AMA Journal of Ethics. October 2016, Volume 18, Number 10
Mental Illness as a Cause of Disability among Physicians and Medical Students: An Interview with Louise Andrew
This is Ethics Talk from the AMA Journal of Ethics. This month, AMA Journal of Ethics theme editor Sarah Waliany, a fourth-year medical student at Stanford University School of Medicine, interviewed Louise Andrew, MD, JD, about mental health challenges confronting physicians and medical students. Dr. Andrew is a fifth-generation physician attorney who deals with physicians in many kinds of crisis situations and has a longstanding interest in prevention of physician suicide. She maintains a website devoted to that topic called physiciandepression.com.
According to the CDC, about 25 percent of US adults have a diagnosable mental illness. Health care professionals can also suffer from mental illness. Physicians specifically tend to have higher rates of depression and suicidal ideation and completion than the general population, as described in a consensus statement published in JAMA in 2003. Do physicians suffer from depression at higher rates than the general population?
Physicians have a prevalence of depression that is at least equal to that of the general population, somewhere between 12 and 20 percent. And it may in fact be a little bit greater in physicians. We do know that physicians are now inching up on a 50-60 percent burnout rate in the United States, and there is some correlation—but we don’t know [what] it is—between burnout and depression. But in all populations, the worst outcome of inadequately or untreated depression is suicide. And physicians are definitely more vulnerable to the completion of suicide than the general population. We’re known to have the highest suicide rate of any profession or occupation. Medical students have even higher rates of depression than do physicians. Perhaps 15–30 percent of medical students are exhibiting depression at any given time. It’s suggested that perhaps as many as 300 to 400 physicians a year die by completion of suicide. That’s a lot of doctors to lose.
The stigma of mental illness affects the decision of many individuals, perhaps especially physicians, regarding whether to seek treatment for their symptoms. Unlike members of the general population, however, physicians have access to PHPs or physician health programs. What are PHPs? What types of services do these programs provide?
Physician health programs were developed as a way to assist physicians suffering from alcohol or other addictions to receive treatment and at the same time be protected from losing their licenses at the hands of the medical licensure boards. PHPs accomplish this by performing initial evaluations and if it’s appropriate, facilitating treatment and monitoring physicians in recovery through drug testing, work site monitoring, support groups, mentoring. And they do this under a contract whereby the physician consents to disclosure of their progress in the physician health program to the medical licensure board, if there is any deviation from the terms of this contract. Now in recent years, physician health programs have also begun to intervene in other areas, such as mental or physical health issues.
There’s a bit of controversy about how effectively PHPs address physician health issues. Advocates suggest that these programs are a safe and effective means by which physicians can get help while maintaining their licensure to practice medicine. Detractors suggest that these programs may in essence coerce physicians, by threatening them with licensure suspension or revocation, into treatment that might not be appropriate or helpful. All agree that health care professionals with mental illness, because of their increased vulnerability to suicide specifically, deserve good care that responds to their unique needs. So, how should colleagues of a health care professional with mental illness symptoms respond to him or her? How should they try to help? Are physician health programs the best alternative?
PHPs can be lifesaving, especially in substance or other addictions such as compulsive gambling where insight and motivation for functional recovery can be lacking. PHPs can use the threat of the medical licensing board action as a very effective form of leverage to both get physicians into treatment and to keep them under intense monitoring for an average of five years. Many, however, believe that physicians with pure mental or physical illness can be channeled into programs that are more specifically tailored. One common example of this is that of the physician who has maybe a pure, mild, or stable longstanding mental condition, such as anxiety or low-level depression. These are very prevalent in all populations and it would actually be illegal in most employment settings to require disclosure of them. But for physicians, such disclosure may actually be required, for example on a medical licensure or employment application, and it may trigger a number of additional questions, examinations, and proofs of fitness for practice. It’s for this reason that many physicians will avoid reporting either themselves or colleagues to physician health programs.
If a colleague seems to be suffering from some condition that appears to be affecting his ability to practice effectively, in many states there’s actually a legal requirement to report the condition, either to the medical board or to the physician health program. And this can in most cases be undertaken anonymously. And it is much safer for the colleague if such reporting is done to the physician health program, which can then determine whether there is a need to report to the medical board. It is a kindness, however, first to approach any colleague who is in that situation with your concerns and offer to be a sounding board or to assist. A sharing of ideas, a nudge, perhaps, to seek professional help in dealing with very common things like bereavement or early stages of burnout or the stress of litigation, this may be all the intervention that’s needed.
Some, including health care professionals, might hear the term “disability” and think mainly of physical disabilities. However, according to Healthy People 2020, mental illness is one of the most common sources of disability in the United States. Are physicians often disabled by mental illness, such as depression?
It is widely acknowledged that a physician who is affected by either a mental or a medical condition will redouble his or her efforts to be competent, so that the workplace is the last place the disability or an impairment will be noticed. In many cases, physicians who experience depression will seek treatment at the point where they believe their work may be starting to suffer. And when this happens we must be very careful to encourage them to seek the best and most professional care possible and not to encourage self-treatment. And lastly, only if the colleague utterly resists any sort of evaluation or treatment should one consider reporting directly to regulatory authorities. Physicians do deserve autonomy in the determination of their own care.
What role can physicians take in helping members of the public, organizational leaders, and policy-makers understand mental illness, particularly depression, as a source of disability that needs more attention at the national level?
Physicians could be very influential in the discussion at the public and policy level about the very great prevalence of mental illness in all populations and the increased vulnerability brought about by failure of help-seeking due to stigma. Personal disclosure of mental illness by physicians could be quite empowering to the public and could encourage further discussion and help-seeking. On a practical level, though, several surveys have clearly illustrated that physicians are reluctant to enter into such disclosure because of the fear that this could open them up to examinations, potentially inappropriate treatment and monitoring, or exclusion from employment opportunities, insurance coverage, or professional advancement. If we could make physicians feel more safe in disclosure, we might be amazed at the numbers of our colleagues who are affected by mental illness. And in many cases, these would be the colleagues that we most trust to provide passionate, conscientious, and competent care.
We would like to thank Sarah Waliany and Dr. Louise Andrew for this month’s podcast. To learn more about health professionals with disabilities in the October 2016 issue of the AMA Journal of Ethics, please visit www.amajournalofethics.org. You can also follow us on Twitter by searching @journalofethics. This is Ethics Talk from the AMA Journal of Ethics.
The viewpoints expressed in this article are those of the author(s) and do not necessarily reflect the views and policies of the AMA.
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