that in states that asked those questions, physicians are 21% more reluctant to seek care. So it's not just a hypothetical or something that we postulate. It's they're less likely to seek care and and I'll also echo that, I think it's sort of a critical first first step, because we if that, if that culture in these applications persists. It sort of gives life to all the stigma that follows. Now, I will say that even if all of the licenses and credentialing applications and malpractice insurance and commercial even if all of those were were fixed today, we would still have issues with stigma, issues with fear of getting jobs or. Getting into different residency programs, we'd still have the culture of stoicism and and we'd still have logistical barriers. So there's still a lot of work to be done, but it's such a critically important first step that it's just it's fantastic that that so many groups have been focused so so so intently on making sure that that's taken care of. Your 25:22 article includes a concise, multi level approach for overcoming barriers and seeking help. There were numerous options that you outlined, and wanted to ask both of you if there was one you'd really like to highlight. 25:35 Oh, gosh, it's hard to pick just one. I guess the way that I would look at approaching this important topic is to you know, if you're if you're a leader in a hospital or in a training program, don't go it alone. Find a team of like minded people who care deeply and passionately. Try to get leadership buy in and approach this as a sustained, strategic effort over months to years, not as a one and done, kind of, you know, this isn't something where we can flip a switch and have all the solutions ready to go, unfortunately, but, but most important things don't work that way. I think I will just highlight the the anonymous screening programs like a FSPs, interactive screening program that can make a huge difference in terms of lowering the barrier to disclosing that you're actually suffering and having the opportunity to engage with someone who can, who can lead the individual to sort of customized, best, Next, safe resources, because it does need to feel psychologically safe. 26:45 That's that's actually perfect. I was going between that one and one other one. So you guess I'll be able to share spotlight the other one. You know, I think opt out programs have significant potential. So opt out programs, they reverse the paradigm, rather than waiting for distress to happen for certain groups, the default is actually care. Therapy is actually set up. It's part of the curriculum. I see this as kind of, you know, you turn 45 you get your colonoscopy. It's not because you're a bad person, it's because you're at risk. And we look for stuff because we care about you. And so these, these these by by changing the default from requiring physicians to actively seeking help to just making a standard part of training or practice. I think it overcomes a number of the different barriers. It normalizes help seeking. It takes away the fear of professional repercussions, and it gets over the logistical challenges because it's just embedded in the curricula. Now, obviously it has some challenges in implementing because logistically, in funding wise, it's one of the more expensive options. So maybe the more pragmatic solution there, or approach would be to really prioritize vulnerable populations so trainees, or we know that suicidality increases threefold in the wake of medical errors. So maybe it's just part of of standard approaches to legal proceedings or in the wake of medical errors. That'd be the other one I'd 28:12 highlight. We also saw in the latest ACGME mortality study that came out in 2025 that the first quarter of the academic year appears to be the most vulnerable period for suicide risk for residents. So that's another consideration. 28:28 I'm Richard perch in reporting for medical economics. Mike, I've had two guests here today, Dr Christine you moutier and Dr dan sadawi kunefka, are co authors on a special communication that outlines the state of mental health challenges and resources for physicians. It's been a great conversation. Thank you both so much for taking the time. 28:47 Thank you so much. Thanks so much for having us. 29:02 You once again, that was a conversation between medical economics senior editor Richard periton, Dr Daniel sadawi kine, an anesthesiologist and president of the emotional PPE project, and Dr Christine yamoutier, a psychiatrist and CMO of the American Foundation for Suicide Prevention. My name is Austin Luttrell, and on behalf of the whole medical economics and physicians practice teams, I'd like to thank you for listening to the show and ask that you please subscribe so you don't miss the next episode. Be sure to check back on Monday and Thursday mornings for the latest conversations with healthcare experts, sharing strategies, stories and solutions for your practice. You can find us by searching off the chart, wherever you get your podcasts. Also, if you'd like the best stories that medical economics and physicians practice published delivered straight to your email six days of the week. Subscribe to our newsletters at medical economics.com and physicians practice.com off the chart, a business of medicine. Podcast is executive produced by Chris mazzolini and Keith Reynolds and produced by Austin Latrell. Medical economics and physicians practice are both members of the MGH life science. Prince's family, thank you. You.