The Painful Truth: Physicians Are Not Invincible

Merry N. Miller, MD, K. Ramsey Mcgowen, PhD, Department of Psychiatry and Behavioral Sciences, James H. Quillen College of Medicine, East Tennessee State University, Johnson City.

South Med J. 2000;93(10) 

In This Article

Possible Sources of Vulnerability Among Physicians

This overview provides a glimpse of the types and rates of distress among physicians, but it does not begin to tell us why this is occurring. What might account for this increased vulnerability among physicians? Several hypotheses are available: Do those more at risk self-select to enter medicine? Do certain traits among physicians increase risk? Do physicians tire from repeated patient contact and become depleted? Do physicians have more difficulty trusting others and confiding in them? Does being a doctor increase risk because physicians become more reluctant than others to seek help? Do physicians have no one to talk to about their concerns? Are they too proud?

Traits of Physicians That May Increase Risk

Psychologic vulnerabilities of physicians were examined in a study of students who were initially psychologically evaluated during college.[22] The study included a 30-year follow-up. Of the students initially evaluated, 47 became physicians. This study found that at follow-up, physicians, especially those involved in direct patient care, were more likely than socioeconomically matched controls to have poor marriages, to abuse alcohol and drugs, and to have obtained psychotherapy. However, closer examination of the early histories of these physicians revealed that these difficulties were strongly associated with life adjustment before medical school, such as childhood instability and adolescent adjustment problems. The study also found that physicians were more likely than controls to show traits of dependency, pessimism, passivity, and self-doubt. The authors concluded that problems are more likely to develop when physicians ask themselves to give more than they have been given.

A number of personality features related to these findings have been hypothesized to be widely shared among physicians. One such characteristic is perfectionism. Perfectionism may lead to conscientiousness during medical school and to a thorough clinical approach, but it may also breed an unforgiving attitude when mistakes inevitably occur. Fear of medicolegal consequences may exacerbate this distress about clinical errors. Christensen et al[23] conducted in-depth interviews with physicians about the impact of making clinical mistakes. They found physicians experienced great distress over making mistakes. Even though they recognized the ubiquity of mistakes in clinical practice, they nonetheless believed they could not disclose the mistakes to colleagues and experienced a lack of support from colleagues in addressing these concerns. Perfectionism and the competitiveness engendered in medical training were cited as key reasons for experiencing distress about clinical errors.

McCranie and Brandsma[24] used a prospective design to look for personality antecedents of burnout among 440 physicians. These physicians had been given the Minnesota Multiphasic Personality Inventory (MMPI) shortly before entering medical school and then were surveyed an average of 25 years later for symptoms of burnout. The study found that higher burnout scores were significantly correlated with MMPI scales measuring low self-esteem, feelings of inadequacy, dysphoria and obsessive worry, passivity, social anxiety, and withdrawal from others.

Another study approached this issue from the other direction, by looking for predictors of psychologic well-being among physicians. Weiner et al[25] surveyed more than 300 physicians and found that individuation (the ability to maintain individual identities around family members) from the family of origin was a strong predictor of psychologic health. Other predictors of well-being were high levels of support from one's closest relationship and lower levels of practice stress.

Impact of the Culture of Medicine

Could the medical training process be promoting an unhealthy life-style? While going through training, physicians are pushed to endure sleep deprivation, which can result in both cognitive impairment and emotional fragility. In addition, during both medical school and residency, physicians become introduced to the medical mentality of distancing from patients, taking on more and more work without complaint, and learning to compartmentalize feelings. The culture of medicine is one in which perfectionism and "workaholic standards" rule the day. Many practice settings reward long hours and self-neglect. Physicians are encouraged to disregard themselves and deny their own needs. The process of medical education may enhance development of defense mechanisms that make it difficult to ask for help. Could this be part of the problem?

The field of medicine brings with it unique stresses, including coping with intense emotions around issues of suffering, fear, sexuality, mortality, problem patients who can be demanding, and pervasive uncertainty due to the limits of medical knowledge.[26] Physicians often struggle during training and in later years to harden themselves to these issues.

Residents respond to the stresses of training in a variety of ways. Some have problems with depression, substance abuse, and marital conflict; others may not have overt psychiatric illness but display other signs of psychologic impairment.[27] Kirsling and Kochar[28] have reviewed many problems that residents have during training, including the almost universal experience of episodic cognitive impairment, chronic anger, pervasive cynicism, and family discord. Such signs of distress certainly merit examination of the process of medical training.

A "macho mentality" pervades medicine. One report indicates that physicians do not follow schedules for routine medical care for themselves and their families and prescribe medication for themselves rather than seek consultation from a practitioner.[29] This macho mentality may also play a role in the increased rates of psychosocial distress within medicine's ranks. Doctors are commonly expected to be strong and support others, but many doctors believe that it is not acceptable to reveal their own weaknesses and vulnerabilities to others. Abraham Verghese[30] recently wrote a novel based on his friendship with a physician who was depressed and addicted to drugs and who ultimately committed suicide. He describes this attitude within medicine as "a silent but terrible collusion to cover up pain, to cover up depression; there is a fear of blushing, a machismo that destroys us."

Difficulty with trust may also be part of the problem. Although physicians are accustomed to hearing and protecting the confidences of others, it may be hard for them to let their guard down and really believe that they can trust another.[29]

Another phenomenon that may play a role in physician depression and suicide is that of being labeled a "VIP."[31] Everyone likes to be considered special, and with fellow physicians, doctors often enjoy special treatment when they do seek help. However, the very fact that they are doctors themselves may cause other doctors to be less aggressive in their treatment. An example of this is found in the friends who committed suicide as mentioned earlier. Two of them were in treatment for depression. Neither was hospitalized, though the wife of one of them requested a hospitalization for him a week before he died. Being a VIP may also increase a physician's own sense of shame and stigma. Physicians may be more reluctant to go for help and admit their own problems if they believe they have been labeled by others as strong and healthy.

Difficulty setting appropriate limits is another characteristic hypothesized to be common among physicians. There is a common expectation that physicians must be available whenever needed, and this can lead to a sense of obligation that makes it difficult to set limits without great guilt. Medical training observes few time boundaries; long hours are assumed to "come with the territory." Professional identity often internalizes this assumption, so that setting limits is perceived as lacking in professional commitment. Even when setting limits is possible, some do not acquire this essential skill and do not discern when setting limits is appropriate.

Self-denial, especially during the training years, also occurs. Physicians become masters at delayed gratification. Many medical students and residents spend years coping with the high level of demand required in medicine, often harboring the expectation that later they will be rewarded with a happy, more balanced life. However, the task-oriented coping skills developed during training do not go away automatically after training. Also, the goal-oriented approach leads to neglecting alternative sources of gratification or self-esteem; thus, after training, physicians may not have a way to find a meaningful balance between work and other life activities.

Sources of Risk for Female Physicians

Why are women especially at risk? A number of possibilities come to mind. Relational theory, a leading current theory for the psychology of women, proposes that self-esteem for women is predicated on establishing mutually satisfying, reciprocal relationships.[32] These relationships are characterized by mutual support and empathy, which enhance the growth and development of each party in the relationship. This reliance on connections with others is inconsistent with the competitive, detached, and self-contained identity traditionally associated with medical practice. The socialization involved in becoming a physician may make it more difficult for women to maintain meaningful relationships with others. This adds a level of stress for professional women since professional practice is, in some ways, incongruent with personal identity. Not only are professional women busy because of their careers, but also the opportunity for empathic relationships is impeded by their career involvement. Some evidence points to this. Carmel and Glick[33] surveyed 324 physicians (more than 80% male) and found that while empathy and compassion were characteristics valued by physicians, they were characteristics identified as least likely to be associated with promotion and career advancement.

An additional factor may be that women experience role strain because of the demands of the "second shift." Women professionals nurture and care for patients all day just as their male counterparts do but are more likely to carry the majority of responsibilities for caring for their families at night. Again, some evidence supports this idea. Johnson et al[34] found that in marriages between two physicians, wives were more likely to make accommodations in their career based on consideration of effects on spouses and children, while men were less likely to do so. Carr et al[35] surveyed 1,979 faculty at academic medical centers in a study of the relationship of family responsibilities and sex to academic productivity. They found men and women faculty without children had equivalent career accomplishments. Among faculty with children, this variable (having dependent children) had a much more deleterious effect on the women's career and seemed to account for much of the slowed career progression of women physicians in academia. A related study by some of the same researchers[36] had determined that women and men had equivalent career motivation, so this factor does not explain the career accomplishment differences. It seems, then, that work-family conflict may exert a special stress on women physicians.

It is also possible that part of the increased suicide rate found in women physicians is explained by the fact that these women make better informed attempts than other women, because they have full knowledge of the requirements for lethality. It is likely that all these factors contribute to some degree to the increased vulnerability of women physicians.

These findings suggest that life adjustment before medical school, personality variables such as perfectionism, and emotional problems such as depression and substance abuse all contribute to physician vulnerability. Improvement in physician self-awareness and development of ways to support and intervene in the problem areas are needed.

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