By Joe Michael Feist
Stacy, now a practicing physician, was a resident at UT Health San Antonio when her world grew dark and frightful, shaking her as it spiraled downward. “Everything was painted black. Everything was negative. I didn’t want to do this anymore. I didn’t want to do anything,” said Stacy (not her real name), describing her descent into clinical depression. “I was changing from ‘This is great, I love this, I enjoy seeing patients,’ to ‘Why am I waking up at 4 a.m. to see this [patient] who’s just going to complain, and they don’t even know what I’m going through and they don’t care,’” she said. “I started seeing patients as a burden instead of seeing them as people I became a doctor to help.”
She was depressed, anxious, moody, had low self-esteem and seriously questioned her choices and abilities. She constantly told herself she wasn’t smart enough, that she was an impostor. Her dream of becoming a doctor became a recurring nightmare. And worst of all, Stacy added, was the feeling that she couldn’t tell a soul what she was going through. “No one can find out,” she thought. “If anyone knew, that would be the end of my career.”
Stacy felt totally alone, but in fact was far from it. In the past few years, a full-blown crisis has emerged among residents and practicing physicians suffering from burnout, depression, substance abuse and suicide.
The numbers alone are staggering.
• An estimated 56 percent of all physicians are burned out, reaching close to 70 percent in some specialties.
• One out of three physicians is suffering from clinical depression.
• Seven percent of physicians are actively abusing substances, whether illegal substances, alcohol or prescription meds.
• Seven to nine percent of physicians have had suicidal ideations in the past two months.
• An estimated 400 doctors commit suicide each year, or the equivalent of two entire classes of medical students at UT Health San Antonio. Physicians are far more likely to commit suicide than the general population. And female doctors are three times as likely to kill themselves as male doctors.
The bleak story told by the numbers means “the practice of medicine in this country is faced with a momentous challenge, perhaps even an existential crisis,” said Jon Courand, M.D., vice chair of education and training for pediatric residents and fellows, and chair of the Wellness and Resident Worklife Standing Committee at UT Health San Antonio.
Computers are not people
Dr. Courand, who has reviewed the issue extensively, pointed to several factors commonly cited as root causes of physician burnout, depression and suicide. Among these are administrative burdens, intrusion of technology, staggering patient volume and the intricacy of patient care.
“The workloads are increasing, but more than just the workload, the complexity of the patients, the acuity,” Dr. Courand said. “They’re more complex, they’re sicker and there are more of them. We’re putting a greater workload on our physicians.”
Another huge source of stress is electronic medical records (EMR), he added.
“The issue is it removes us from the patient,” Dr. Courand said. “There’s an interesting study that shows if a resident has, for example, eight patients, on average they spend about seven minutes with each patient. For those eight patients they spend less than an hour a day physically talking to people, but another four-plus hours on the EMR.
“My personal belief is we went into medicine to do one thing, and that is to take care of people, but increasingly we’re taking care of a computer screen and not people. I think that leads to disillusionment, burnout and depression,” he said. “There are a lot of people, I think, who believe the same thing.”
Years ago, most doctors worked alone in a private practice, were paid in cash, and dealt with few regulations and technology. Today, doctors across the board are under extraordinary pressure to make money, to meet “relative value unit goals,” Dr. Courand said, adding that faculty physicians in academic health institutions are not immune.
Because of “paperwork” and financial concerns, most physicians in the outpatient world spend only about 10 minutes with a patient, Dr. Courand said. “It used to be 20 minutes, then it was 15, now it’s 10.”
Straightforward cases, such as an ear infection, may only get five minutes of the physician’s time. “It’s just move ’em in, move ’em out. Patients feel that. They don’t feel that there’s that bond,” he said.
The complexity of medicine, the demands of technology and the financial pressures all affect the way doctors view their role and their self-worth. Thus the levels of burnout, depression and suicide.
“Real burnout is a low sense of personal accomplishment, emotional exhaustion and depersonalization,” Dr. Courand said. “Depersonalization is saying, I have this patient in front of me who’s suffering and may die, and I couldn’t care less. I feel nothing for this person. That’s scary. There’s a large percentage of physicians in the country who right now are either emotionally exhausted or depersonalized.”
High stress, high stakes, real expectations
For faculty and administrators at an academic health institution, one obvious way to prevent physician depression and suicide is to face the issue head on, openly and honestly, with today’s residents and students. Knowledge, and the early identification of stressors, is the key to preventing tomorrow’s depression and suicide, educators believe.
To that end, UT Health San Antonio this year hired two Ph.D. psychologists to focus on wellness with its 700 to 800 residents and fellows. The psychologists will run an interactive screening program that will send surveys to every resident and fellow asking questions about depression, suicidal ideation, burnout, substance abuse, even eating disorders.
“It’s a voluntary, completely anonymous, encrypted program that allows residents to enter into a counseling relationship with one of our providers, either anonymously through the computer or face to face,” Dr. Courand said. “And the psychologists will be promoting 45 separate wellness activities designed to promote resilience,” including everything from healthy eating to mindfulness training to quiet areas for meditation.
And it’s not just practicing physicians and residents who are dealing with these issues. Medical school students are susceptible to the same stressors.
“It’s a high-stress field,” said Thomas Matthews, M.D., clinical professor/psychiatry who spent more than nine years as associate dean for student affairs in the Joe R. & Teresa Lozano Long School of Medicine. “Even to get into medical school, you’re expected to do research, volunteer, keep your grades up. There’s so much you have to do to get in. What you’re doing is taking people who are Type A personalities or high-stress people anyway, and you’re piling things on. They come in to med school and they’re already very stressed.”
Dr. Matthews, along with Kristy Kosub, M.D., professor and director of student education for the Department of Medicine, have long worked on wellness issues in the medical school.
Just recently, Dr. Kosub said, “We have as a school really started to ramp up how we’re going to expose our students to the reality that this [burnout and depression] exists. And really making a concerted effort to make sure we’re addressing it all four years.”
Both Drs. Matthews and Kosub pointed to Veritas, the school’s student advisory group with both faculty-student and peer-to-peer advising and counseling, as a way of talking about burnout and stress.
“It’s a way for students, within their Veritas group and faculty advisers, to engage in regular meetings with various topics like burnout, so that they don’t have that feeling of isolation as they go through medical school,” Dr. Kosub said.
Other avenues toward self-awareness for students include the opportunities offered by the Center for Medical Humanities & Ethics, she said. Through electives, community service-learning projects and speakers, the center “provides the crucial element of humanism, to remind people it’s not just all about one’s medical knowledge, it’s taking care of people and taking care of yourself.”
There are many more wellness activities, lectures, social gatherings, informal talks and direct mentoring as well.
Doctors are people, too
What’s critical, faculty agree, is creating a positive environment where people feel comfortable enough to talk about stress, depression, feelings of inadequacy or being overwhelmed. And that applies not just to students, said Dr. Kosub.
“We don’t have a wellness program for existing faculty and staff,” she said. “That’s where we’re falling down. I’m hopeful that the School of Medicine and the university as a whole will start to build on that. The key is to make this part of the culture of the school, the residency program, the entire institution.”
At an academic health institution, Dr. Kosub added, faculty need to role-model healthy lifestyles. She noted that Stanford Medicine, in a first for a U.S. academic medical center, just hired a chief wellness officer charged with countering physician burnout and improving physicians’ sense of fulfillment and well-being.
The broader cultural issues need to be acknowledged as well.
“The stigma surrounding mental health issues and depression is rampant in all professions, including among doctors and health care workers,” said Dr. Kosub. “And it’s not just doctors. It’s a human quality of not wanting to disappoint people, not wanting to show weakness.”
As for Stacy, the former resident who walked on the edge of depression and even suicide, she found the strength and the trust in the institution that saved her.
“Finally,” she said, “I went to the program director and said, ‘I need to figure this out because I don’t want to get to the point where I can’t work anymore. It’s bad enough that I have to talk to you about it.’ And my program director actually smiled. And it was like, you’re not the first and you won’t be the last.”
Stacy began seeing a psychiatrist “who taught me a lot of tools to be able to cope with those negative thoughts and emotions.”
She began paying more attention to her own health and well-being and became more aware of stress triggers. She pulled through.
The bottom line, said Dr. Matthews, is that “doctors are people, too. When it comes down to the core of each of us, we’re all just a person. And sometimes life can overwhelm each of us, no matter how smart you are.
“When you’re drifting in a storm, you really need someone to throw you that lifeline.”
UT System addresses well-being of physicians
The public health care crisis created by physician burnout and depression is being addressed by The University of Texas System, of which UT Health San Antonio is a component.
“As the employer of thousands of physicians, University of Texas institutions have a great stake in assuring that they can thrive despite the many stresses and pressures of their work environment,” said Ray Greenberg, M.D., Ph.D., the UT System’s executive vice chancellor of health affairs. “The UT System aspires to be a leader in developing and implementing strategies to support the well-being of our caregivers.”
In September, the UT System sponsored a symposium at The University of Texas MD Anderson Cancer Center in Houston that brought national leaders to discuss the causes, consequences and solutions for physician burnout in academic health settings. A multi-pronged plan includes conducting a systemwide assessment of the problem, creating focus groups and recommending solutions at the clinical, departmental, institutional and system level.
Chancellor William H. McRaven said reducing physician burnout needs to be a priority because of its broad repercussions.
“I think this is a major, major issue … and we have to aggressively address it,” McRaven told the UT System Regents recently. “We can be a national leader in this and we should.”