Although it may be hard for us to admit, physicians face the same types of mental health conditions as our patients.
Although it may be hard for us to admit, physicians face the same types of mental health conditions as our patients, including depression. While studies show that male physicians have same rate of depression as the general population at around 12-13%,nearly 20% of female physicians experience depression, with even higher rates of up to 30% among medical students and residents. Further, depressed doctors have higher rates of suicide than the average population, with a relative risk of 1.1-3.4 for men and 2.5-5.7 for women. It is important for physicians to understand this risk, not only for our ourselves, but to help identify and support colleagues that may be experiencing depression.
Be on the lookout for signs of physician distress
According to psychologist Steven Cohen PsyD, depression in physicians may be difficult to detect, because depressed doctors often present a mask to the world that everything is ‘ok.’ Friends and colleagues must be attuned to signs of physician distress, which may be subtle. “Learning to identify these signs is the first step in intervention,” says Cohen.
One of the most common signs of emotional distress is a change in typical pattern of behavior. “For example, a physician who is usually cheerful suddenly becomes irritable and cranky; one who is always on time is now suddenly rushed and last minute, or someone who is known to be very organized is now constantly misplacing things,” says Cohen.
Another sign of distress is isolation from others, such as withdrawal from interactions with friends and colleagues. “This may manifest as last-minute cancellations, in which the physician repeatedly agrees to attend events or activities, then cancels at the last minute when something unexpectedly ‘comes up,’” says Cohen. Isolating physicians may come in to work late or exceptionally early to work to avoid small talk with colleagues or time with family. Another sign of isolation is ignoring or failing to respond to texts, phone calls, or emails.
Doctors dealing with depression may also experience any of the typical anhedonia symptoms we observe with our patients – lack of interest in activities they used to enjoy. They may report fatigue, somatic or physical complaints, or changes in appetite or weight.
Don’t ignore warning signs
In some cases, physicians may notice signs of a colleague in distress, but fail to act because we assume that someone else, such as a higher-up, will address the situation. In some cases, we may not reach out because we don’t know what resources are available or what to do if a colleague does share mental health issues. Since medical training has traditionally emphasized stoicism and self-denial, we may also fail to act because of a general discomfort with feelings and emotions.
In some cases, we may fear that we are misreading cues that could lead to angering or stigmatizing a colleague. But Cohen says that if your gut says that something is wrong with a colleague, you should believe it. He also recommends intervening if you hear others expressing concern about signs of a physician in distress. “Don’t just assume that someone else will step up, as often no one will,” he says.
Talking to colleagues about emotional distress
Cohen says that the best way to address physician distress is to simply open a dialogue. Find a time when the physician is not rushed and when you have enough time to give your complete attention. “I recommend the end of the day when they have finished with patient care and are wrapping up paperwork,” says Cohen, who also advises that this conversation take place in a private area, like the physician’s office.
Start by asking in a general way: “How are you?” or “I noticed that you haven’t been showing up at our social events lately – is everything ok?”As they answer, watch them carefully for their facial expression and body language and listen to their tone of voice. While many distressed physicians may give a noncommittal response, like “I’m fine,” Cohen says that you may see certain cues to indicate that the physician is not fine, such as a head shake from side to side after answering or a lack of eye contact.
“Many physicians in distress are initially hesitant to open up about their feelings,” says Cohen, noting that it can be difficult for a depressed physician to even believe that a colleague really cares because of the cognitive distortions associated with depression. In this case, Cohen recommends probing a bit further to show that we are genuinely concerned. We can respond to the answer of the physician that “I’m fine” by saying: “You’re fine?OK, I just feel like something is off and I am worried about you.” This lets the physician know that we truly want the answer to how they are doing, and not just a platitude.
At this point, the physician may start to open up or give hints regarding emotional distress. Be prepared to listen and show empathy—but Cohen says that no matter what, don’t start trying to problem solve!
Don’t try to problem solve
“Often when a physician does start to open up about emotional stress, they do it in a more general and ‘safe’way,” says Cohen. “They may start listing the problems they have at work, like having too many patients to see, or problems with the electronic health record.” While our natural inclination may be to try to start problem solving: (“OK, well, let’s strategize on ways to work more effectively with the EHR”), Cohen says that the concerns a physician shares may only be a small part of their general emotional distress. “The physician needs to start opening up and sharing emotions, but when you shift into‘problem solving’ mode, you actually shut down the flow of emotion,” he says. “You need to allow the physician the opportunity to continue to express feelings and emotions, and validate those feelings, without trying to ‘fix’ them.” Cohen acknowledges that this can be difficult. “When others share their feelings, we get uncomfortable. We may feel helpless,” he says, which is especially difficult for doctors who often feel the urge to ‘fix’ things. But Cohen says that “feelings can’t be fixed, nor do they need to be fixed. They just need to be acknowledged.”
To help our colleagues to acknowledge these feelings, we can use the technique of emotional mirroring and validation. Listen to the ‘feeling’ words or descriptors that the physician says and repeat them back, or use a synonym. For example, if the physician says, “I’m just totally overwhelmed with all this documentation,” you can respond: “It sounds like you feel like you’re never going to get it all done.”
Cohen says that you will know if you are getting it right if the physician responds in an accepting way, in agreement, and continues talking and sharing. But if the physician indicates that you are getting it wrong, try again. For example, they may respond, “no, I can get it done, but now I’m going to get home late again.” Try the mirroring/ validation technique again with this new information. “Oh, I see, you’re going to be stuck here getting your charts done. That would really upset me, too.”
Encourage professional help
Once a colleague has started to open up about concerns, this is a good opportunity to share professional resources for help. Share the Physician Support Line, a free and confidential hotline for physicians staffed by volunteer psychiatrists, or PhysicianMentalHealth.com, a website of psychiatrists dedicated to caring for physicians. Learn about the resources in your community - perhaps your county or organization has a Physician Wellness Program that provides free and confidential psychology sessions to members. If not, start one!
As physicians, it is our responsibility to reduce the stigma towards mental health care. We must remind our colleagues that it’s not a weakness to ask for help, and that it takes more courage to accept help. Getting help makes you a better person and a better physician. Even if the physician isn’t ready to accept a referral for further help right now, just starting the conversation may open the door for future consideration. It also lets the physician know that you are truly concerned and available if they need to talk in the future.
Rebekah Bernard MD is a family physician in Fort Myers, FL and the co-author of Physician Wellness: The Rock Star Doctor’s Guide.
This article was initially published by our sister publication Medical Economics.