The biggest stressors of being a physician, unraveled

Although physicians and physician-trainees experience a high degree of job-related mental distress, and even depression, many are reluctant to seek help. This is in part due to their perfectionistic tendencies or even fear of professional repercussions. Left untreated, the results can be tragic.

What the research says

Research on the subject is murky and often outdated, but physicians seem to be particularly prone to burnout and depression, due to lack of sleep and the demanding nature of their job, including heavy workload, work inefficiency, lack of autonomy and meaning in work, and work-home conflicts. Not to mention the stress of COVID-19. A 2021 Medscape survey^[] of more than 12,000 physicians found that more than half of female (51%) and more than one-third of male (36%) physicians report feeling burned out. 

Major depression—which is marked by feelings of worthlessness, guilt, loss of interest or pleasure in previously enjoyed activities, and thoughts of death or suicide—is a growing problem among the population at large, as well as among physicians. The 2021 Medscape survey found that 20% of physicians report clinical depression—defined in the survey as “severe depression, lasting some time, not caused by a normal grief event”—while a whopping 69% report colloquial depression ("feeling down, blue, sad," as defined by the survey).

Nearly two-thirds of healthcare professionals report that worry or stress related to COVID-19 has had a negative effect on their mental health, according to a recent Kaiser Family Foundation (KFF)/Washington Post survey.^[] A majority feel “burned out” going to work, and nearly half said worry or stress has caused them to have trouble sleeping or to sleep too much. Depression may be even more prevalent in physician trainees: Nearly one in three resident-physicians screened positive for depression or depressive symptoms, according to a meta-analysis published in JAMA Network^[] involving nearly 18,000 physicians-in-training.

According to the Medscape survey, female physicians have consistently reported higher percentages of burnout than male doctors, but the disparity is greater than ever, partly due to increased pressure caused by COVID-19.

“Many women physicians are in families with children at home,” noted psychiatrist Carol Bernstein, MD, at the Montefiore Medical Center in Bronx, New York, in the Medscape report. Parenting pressures have increased since the pandemic (ie, homeschooling, lack of regular childcare, grandparents being unable to pitch in due to social isolation, and worry about bringing the virus home to their families).

While those concerns are certainly not limited to female doctors (or even just doctors, for that matter), Dr. Bernstein points out that, “It’s already known that women assume more responsibilities in the home than do men."

Burnout vs depression

Burnout and depression are two closely related hazards that doctors face, and due to this overlap, it can be difficult for the person suffering or their loved ones to sort out the difference, explained Michael F. Myers, MD, professor of clinical psychiatry in the Department of Psychiatry at Behavioral Sciences at SUNY, who exclusively treated physicians for several decades in his private practice.

In an exclusive interview with MDLinx, Dr. Myers explained, “Burnout is an occupationally defined illness caused by stress in the workplace. Caused by more than just hard work, it has to do with lack of agency, or feeling like you don’t have a voice, that you’re just filling orders."

He added, “With depression, there is often a family history or genetic component, as well as a psychological piece, such as a loss or trauma, and a social component, such as getting fired or receiving a patient complaint...Depression really needs to be treated, often with medication, but always with therapy,” Myers said. “Patients with depression who quit their job thinking they are just burned out will feel just as crappy in the next hospital as they did in the first one.”

In the KFF/Washington Post survey, one in five health care professionals say they need mental health services or medication due to worry or stress but have not gotten them. Dr. Myers noted that stigma along with physicians’ perfectionistic tendencies and fear of loss of licensure are top reasons they may avoid seeking help for depression or mental illness. 

While some states have removed intrusive questioning about past or current mental health treatment from their physician licensing procedures, not all have done so, Myers said. In fact, decisions by the courts and the Department of Justice have increasingly sided with physician groups on this point—namely that questioning doctors about receiving mental health care violates the American Disabilities Act, according to an article in The Journal of the American Academy of Psychiatry and The Law.^[]

Suicide risk among physicians

Suicide among physicians is a growing concern: Male doctors die by suicide 1.41  times more often than the general male population and female doctors die by suicide 2.27 times more often than the general female population, according to a meta-analysis published in the American Journal of Psychiatry.^[] The authors noted that few studies have investigated risk factors relating to the working environment, stress factors, or specific personality traits associated with the phenomena.

“The literature also suggests that physicians who kill themselves [were] more critical of others and of themselves and [were] more likely to blame themselves for their own illnesses,” the authors wrote.

Lack of proper treatment, along with self-medication, may be one reason for the increase. 

Physicians who died by suicide “were significantly more likely than non-physicians to have antipsychotics, benzodiazepines, and barbiturates present on toxicology testing but not antidepressants,” wrote the authors of a study published in General Hospital Psychiatry.^[] Researchers used data from the National Violent Death Reporting System to examine more than 200 physician suicides and compared them to non-physician suicides in 17 states. 

Physicians who died by suicide were also likely to have a known mental health disorder or a work-related issue that contributed to the suicide. “Inadequate treatment and increased problems related to job stress may be potentially modifiable risk factors to reduce suicidal death among physicians,” the report noted.

Dr. Myers, who studied more than 100 physician suicides and authored Why Physicians Die by Suicide: Lessons Learned From Their Families and Others Who Cared, told MDLinx that there is not one specific risk factor. “Rather, many factors that come together in a horrific storm that ends in the physician dying by suicide. In 85% to 90% of cases, there is unrecognized, untreated, or partially treated mental illness.”

The power of sleep hygiene

Proper sleep hygiene may be one of the best ways physicians can ward off depression, according to a yearlong study of physician interns recently published in Digital Medicine.^[] Researchers at the University of Michigan found an association between better sleep habits and improved next-day mood among physicians. These habits include getting more sleep, waking up/going to bed later, and having less sleep variability. What’s more, an irregular sleep schedule—in total hours slept as well as sleep and wake times—was associated with greater risk of depression over the long term than getting fewer hours of sleep overall, or staying up late most nights.

However, variability in sleep duration had an even stronger effect: The more the sleep duration varied, the higher the depression score, even after adjusting for total hours slept.

In an exclusive interview with MDLinx, lead study author Yu Fang, Michigan Neuroscience Institute, University of Michigan, noted a surprising finding: Setting the alarm clock for the same time each day (ie, regularity of wake time) was even more important in regulating physicians’ depression risk and mood than regularity of bedtime. Fang hopes that her findings will encourage hospitals, administrators, and other employers to offer more optimized scheduling strategies. "Intervention or support programs on improving interns’ sleep quality would also be helpful," she said.

Dr. Myers noted that in addition to good sleep hygiene, other forms of self-care are critical for good mental health. This includes eating nutritionally balanced meals, exercising, limiting alcohol and other substances, and spending time with friends and family members. “Way too many doctors, especially men, don’t have their own primary care physician,” he said. “Make sure you have a primary care physician you feel comfortable with and who feels comfortable with having a doctor as a patient. You should get the same level of care as any other patient.” 

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