The other day one of my physician colleagues shared a story with me about some seemingly helpful advice he was given during the first week of his medical school orientation. He and his classmates were advised to not tell anyone in the medical school if they developed mental health problems during their training, and if they needed mental health treatment to make sure to go outside of the system, which meant paying for their care out-of-pocket.
He then went on to share the story of an unfortunate classmate of his that did open up to one of his attending physicians about his mental health struggles, which eventually resulted in a painful betrayal and the student leaving medical school all together. Another colleague overheard us having this conversation and chimed in about one of her fellow residents who had a similar issue and was pushed out of her residency.
It’s hard to believe that not only was my colleague advised to keep his mouth shut, but that others who had not kept quiet suffered the serious consequences of no longer finding a place to work in medicine. I know that physicians don’t speak up about issues such as anxiety or depression as there is still so much cultural stigma toward any person with mental health illnesses. But when it comes to those practicing medicine, it’s much more than that. State medical licensing boards, hospital job applications, and insurance credentialing applications ask about mental health illnesses. This is the reason physicians go outside their own healthcare networks to get mental health care, making sure there is no record of their diagnosis and/or treatment.
In the last ten years there has been several court cases as well as statements from the US Department of Justice clearly establishing that questions of this nature on medical licensing applications violate the American with Disability Act (ADA). Despite these legal decisions, many states still have questions asking about any previous history of a physician’s mental illness treatment or diagnosis, rather than focusing on whether there is any current impairment due to mental illness that interferes with the physician’s ability to practice medicine. While these cases have focused on medical licensing boards, there has not been scrutiny regarding these same questions on job and credentialing applications. Credentialing is necessary of course, as it establishes the physician is actually a licensed medical profession and qualified to practice medicine.
I understand that physicians need to be physically and emotionally healthy in order to safely take care of patients. But who is looking out for the physician’s well-being? It’s not their instructors in medical school, their attending physicians in residency, or their primary care providers, but some other doctor or therapist in the next town over to which they pay cash in secrecy. As Dr. Pamela Wible so astutely notes, “Medical boards exist to protect the public. Employment applications protect the needs of employers. Insurance credentialing applications protect the needs of insurance companies. So, who’s protecting doctors? Nobody.” We need our physicians to be healthy in order for them to have the capacity to heal others. And to support the mental health of our physicians, we need to make changes in the licensing and credentialing processes.
At the start of training medical students are emotionally healthy. In fact, they report a better quality of life as well as better physical, mental, and emotional health, as compared to age similar college graduates. This however changes several years into medical school. Despite having better mental health profiles as compared to college educated peers at the outset of their education, medical students quickly bypass their peers and develop depression, anxiety, burnout and suicidal ideation. Over half of medical students report symptoms of burnout characterized as emotional exhaustion, depersonalization, and a reduced sense of competence. In addition, over a quarter of medical students turn to unhealthy modes of coping including alcohol abuse, with some developing alcohol dependency. And sadly, over 2% develop suicidal ideation, although the exact number of student suicides is unknown due to lack of reporting and research.
I saw it all during my medical school and residency training. I saw my classmates struggle as time went on, trying hard to keep up with the heavy weight of new knowledge, the daily exposure to patient suffering, as well as the burgeoning moral burden of feeling responsible for the life and death of patients. I could see the struggle in the faces of my classmates, hear it in their exhausted sighs, feel the anxiety and stress coming off them in waves. I could see it all in my own mirror, and though I was not clearly advised to keep quiet as my colleague was, I did anyway, instinctively knowing that to show any sign of weakness meant I would be devoured by the pack.
Not every medical student, resident, or physician has mental health challenges during their training and career of course, just as not every patient that enters our clinics and our hospitals suffer from these illnesses. But enough suffer in silence that it’s beyond time to makes changes to the system. As a good friend of mine believes, someday in the future mental illness will transform like AIDS/HIV and LGBTQI+ have, no longer carrying the burden of shame. The first step in any transformation or revolution however is to expose the truth: physicians, therapists, nurses, and many of those who take care of patients, do not have safe places to get support for their mental illnesses, without the fear of losing their jobs and medical licenses.