Abstract and Introduction
Physicians are not immune to psychosocial problems but may face unique impediments to attending to them. Self-care among physicians is not a topic generally included as a part of professional training, nor is it a topic that readily receives consideration in professional practice. The stresses of professional practice can exact a great toll, however, and self-neglect can lead to tragic consequences. In some areas, particularly suicide rates, physicians have increased vulnerability, and in other areas problems may be unrecognized (depression, substance abuse, marital problems, and other stress-related concerns). Female physicians show some particular areas of risk. In this paper, we raise questions about how and why physicians may be particularly vulnerable, review the available literature about the extent and nature of such problems in physicians, discuss possible factors related to the development of these problems in physicians, and suggest a variety of solutions to improve physician self-care.
Thomas was a 40-year-old child psychiatrist who was married and the father of three at the time of his suicide by drug overdose. He had been an energetic and successful psychiatrist who was trained at prestigious universities, but he also had a long history of poor self-esteem and much insecurity. He had a deep love for children and was thrilled when he and his wife began to have children of their own. Thomas had begun to have depression after his fellowship, and this depression had worsened considerably during the 2 years before his death. He was dissatisfied with his career and was contemplating a job change. He had become increasingly irritable and withdrawn during the last 2 years of his life, and sometimes attempted to relieve his symptoms with alcohol and/or drugs. He attempted to treat himself for his depression by taking courses of various antidepressant samples that were available in his clinic. He also was in treatment with a psychoanalyst. In his suicide note, Thomas included a message urging two of his adolescent patients who were suicidal not to make the same choice that he was making.
Susan was a 27-year-old married intern (first year resident in psychiatry) at the time of her suicide. She had had depression previously, during medical school, but had responded well to a combination of psychotherapy and medication. By the time she completed medical school, she was in good spirits, excited about her choice of residency, and hopeful about the future. However, Susan had a long history of perfectionistic standards and harsh self-criticism. A few months into her residency program, she began to have depression again. She was reluctant to seek help at that time because she feared lack of confidentiality if she used her insurance. She and her fellow residents shared fears of the possible impact of psychiatric treatment on their ability to get a medical license. She waited 3 months before beginning treatment, and meanwhile her depressive symptoms escalated. She was unable to sleep and to concentrate, which increased her difficulty functioning and produced more self-condemnation. She hid her depression from others. She began therapy and also began treatment with an antidepressant just 3 weeks before her death. A few days before Christmas, while her husband believed she was making preparations for their trip home, she committed suicide with carbon monoxide poisoning. Her husband, family, friends, and colleagues were deeply shocked, never dreaming that she would take her life.
Suicide and other mental health problems among physicians need to be addressed -- a fact that has become clear to us in a personal way. One of us recently lost three psychiatrist friends to suicide. These two women and one man were all married, and one had three young children. All three had been trained at well-respected universities and had at various points been successful in their careers. They were bright and funny (sometimes outrageously so). They were all in their late 30s or early 40s at the time of death. More recently, an intern known by both of us also committed suicide. These deaths have prompted reflection about aspects of the professional role that potentially contribute to the difficulty professionals may have in fulfilling perfectionistic expectations and seeking support or assistance when they do. The goals of this paper are not so much to give answers as to raise questions, review available information about physician distress, provoke thought about issues of well-being for physicians, and identify options for promoting our own mental health.
Physicians fulfill a special role within our society. While they are given many privileges and rewards, they also carry serious responsibilities. Physicians are expected to be healers, available to others whenever a crisis occurs or a medical need arises. They are expected to have unfailing expertise and competence, to be compassionate and concerned, and to provide universally successful care in a cost-effective manner. Such idealized expectations emanate from patients, from families, from society (including payers and regulatory and accreditation agencies), and from within the profession of medicine itself. Self-imposed expectations inhere in the institutions of medicine -- medical colleges, clinics, hospitals, professional associations, and collegial relationships -- and are internalized by students of medicine as they are socialized to become practicing professionals. These expectations become a part of how physicians define themselves.
No physician can consistently meet these idealized expectations. Physicians have human fallibilities and they, too, have needs for support and compassion. While all physicians struggle with these expectations, most find ways to successfully cope with them. Others, however, can develop serious emotional problems. When this occurs, the role of "physician" may actually become a barrier, preventing those in need from getting the help they require. The expectation that being a physician implies being able to perform professionally without faltering, and to meet all expectations without experiencing distress or dysfunction, means that personal problems can be perceived as professional failings. This can foster denial of personal vulnerability. The consequences can be tragic.
South Med J. 2000;93(10) © 2000 Lippincott Williams & Wilkins
Cite this: The Painful Truth: Physicians Are Not Invincible - Medscape - Oct 01, 2000.