Physician health: reducing stigma and improving care
John Bradford always prided himself on being psychologically tough. After all, he needed to be. As one of Canada’s top forensic psychiatrists, he analyzed some of the country’s most high-profile murderers including Paul Bernardo, Karla Homolka and Robert Pickton. In order to keep healthy and reduce stress, Bradford exercised regularly and played competitive squash and tennis. “I was very sensitive to my physical health,” he recalls “I was probably less sensitive to my psychological health.”
So when his mental breakdown hit, Bradford was totally unprepared. He unraveled after analyzing the videotapes of ex-Canadian Air Force colonel Russell Williams sexually assaulting two young women.
“I really had an acute event where I sort of broke down completely within half an hour of viewing the tapes,” he recalls. “I was crying uncontrollably, I felt like a complete failure.”
Bradford did not seek help immediately. “I was sort of thinking I’ll get over it,” he remembers, “I had about two months of this where I was struggling.” Then things came to a critical point when he came just short of an angry outburst while testifying in a dangerous offender’s case.
“Immediately after that I sought help, I got in contact with the Physician Health Program at the Ontario Medical Association.”
Bradford realized he was suffering from post-traumatic stress disorder or PTSD, an anxiety disorder characterized by reliving a psychologically traumatic situation through flashbacks and nightmares.
But even after being connected with a Canadian psychiatric expert in PTSD, Bradford had further delays in receiving treatment. The PTSD expert was someone Bradford knew professionally, creating a potential conflict in the doctor-patient relationship.
“He didn’t want to treat me so he referred me to someone else,” says Bradford. “I was also resistant to treatment because I felt it would go away.”
Bradfords’ health continued to deteriorate. “Things got bad,” he remembers. “I became very depressed to the point that I was actually suicidal.” He then became serious about seeking out treatment – starting medication and undergoing specialized psychological therapy for his PTSD.
“Delay in treatment was my own resistance,” he recalls. “Part of the reason that I talk about it is to help others. Not only educating people about vulnerability in medicine, but about resistance to treatment.” Bradford says that he believes “physicians are resistant to treatment, particularly for psychiatric issues. As much as we try to de-stigmatize it, it’s not an easy thing to come out and say- I suffer.”
Doctors get sick too
Bradford’s story might sound exceptional given the often-disturbing nature of his work as a forensic psychiatrist. However, his struggle with mental illness, and his challenges seeking and accepting care are common to physicians across Canada.
Much of the data on this comes from the The Canadian Physician Health Study, which surveyed nearly 8000 of Canada’s 75,000 licensed physicians in 2007. The study reported that Canadian physician physical health is comparable if not better than that of the general population. Indeed, more than 90% reported being in good to excellent health, and leading healthy lifestyles.
While Canadian physicians have satisfactory physical health, there is substantial concern about their mental health. The study revealed that nearly half of all practicing physicians are in the advanced stages of burnout. About one quarter of physicians reported having a 2-week period of depressed mood, having mental health concerns that made it difficult to handle their workload, and a poor work-life balance.
One area of concern is the risk of suicide among physicians. This area is not well studied in Canada, and there is little recent information in the research literature. A study which reviewed causes of death for a sample of American physicians over a 50 year period from 1948 to 1998 found that physicians are at substantially lower risk of dying compared to the general population for all causes of death – except suicide.
In addition, a 1997 study on the causes of death for over 20,000 physicians in the United Kingdom revealed that physicians, in particular women, face higher risks of suicide compared to the general population. A 1999 United States study, however did not find a higher suicide risk among women physicians.
With the Canadian Physician Health Study data nearly a decade old; there are many gaps in data and knowledge around physician health.
Struggling in silence
Michael Kaufmann, medical director of the Physician and Professionals Health Program of the Ontario Medical Association points out that there are important issues beyond studying the prevalence of physician mental health issues.
“From my perspective, the issue is not how prevalent these problems are, it’s how easy it is for us to get help and how quickly we can get that help,” says Kaufmann. The Canadian Physician Health Study suggests most physicians were not aware of available resources when they were in need of help.
The problem starts with primary care. An American study found that almost one third of physicians have no regular source of medical care, resulting in a whole host of problems including self-diagnosis, self-referral and self-treatment.
Indeed, The Canadian Physician Health Study found that over 50% of physicians agree that if it’s possible to take care of their own medical needs – they will.
A 2011 systematic review found that more than half of physicians self-prescribe medications. More specifically, a 2005 Norwegian study reported that more than half of physicians had self-prescribed medication at least once during the previous year. The most frequently self-prescribed medications were antibiotics, contraceptives, painkillers, and sleep aids.
But perhaps of greater concern are the multiple barriers to physicians seeking help. Michael Kaufmann suggests that the culture of medicine itself discourages physicians from seeking help when they need it.
“Traditionally it’s a culture that does not allow us to become unwell, it’s a culture that champions putting the needs of others before our own; self-denial in all kinds of ways is modeled,” he says.
Indeed, the heavy workload of physicians and the associated time and scheduling difficulties influence the ability to obtain care. Additionally, many physicians struggle with moving from a position of authority as a practicing physician to a vulnerable position as a patient. Moreover, fears about the potential for breach of privacy may lead physicians to delay seeking care or to minimize symptoms or aspects of their medical history. Finally, some doctors fear damaging their careers or putting their medical license in jeopardy if they seek treatment.
But most disturbing is the profound stigma towards physicians who are mentally ill. While this stigma is certainly endemic to society as a whole, physician health experts remain baffled by its pervasiveness within the profession of medicine itself.
“It’s a culture that stigmatizes its members when they have mental health problems or substance use disorders,” says Kaufmann. “It’s a culture that teaches us to act as if we’re fine no matter what we feel inside as part of professionalism, and it’s a culture that until recently hasn’t had a wide array of easily accessible support services,” he says.
Michael Myers, Professor of Clinical Psychiatry at SUNY-Downstate Medical Center is a leading expert in physician health who practiced medicine in British Columbia for decades. He points to this culture and attitudes as adding to higher suicide risk among physicians.
“Unfortunately in the medical world there are too many doctors who totally fall through the cracks who we know kill themselves without ever receiving a diagnosis or treatment,” he says. “They may self-treat, they have no primary care provider or psychiatrist, and they have no file.”
Healthy doctors for a healthy system
Physician wellness is undoubtedly critical for the overall functioning of the health system. In fact, some experts have suggested that physician wellness is a missing quality indicator of health system performance.
Derek Puddester is an associate professor of psychiatry at University of Ottawa and director of the Canadian Physician Health Institute.
Puddester says unwell physicians impact patient care, and health care costs. For each physician who leaves practice, thousands of Canadians are left without care. In addition, he highlights the public costs associated with medical education – estimated at $285,000 for a family physician, and $760,000 for a specialist.
“Until we make a rock solid commitment to the health of our professionals, the health of our system is at risk of lurching from crisis to crisis,” remarks Puddester.
With over half of Canadian physicians in advanced stages of burnout, Puddester also worries about the impact on the doctor-patient relationship. These concerns are validated by several recent studies, including a large American study, which reported that physician burnout was associated with unprofessional conduct and less altruistic professional values. Another study reported that depressed physicians made significantly more medical errors than their non-depressed peers. Finally, a survey of resident physicians reported that burned-out residents were significantly more likely to provide suboptimal patient care including the failure to fully discuss treatment options and answer patient questions.
Canadians are helping lead the way in physician health
Despite the unique struggles and challenges faced by unwell physicians, there is hope for improvement.
Myers has dedicated his career to physician health and has witnessed tremendous progress. He recalls the suicide of a classmate while he was a medical student at the University of Western Ontario in the 1960’s. “Back in those days we just buried ourselves in our work and textbooks. Losing him was really awful, but that’s how we dealt with things.”
Today Myers points to the presence of physician health programs in every province. These programs provide dedicated personal assistance to physicians, medical students, residents and their families.
Myers also highlights the 2012 launch of the Canadian Physician Health Institute through the Canadian Medical Association, a pan-Canadian and multi-stakeholder program aimed at supporting physician health and wellness.
The institute is actively working to support physician access to health care, improve awareness about the importance of well-being, and combat stigma associated with mental health issues. Additionally, the institute is developing promotional activities for physician mental health.
But above all, experts in physician health are sensing a cultural shift in medicine’s approach to the health of its professionals. “Overall a lot of younger physicians say they have much more balance in their lives,” says Myers. “I think there’s finally recognition that we physicians are human.”