The Psychiatrist's Role in Physician Health

Peter M. Yellowlees, MBBS, MD

Disclosures

October 30, 2019

A specialist physician was recently referred to me with a history of stimulant use and abuse for long-standing depression. He'd used the medications sporadically for years. At times they were prescribed by a colleague; on other occasions he prescribed them to himself. He wound up in my office after restarting stimulants in an ineffective attempt to help him study for his board recertification. With appropriate treatment of a combination of antidepressants and cognitive-behavioral therapy, he did quite well: He passed his boards and has had no further use of stimulants, as far as I know.

I have treated many physicians as patients and never cease to be amazed at how late they tend to be referred to me, and at how lacking or inadequate any mental health treatment they have had in the past has been.

The mental health of physicians has assumed increasing importance in recent years, with a multitude of causes for mental problems being investigated. Physicians have become more open about their struggles with depression, suicide, and burnout, and the adverse consequences at personal, professional, and organizational levels are becoming better understood. This comes at a time when health systems and the healthcare industrial complex are putting increasing pressures on physicians, who are often already in short supply.

Physicians Speak Out

A number of physicians have written highly publicized and painful descriptions of their own experiences of depression, suicidality, and other mental health problems. Trauma surgeon Michael S. Weinstein recently penned one such account in the New England Journal of Medicine. In describing the longstanding depressive illness that led to him being locked up and treated with electroconvulsive therapy, among other modalities, Weinstein made two very important points.

The first was about the evolution of mental illness and burnout, and his ignorance of this:

I had heard of burnout but didn't really comprehend it. And though I had mental illness, I still saw it as a weakness, a personal fault. I remember early in my career hearing of a colleague who took a leave of absence for a "nervous breakdown." I joked about it, said he was weak. Now it was my turn...I wanted out, out of work and out of life. I wished I would get hit by a car, and sometimes took steps to increase my risk. I felt trapped in my work and worried that I would expose my shortcomings if I sought a leave or disclosed my feelings.

The second was about the effectiveness of treatment and the promotion of wellness after many years of being, in his words, "treatment resistant":

You would not be reading this today were it not for the love of my wife, my children, my mother and sister, and so many others, including the guards and doctors who "locked me up" against my will. They kept me from crossing into the abyss. I had convinced myself that I had end-stage depression, that there were no other treatments, and that I would be forever depressed, as I remember my grandfather being. Yet my healing has been considerable. I am happier and more optimistic than I have ever been in the past 50 years. I have never enjoyed being alive more than I do now, in each present moment.

Weinstein's account of his experience raises some important questions. First, why is it often so difficult for physicians to understand or accept the need for mental health treatment? Second, why is it hard for physician-patients to obtain expert treatment?

The Often-Hidden Networks Aiding Physician Mental Health

As a profession, psychiatry should be able to answer both of these questions. But before that can happen, psychiatrists need to come out of the shadows on this topic and make it clear that we are here to help care for our colleagues. The medical profession needs our expertise. We should promote and formalize the work that we have been doing to help other medical professionals (and, of course, also psychiatrists with mental illness) for many years.

Having lived and worked in three Western countries during my career, it is evident that psychiatrists as a professional discipline have always served as the physician's physician, although usually confidentially and quietly. In all major cities, a few psychiatrists have gradually developed a reputation for being able to care for colleagues in distress. These are often quite senior psychiatrists, usually in private practice. They typically have considerable clinical expertise and have fallen into this role almost by accident, as over a number of years they gradually received more and more referrals of physicians through an informal collegial network.

This works well if the physician who wants to receive treatment is able to access this system, what is often relatively hidden. That is not always the case, of course, and physicians, like many other patients, may still find it hard to access a psychiatrist when they need one. However, the fact remains that these networks do exist, and psychiatrists and others involved in physician well-being should actively promote them to all local physicians.

How to Help Our Colleagues

What roles are available for psychiatrists in relation to physician well-being? Several of these have been discussed recently:

  • Educating physicians about burnout and their own mental health. There is plentiful material available on numerous professional sites such as the American Psychiatric Association, the American Medical Association, and the National Academy of Medicine. Psychiatrists can also take a lead role in increasing teaching about self-care in medical school and residency programs.

  • Treating our colleagues. We should be more overt about making our expertise available to our colleagues and promote rapid access to psychiatrists for physicians who seek treatment.

  • Reducing the stigma of psychiatric treatment among our colleagues. We can do this by joining with, leading, and collaborating with our physician colleagues in other disciplines to promote the evidence base for psychiatric treatments of illnesses that are of a biopsychosocial nature, just like all other illnesses treated by physicians.

  • Taking up specific career positions in physician well-being. A career interest in physician well-being is now more available to psychiatrists, whether they work on well-being committees, in physician health programs, or become chief wellness officers. It is hoped that psychiatrists will increasingly take leadership roles in what is a relatively new career direction.

  • Researching the stressors affecting physicians. This is an area almost devoid of research beyond studies focusing on the prevalence and management of burnout. Many questions remain unanswered.

  • Acting as role models for our colleagues. We need to improve and promote our own well-being, training, and lifestyles, and actively demonstrate the positive impact this can have on our profession, as a model for other medical disciplines.

The role of the physician's physician is an honored and important one. Psychiatrists, by nature of our training and expertise, are the logical group to take this up. Right now, many career options are opening. As a profession, we need to focus on this area and ultimately help many more patients than we do now by ensuring that our colleagues in other medical disciplines remain healthy.

Peter M. Yellowlees, MBBS, MD, is a professor in the Department of Psychiatry at the University of California, Davis. He is a longtime Medscape contributor.

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