Doctors’ Mental Health: If We Wait, It May Be Too Late

Losing spatial awareness and freezing up in the middle of an athletic skill (known as the “twisties” in gymnastics) is a limbic system response to perceived trauma that can be triggered by a number of mental, emotional, or physical stressors. Essentially, an individual’s subconscious urges override the brain’s typical cognitive processes and trigger an automatic “fight or flight” survival response. Unfortunately, the primitive brain response does not take into account that freezing up or aborting the skill is actually more dangerous—it just perceives a threat and attempts to avoid it. Typically, at some point after repeated exposure and conditioning, the brain stops recognizing the action as a threat and the “twisties” go away. However, it is a healing process like that of any physical illness, and it takes time and often therapy or rehabilitation to recover fully.

Simone Biles brought awareness to this issue and the link between mental and physical well-being when she withdrew from several events during the Summer Olympics in 2021. Biles told the public that she needed to remove herself from competition out of concern for her mental state and the impact that was having on her physical safety: “I have to focus on my mental health and not jeopardize my health and well-being.”(1) This kind of honesty and candor from an elite athlete who is renowned for her unsurpassed mental and physical strength helps to destigmatize discussions around anxiety and depression. Biles received an abundance of support from the majority of the public, with only a few people criticizing her for withdrawing. Biles is not the only famous athlete who has been affected by mental stress. The tennis player Naomi Osaka withdrew from the French Open in May of 2021, stating that the mandatory post-match press conferences were harmful to her mental health.(2) Further, legendary swimmer Michael Phelps has been very candid about his struggles with anxiety and depression throughout his illustrious career, and now serves as a mental health advocate.(3)

We need to face the reality that becoming and working as a physician is a high-risk endeavor.

It is thanks to the efforts of these mental health activists to fight the stigma surrounding mental health that people will be able to talk openly about their well-being. So how does Simone Biles’ experience relate to the healthcare professions? We are all aware of the increasing rate of anxiety, stress, and burnout among physicians, which affects more than 50% of doctors in some specialties.(4) Unfortunately, most physicians can recall a mentor, colleague, or trainee who struggled with mental health, many of whom were lost from suicide. Rates of suicide among physicians have been estimated to be 40% higher than those in the general population in men and a shocking 130% higher in women compared with their non-physician peers. We need to face the reality that becoming and working as a physician is a high-risk endeavor, which includes not only exposure to infectious diseases, but also an increased risk of stress and mental disorders.

Rather than offering treatment only after we identify physicians who are experiencing stress, burnout, depression, and are at an increased risk of suicide, we need to begin with the prevention of these mental disorders. This improves the lives of healthcare providers, and also will prevent medical errors and decrease the number of physicians leaving clinical medicine due to burnout. Just as elite athletes are expected to “suck it up” and often are encouraged to perform despite physical pain and injuries, doctors also are members of a high-pressure profession and are expected to endure sleep deprivation, work even when ill, and hide their feelings from colleagues or employers. This is an untenable position and is not in the best interest of doctors or their patients.

Preventive Methods for Improving Doctors’ Mental Health

Having a luncheon to celebrate Doctors’ Week or sending doctors cheerful emails thanking them for their dedication and compassion are not going to solve the problem. Although well-meaning, these approaches do little to lessen the massive problems of physician burnout and suicide. In the past, physicians with a mental illness who sought help have been stigmatized. We have made strides in helping doctors with drug or alcohol abuse who seek help and rehabilitation; however, physicians seeking other types of mental health treatment still face many obstacles, including the need to take time away from caring for their patients, shame, and fear of retribution. Additionally, medicine’s culture of minimizing stress as part of the physician’s badge of courage, rather than support and cooperation, leads to the epidemic of burnout. What if we had a paradigm shift in the profession and permitted doctors to speak safely of the challenges they experience during day-to-day activities in a safe and confidential environment, without fear of retribution?

The Mayo Clinic study demonstrates that trained coaches (none of whom were medical doctors) can help resolve mental health problems.

As a preliminary step in this direction, the Mayo Clinic has introduced a coaching program for physicians. This program investigates the use of professional coaching—focused on goal setting, work choices, professional relationships, and influencing change at work—to reduce burnout.(5) Theirs is the first report specifically exploring the effects of coaching on physician burnout. The study included 88 practicing physicians, who began by filling out several self-assessment questionnaires addressing burnout, quality of life, resilience, and job satisfaction. The doctors then completed six sessions with a professional coach who had experience working with doctors. After just six sessions (3.5 hours total), the physicians filled out the same questionnaires to chart their progress. The doctors reported less burnout and a higher quality of life after coaching. The researchers also administered the same self-assessment questionnaires to a control group of physicians who were not coached. These physicians reported more emotional exhaustion and lower quality of life when left unaddressed. These encouraging findings are even more noteworthy when considering that the time spent on professional coaching to improve physician well-being was less than the time required to renew a doctor’s CPR certification!

The Mayo Clinic study demonstrates that trained coaches (none of whom were medical doctors) can help resolve mental health problems. This provides a unique opportunity to train coaches from a variety of backgrounds to help enhance physician well-being. For example, an innovative program called the Confess Project (www.theconfessproject.com) is a nationwide initiative that trains barbers to be mental health advocates. If the Confess Project is effective in their mission, then we might consider other commonly used service providers (e.g., hairstylists, manicurists, masseuses) as mental health advocates as well.

Revisiting our earlier analogy, what did Biles do to help improve her mental state and return to the balance beam for event finals on the last day of Olympic competition? She removed herself from competition for a few critical days and gave herself a much-needed break from the high-pressure situation by practicing in a secluded training center out of public attention. While there, she focused on her most basic and fundamental skills to relieve stress and renew her mindset, trained on soft mats and foam pits to make sure that she could safely attempt to work again, performed fewer skills to give her body a physical break, and reorganized her routine to temporarily remove the more complicated and dangerous activities. In fact, for many athletes this kind of recovery strategy is a planned and structured component of their regular training program that enables them to perform at high levels during critical periods, and then recover during off-seasons to rest the mind and body in preparation for the future.

Unfortunately, doctors do not have on-season versus off-season responsibilities. Doctors are always on-season. Nonetheless, some of these recovery strategies could still be used as a proactive means of preventing physician stress and burnout. For example, doctors could periodically rotate through low-pressure clinic or laboratory settings that are largely out of public attention. While there, they could focus on only their most basic and fundamental skills to relieve mental stress, treat patients in a low-risk environment where they feel safe and relaxed, work fewer hours to give their body a physical break, and reorganized their routine to temporarily remove the more taxing and hazardous activities. Although this might not be possible for long periods of time, with a little organizational creativity it should be possible to routinely schedule “off-season” workdays every few weeks. Coordinating these proactive recovery periods will take effort, but this additional medical practice management task is surely worth the reward of helping physicians stay mentally healthy.

Bottom Line: Doctors, like professional athletes, are at risk for high stress, anxiety, burnout, depression, injury, and suicide. Perhaps we can begin with physician coaching to lower the risk of future mental health issues. We cannot wait until a doctor shows visible signs of mental illness or substance abuse to intervene. The solution is not to encourage doctors to keep pushing forward, neglecting their mental health, and feeling ashamed of drowning in stress and burnout. It is important to recognize that doctors need support as they are in a high-pressure and high-risk career. There should be no penalty for either doctors or athletes who seek help for mental health issues.

References

1. Ramsay G, Sinnott J, Wright R. ‘I have to focus on my mental health,’ says Simone Biles after withdrawing from gold medal event. CNN.com. July 29, 2021. www.cnn.com/2021/07/27/sport/simone-biles-tokyo-2020-olympics/index.html .

2. Futterman M. Naomi Osaka quits the French Open after news conference dispute. The New York Times. May 31, 2021. https://www.nytimes.com/2021/05/31/sports/tennis/naomi-osaka-quits-french-open-depression.html .

3. Drehs W. Michael Phelps: “this is the most overwhelmed I’ve ever felt.” ESPN.com. May 18, 2020. www.espn.com/olympics/story/_/id/29186389/michael-phelps-most-overwhelmed-ever-felt .

4. Shanafelt TD, Dyrbye LN, West CP. Addressing physician burnout: the way forward. JAMA. 2017;317: 901-902.

5. Nellis R. Professional coaching alleviates burnout symptoms in physicians. Mayo Clinic. August 5, 2019. https://newsnetwork.mayoclinic.org/discussion/professional-coaching-alleviates-burnout-symptoms-in-physicians/ .