Medical school graduates take the Hippocratic Oath, which for centuries has been the physicians’ ethical code when treating patients. While graduates swear to uphold its modern version, many physicians may, without realising it, end up violating part of the traditional Hippocratic Oath: “In purity and holiness I will guard my life and my art.” Doctors practice the best medicine on people other than themselves. Physicians struggle to face their vulnerability, whether physical or emotional. The fact is that doctors are professionally trained to treat the sick, but for many reasons, feel it is not permissible for them to be ill themselves. Medicine maintains a pressured culture which urges physicians to ignore their own symptoms or discomfort. As this phenomenon takes its toll, physician burnout and suicidal ideation rates are significantly higher than in the general population.
Burnout & suicidal thoughts
The condition defined as physician burnout usually combines emotional exhaustion, a decreased sense of personal accomplishment and depersonalization. The physical symptoms associated with burnout include fatigue, exhaustion, eating disorders, migraines and insomnia. Doctors’ mental health may decline, with problems such as depression, anxiety, substance abuse, and suicidal ideation. Another consequence is the quality of medical care doctors provide; patients may be endangered as burnout can blur doctors’ judgment, which may result in poor patient care and increased errors.
Many factors contribute to physician burnout- long working hours, non-clinical tasks and bureaucratic obligations, disrespect from colleagues, and inadequate salary. As troubling as it may sound, burnout begins during medical studies. Physicians may start to experience burnout symptoms as early as in their 20’s, and these symptoms may continue in differing forms throughout their careers. Wellness falls behind because the culture and intensity of training emphasises the need to be knowledgeable with outstanding clinical, practical and ethical standards. The medical curriculum currently does not accentuate enough well-being and empathy as key aspects of the profession. In addition to studying, medical students and junior physicians juggle establishing their careers with starting families, adding another source of pressure to their lives. Life is even more difficult for doctor couples. The emotional and practical challenges of medical studies and work conflict with the need to plan shifts, allowing one parent to be free for childcare while the other is on duty. According to Medscape, 38% of millennial physicians are suffering from burnout.
The long-term effects of the COVID-19 pandemic on physician burnout are yet to be fully evaluated. It is not clear how the unrelenting pace of the past few months will impact doctors’ well-being. For the first time in their careers, doctors often do not have the answers regarding how best to treat patients suffering from Coronavirus. On top of that, they are working extended hours, treating more people, and witnessing patients dying from the disease, often alone and without their loved ones. Home is no longer a safe place for the physicians as their families are stressed too, and doctors worry they may bring the virus home and infect their relatives.
Most doctors will ignore burnout symptoms and will keep on working. However, with increasing severity, burnout can lead to doctors dropping out of the profession. Others may turn to substance abuse, and sadly many physicians end up taking their own lives. The suicide rates among doctors are significantly higher than in the regular population. Approximately 400 physicians commit suicide every year in the USA alone.
The wellness conundrum
In many countries, psychology and psychiatry students are required to undergo therapy as part of their formal training. Mandatory therapy is controversial, but may benefit those who take part voluntarily and even enhance personal development. Can this solution be helpful for physicians? On the one hand, going to therapy throughout medical studies and internship might reduce the risk of early burnout, help doctors identify their own depressive symptoms and reduce the stigma of seeking help for mental health issues. In addition, experiencing regular therapy may improve physicians’ communication skills with patients and colleagues. On the other hand, regular mandatory therapy does not guarantee a successful outcome, and doctors may be rightfully cynical about the process due to lack of good evidence for its effectivity. Ironically, finding time to attend therapy in an already packed working week can itself be a major stressor. Mandatory therapy for doctors would require substantial funding which would further challenge overstretched healthcare systems.
Another option would be for health institutions to offer mental health assistance to physicians similar to the Employee Assistance Programs (EAP) which companies and organizations fund to promote employee well-being. The EAP provides workers with free-of-charge sessions with qualified therapists and in some cases, their family members too. Many hospitals in the UK offer confidential EAPs to all their staff members.
EAP’s have their challenges as well; sometimes the perception of mental health stigma may deter employees from seeking help. Doctors can be especially reluctant to access mental health support, both due to prejudices and fear of professional discrimination. Doctors also worry that accessing mental health assistance might put their medical license at risk. Having low trust in therapists and fearing disclosure, physicians tend to downplay the severity of their distress as part of their attempt to overcome symptoms of burnout.
Customized physician mental health support programs must consider the culture, environment and the profession’s unique needs. Dr Evie Kemp, former lead Occupational Health Consultant at the Centre for Occupational Health and Well-being, Oxford University Hospitals NHS Foundation Trust, launched the ‘What’s up Doc’ program for junior and senior doctors. The program sought to raise wellness self-awareness, and in the long run, to lower physician burnout rates. In her lecture to physicians, Dr Kemp reviews contributors to burnout which doctors should not ignore; these include night-shift challenges, insufficient self-care, skipped meals, postponed toilet visits and abandoned hobbies. Additionally, Dr Kemp emphasizes that in order to access treatment, doctors need reassurance that it will be confidential and not reach the regulators or their colleagues. The Practitioner Health Service in England has reached a memorandum of understanding with the General Medical Council, which is clearly explained to practitioners at the outset. Confidentiality is maintained regularly — except in those cases where patient safety might be compromised and in cases where the doctor is not complying with the treatment process or heeding advice to remain on sick leave.
Automated emotional support
Preventing suicide by using an AI-based predictor is still in its early stages of development and raises many ethical difficulties, particularly privacy protection issues. However, mobile apps may have the potential to help reduce burnout and suicidal ideation. Nowadays, many doctors utilize social media for stress management, sharing thoughts and feelings alongside their expertise. Physicians find solace in posting their sentiments and by receiving supportive feedback from other social media users and colleagues. MD candidate Catherine Cai from Saint Louis University School of Medicine shared her feelings on Twitter:
“One of my patients died today, and I felt so, so sad — and disoriented by the expectation to rejoin rounds and keep working after listening to the family’s sobbing. I felt cowed by the enormity of grief that is present in the hospital, somewhere, every moment.”
MD Craig Spencer, an ER Doctor at New York-Presbyterian Hospital, shared how a patient’s death sunk in only five weeks later. MD April Butler, from UC San Diego Health, witnessed a patient’s death for the first time and later that day tweeted her experience and associated emotions. These examples demonstrate how physicians utilize social platforms to unload heavyweight feelings and obtain supportive feedback from other users, including colleagues. Lately, especially since the COVID-19 era has begun, doctors have been using the Tik Tok app to let off steam with fun videos. Dr Jason Campbell from Oregon Health and Science University has made a name for himself as a creative dancer. This entertaining medium helps doctors de-stress and cope with the profession’s daily difficulties. Nevertheless, it is hard to prove that social media can reduce physician burnout. It may work for some doctors, but for others, social media may deepen the burnout sensation and drive them to social isolation. Tough feedback, other colleagues’ posts and the time social media consumes may all have an adverse effect, becoming another catalyst for burnout. Many physicians would rather stay under the radar and avoid sharing their feelings as they do not desire the exposure to patients, their colleagues and the regulator. In addition, many countries have strict guidelines for doctors on how to use social media. An automated confidential chatbot could be a solution for physicians who would benefit from self-reflecting on their emotions. A mobile app of this type should not just allow doctors to look back at a situation but also help them to prepare for the next difficult encounter. For example, if a doctor needs to inform a patient they have been diagnosed with an incurable illness, pre-planning the process may provide tools and support for the complex consultation.
Generation Z is now entering medical school. Keeping Gen-Z healthy and well going forward will inevitably involve mobile phones. Gen-Zers praise technology, preferring their smartphones to meeting people in person. A customized app for doctors featuring an interactive preparation tool cannot replace professional therapy for those who suffer from severe depression or are at suicide risk. Nevertheless, the app may have the power to help understand their emotions and prepare for any difficult challenges at work or at home. It could also assist doctors in recognising and dealing with draining emotions and thus help reduce the rates of physician burnout. A dedicated app may break the barrier between physicians and therapists, allowing a seamless transition from being a treating doctor to a person who is receiving support. Predominantly, it should support physicians’ journey through day-to-day stressors with the understanding that emotional difficulties should be addressed and not remain repressed within.
Our special thanks to Dr. Evie Kemp, former lead Occupational Health Consultant at the Centre for Occupational Health and Well-being, Oxford University Hospitals NHS Foundation Trust, for sharing important information about aspects of physician burnout and suicidal ideation.