Society is in upheaval in the way that it discusses mental health. There are many loud voices out there. Some of these advocate for more openness and less stigma with regard to how we treat people with behavioral and psychological disorders, and by "treat," I don’t mean with drugs or therapy, but with our words, actions, policies, laws, and inaction. One example of these voices is Dr. Jake Goodman who posed with a pill on his tongue in a TIC TOC post to demonstrate that even as a physician, he may also need medication assistance for his mental health. The outpouring of support, vitriol and shenanigans that resulted demonstrates how divided our society is on this issue, and in many ways how unrealistic our view of doctors and of mental illness is.
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Welcome PsyDactic residency edition and welcome to 2023 with me. I am Doctor O’Leary a third year psychiatry resident in the national capital region. Nothing about this year has changed anything except an arbitrary number on your calendar. That means my opinion is still only my opinion and does not represent that of my residency program, the Department of Defense, the Federal Government or the Galactic Empire. Nor is my opinion special. I like what I say here, or I wouldn’t say it, but that is not evidence that it is right.
I want to start the year a little differently, and instead of covering a particular disorder or treatment, I want to discuss our psychiatric health and by that I mean the psychiatric health of physicians and other health care providers.
I decided to discuss this, because society is in upheaval in the way that it discusses mental health. There are many loud voices out there. Some of these advocate for more openness and less stigma with regard to how we treat people with behavioral and psychological disorders, and by treat, I don’t mean with drugs or therapy, but with our words, actions, policies, laws, and inaction. One example of these voices is Dr. Jake Goodman, a psychiatry resident, that was reported in an Inverse article titled, CAN DOCTORS PRACTICE WITH MENTAL HEALTH ISSUES? VIRAL PHOTO REVEALS A CONTENTIOUS DEBATE.
Dr. Goodman posed with a pill on his tongue to demonstrate that even as a physician, he may also need medication assistance for his mental health. The outpouring of support, vitriol and shenanigans that resulted demonstrates how divided our society is on this issue, and in many ways how unrealistic our view of doctors and of mental illness is. There are those who believe that doctors must be superhuman and impervious to the same behavioral health struggles that the rest of humanity faces. To be otherwise is to be unfit to practice medicine. This is often tied to the notion that those needing psychiatric care suffer from a flaw of character instead of a flaw of the flesh.
I remember being raised hearing statements like, “Psychiatrists think that pills can solve all your problems,” and other strawman characterizations of the medication-industrial-complex. I even witnessed children being blamed by their father for why their mother was admitted to a psychiatric hospital. Had they only behaved better, she would not be there. Something between ⅓ and ½ of my patients report that they were raised not to believe in mental illness or at least that mental illness was a weakness of will or a supernatural affliction brought on by some deficiency of faith.
For much of the world, these views still predominate. One of the most popular among educated Americans is that psychiatric diagnoses were invented by pharmaceutical companies to sell drugs.
One would think that these views would have been put to rest by our medical associations and medical boards decades ago, but surprisingly the opposite is true. Doctors have over the last century been systematically punished by state medical boards for revealing mental health issues even when there have been no actual performance issues. They report being demeaned and forced to appear to defend themselves for crimes such as seeking marriage counseling. Some report driving hundreds of miles and paying in cash to receive anonymous care that they will never have to report. I know physicians who put off seeking mental health care for over a decade out of fear that telling anyone about their suffering would result in dire consequences for their career.
Medical licensing boards and physician health programs or PHPs, have been criticized for operating without due process in a system where rules and rulings are arbitrary and there is no recourse. The mental health crisis of the pandemic did little to change this. As of September of 2022 fewer than half of state medical boards had made meaningful changes that were recommended by the Federation of State Medical Board in 2018 to reduce stigma and protect physicians from intrusive violations of their personal rights and protected health information. A series published in Qualitative Research in Medicine and Health included a paper titled, “Physician-Friendly States for Mental Health: A Comparison of Medical Licensing Board Applications” It curiously implies that some states have policies that are anathema to physicians seeking mental health care.
Let me read you a question included as a figure for Alaska’s medical licensing application. “Check each condition you have ever been diagnosed with, treated for, or currently have: Bipolar disorder, hypomania, schizophrenia, depression, seasonal affective, depressive neurosis, any dissociative disorder, any psychotic disorder, any organic mental disorder, any condition requiring chronic medical or behavioral treatment, kleptomania, pyromania, delirium, paranoia.” There were 11 other questions on the license application. One of them asked if the applicant is or has ever taken a “controlled substance for any of these disorders.” It doesn’t take a genius to infer that these questions are not included in order to support physician mental health.
One of the defining moments of the pandemic was when Dr. Lorna Breen, after weeks of battling COVID in a New York City emergency room, took her own life. Dr. Breen’s suicide is part of a larger picture. Physicians are at least twice as likely to die by suicide than the general population and this rate is even higher for female physicians than males. The already high rates of burnout among all healthcare professionals skyrocketed during the pandemic, resulting in thousands exiting the profession permanently. This resulted in action from Congress, and President Biden recently signed the Dr. Lorna Breen Health Care Provider Protection Act into law.
JAMA reports that The Breen Act provides 135 million federal dollars over three years with three main objectives. I quote, “First, it requires the Secretary of Health and Human Services (HHS) to establish and share evidence-based strategies to improve mental health and prevent suicides among health care professionals within 2 years. Second, it funds the creation of a national education and awareness initiative to encourage health care professionals to pursue mental health and substance use treatment and to reduce the stigma of doing so. Third, it authorizes the Secretary of HHS to award 3-year grants or contracts to health care entities and training institutions to create new initiatives aimed at improving the mental health of health care professionals.”
For those of us who are more than a little skeptical of impressive sounding initiatives that also seem to lack any concrete objectives or directives, this act may be described at best as “A step in the right direction.” To me, it sounds like a new positive psychology initiative that is flush with cash and anemic of evidence. Greg Jasani in a March 21, 2022 article in STAT called the then bill “fundamentally flawed in its approach and is unlikely to achieve its desired effects.” He points out that initiatives like these in the past have failed to produce any durable results and even worse, fail to address any primary causes of burnout. What is going to stop physicians from feeling like their efforts are either meaningless or unappreciated or not worth the effort?
Politically motivated initiatives certainly aren’t and never have cared much about high quality evidence. They care about optics. Congress could have passed various reforms, such as specific protection of physicians from state licensing boards or limits on physician health programs' unregulated power. They could provide money or mandates to increase salaries or the number of providers. They could have done a million things other than empower an agency to make some recommendations and encourage healthcare institutions to promote dubious yet quote “evidence-based programs” unquote as major breakthroughs in order to secure federal funding and prestige. Maybe you can sense my cynicism.
The legislation could have done something even more simple by formally required what has already been recommended by the Federation of State Medical Board in 2018 for licencing applications:
Medical Economics reported on September 15, 2022 that only 17 states had aligned their applications with the above recommendations. Instead we have a nation of doctors who may never seek psychiatric treatment because they are comfortable with lying on their applications.
I started this episode because I read about a doctor reporting that he takes medication on TIC TOC, and this was reported as a major controversy. The reason it was a controversy is because the medication was used to treat his brain instead of his kidney or heart or skin or esophagus or erection. It is going to take more than some resiliency initiatives to fix this.
1. Congress passes Dr. Lorna Breen Act to promote physician mental health | Dr Lorna Green Bill |AMA. Accessed January 3, 2023. https://www.ama-assn.org/practice-management/physician-health/congress-passes-dr-lorna-breen-act-promote-physician-mental
2. The Breen Act is well-intentioned. But it won’t stop burnout - STAT. Accessed January 3, 2023. https://www.statnews.com/2022/03/21/lorna-breen-act-health-providers-burnout/
3. Removing barriers to physician mental health care in 3 steps. Accessed January 3, 2023. https://www.medicaleconomics.com/view/removing-barriers-to-physician-mental-health-care-in-3-steps
4. Can doctors practice with mental health issues? Viral photo reveals a contentious debate. Accessed January 3, 2023. https://www.inverse.com/mind-body/doctor-mental-illness
5. Sindhu KK, Adashi EY. The dr lorna breen health care provider protection act: A modest step in the right direction. JAMA Health Forum. 2022;3(9):e223349. doi:10.1001/jamahealthforum.2022.3349
6. Manion KT. To heal or not to heal, physician, that is the question. Qual Res Med Healthc. 2019;3(3). doi:10.4081/qrmh.2019.8665
7. Wible P, Palermini A. Physician-Friendly States for Mental Health: A Comparison of Medical Licensing Boards. Qual Res Med Healthc. 2019;3(3). doi:10.4081/qrmh.2019.8649
8. Phelan-Adams AL. A physician’s descent into abject poverty for seeking help from a PHP. Qual Res Med Healthc. 2019;3(3). doi:10.4081/qrmh.2019.8647