Dear community,
In today’s post, we continue our drumbeat of looking at the conditions that promote or detract from clinician well-being. Lots has been written on this topic, and I won’t rehash all of it today — but I do want to lift up some salient points from the literature and low-hanging fruit for reforming our approach, as well as to highlight the recent bright spots and wins in our movement to ensure that healers can thrive.
Though I will often cite examples from the United States, as we know, clinician ill health is a worldwide epidemic with exacerbating factors that make it more problematic in certain countries.
Other parts of this series have included the stories and voices of those undergoing the most grueling parts of training while managing mental illness:
Psychiatrist Dr Ahmed Hankir’s journey in medicine with melancholia and elation
Psychiatry resident Dr Jake Goodman’s journey in medicine with depression and anxiety
Nephrology fellow Dr Justin Bullock’s journey with suicidality and depression in medicine
Emergency medicine resident Dr Ade Osinubi’s journey with hopelessness in medicine
Trigger warning: In this article, we discuss clinician mental illness, suicide, grief, and related themes.
If you or a loved one needs help for a mental health crisis, don’t hesitate to call or text 988 — or reach them online here. Find other resources here, search for a US treatment facility here, and find a US-based therapist here. If you’re a US-based clinician or health student dealing with “any issue, not just a crisis” — reach out to the Physicians Support Line, free of cost and confidentially, at 888-409-0141 (M-F, 8 am to 12 am ET).
Click here to catch up on previous posts — going back to our newsletter’s launch in January 2023.
Wishing you light,
Dr Devika Bhushan
Have you ever at a teaching hospital, taken care of by a bleary-eyed resident — and wondered if they were alert enough to do the job? Have you ever been that bleary-eyed resident? I know I have.
Behind those bleary eyes, that resident may be deeply struggling, often unbeknownst to those around them.
Due a confluence of factors, ~400 US doctors — and many more worldwide — die by suicide every year. This commonly cited figure arises from 1984-1995 data, representing white male physicians from 28 of 50 states — so the true rate is higher, and there’s evidence that rates have risen since then. But even using this conservative estimate, we are losing more than one physician a day in this country alone — at 1.4 times the national average for men and 2.3 times for women physicians, with procedural specialties at higher risk. This is the equivalent of two graduating medical school classes — just gone, every year.
This is heartbreaking — and it is also wholly preventable.
If you received this as a forward, we hope you’ll consider joining our well-being community.
Precursors to clinician suicide
Let’s take depression as an example — an important, though not the only, precursor of suicide:
Recent meta-analyses show that one in three to one in four medical students will have clinical symptoms of depression, and one in nine will experience suicidal thoughts (range: 7.4% to 24.2%). But only one in six of students who are depressed will end up seeking treatment.
Reasons include lack of time, confidentiality, affordability, stigma associated with accessing care, and unwanted interventions. And trainees also cite structural stigma and discrimination: A fear of having a mental health condition on record, and needing to report it on licensing, credentialing, or insurance forms down the road — and be barred from or have it be more difficult to practice medicine. A 2023 survey showed that four in 10 physicians or trainees (and peers) have forgone treatment due to this fear.
After medical school, depression symptoms increase by a median of ~16% in residency — 21% to 43% of residents report depressive symptoms, increasing over time. And when untreated, this can certainly impact patient care outcomes. For example, depressed residents make 6.2 times more medication errors monthly than non-depressed residents.
Suicide is now the second leading cause of death for residents, after cancer — more prevalent in men (unlike clinician suicide deaths overall), earlier on in training, and in the first or third quarters of the year.
Consider — zooming out from the example of depression in trainees — the cumulative burden of undertreated mental illness and burnout (which we won’t have space to address fully here) in all clinicians worldwide.
What makes training so challenging?
“Starting from sleep deprivation, challenging patient interactions, challenging patient situations, because again — this is your first experience as a true provider… Unfortunately, you’ll experience patient death, you’ll experience poor clinical outcomes… [while] trying to afford basic things like food, your rent — when… you’re being paid paycheck to paycheck,” said Ade Osinubi, MD, emergency medicine resident and filmmaker. “I struggled tremendously during intern year with mental health.”
Dr Osinubi wrote: “Despite the advocacy efforts of many, residents are still severely underpaid and subjected to toxic work environments and unhealthy work hours.”
Culturally, this toxic work environment can include perfectionism, belittling, bullying, emotional and sometimes physical intimidation and abuse, unethical conduct, sexual harassment, and outward derision of and low empathy for mental health needs.
As psychiatrist and burnout expert Jessi Gold, MD, MS, says, there is also little redundancy in the system — residents are “basically sustaining the life force of a hospital [system] that’s broken” and their numbers are fixed, with no room for give. We need to move towards a system where, if someone needs a sick day, “the whole system doesn’t implode,” she said. “And… they don’t feel like the bar to do so is 100.”
Clinicians are saying: “Don’t talk to us about resilience — talk to us about getting more doctors and more time off for our health and personal lives,” in the words of Michael Myers, MD, a psychiatrist who specializes in clinician mental health.
Let’s talk about duty hours
Current US duty hour regulations state that resident doctors should:
Work no more than 80 hours per week (averaged over four weeks)
Undertake shifts of a maximum of 28 consecutive hours in a row, not more often than every third night
Have one day off per week (averaged over four weeks)
By comparison, many countries have capped resident work hours at lower numbers:
The European Working Time Directive currently limits residents in Europe to working no more than 48 hours per week, 60% of the 80+ hours common in North America. (It is possible to sign an opt-out contract.)
When it comes to enforcement, Dr Gold points out: it’s up to every resident to self-report their hours. And “they lie” if they have to, she said, “because if you reported your real hours, your program got in trouble, and then you didn’t have a program.” Who really gets penalized if a program goes on probation? Its residents — who now can’t graduate from an accredited program and be licensed to practice.
Recording inaccuracies notwithstanding, since instatement of the 80-hour workweek, some (though not all) studies have shown reductions in patient deaths (by 11% overall and by 42% in surgical settings). Costs also rose — by ~$1.5 million over two years in a surgical context, due to increased attending versus resident time.
This is the trade-off we have to be willing to engage and re-calibrate: lives and well-being on the one side, profit on the other.
Longer duty hours have also been associated with slightly increased patient deaths (odds ratio 1.28) relative to shorter hours, but other studies and meta-analyses have not consistently shown this.
The key issue: As resident psychiatrist and activist Dr Jake Goodman, MD, MBA, highlights in his TedX talk, after being awake for 24 hours, the body undergoes physiological changes that mimic alcohol intoxication — equivalent to a blood alcohol level of 0.1 — above the legal limit to drive (0.08).
“So we are essentially asking resident doctors to operate on or treat a person when… they wouldn’t be able to legally operate a vehicle,” said Dr Goodman. “Find another career in which human lives are at risk that allows that.”
If the pilot of your flight had been awake for 24 hours, he posed: “Would you get on that flight?”
Some experts I interviewed believe that 28-hour calls still exist largely because patients are not aware of them — to carry through the pilot analogy, since no traveler would stand for the example above, it stands to reason that patient travelers are not aware that this is the norm in many hospitals.
The last impetus to meaningfully change duty hours in the US occurred in 1984 — when a teenager named Libby Zion was killed by a medication error by overworked doctors, after which her father’s advocacy led to the creation of the 80-hour workweek, first in New York and much later in the rest of the country.
“Unfortunately, I think it will take someone getting seriously hurt or killed in order for things to change, whether that’s a patient or that’s a resident,” said Dr Goodman.
Discrimination against doctors with mental illness
According to a consensus statement on this topic: “The culture of medicine accords low priority to physician mental health despite evidence of untreated mood disorders and an increased burden of suicide. Barriers to physicians’ seeking help are often punitive, including discrimination in medical licensing, hospital privileges, and professional advancement.”
Once a clinician comes on the record as having a mental health condition, in many cases, ‘monitoring’ contracts can paradoxically make it harder to stay well.
Take the experience of Justin Bullock, MD, MPH, now a kidney medicine Fellow, who lives in bipolar II disorder, when he returned to internal medicine residency at UCSF after a hospitalization that he himself initiated for a suicide attempt:
Dr Bullock describes his return-to-work assessment as “invasive,” “punitive,” and “traumatic.” Despite no prior work-related issues, consistent and excellent psychiatric care, and no substance use disorder history, he was subjected to a full, independent psychiatric evaluation, including drug testing, childhood trauma history, and release of all prior health records. He was made to enter a monitoring contract that included regular check-ins with a therapist other than his own (his “probation officer”) and another physician.
“That is a not a safe place to… process or talk about anything difficult… there was really this huge, massive power imbalance,” he said. “There was always this fear that if I made any mistakes… I would lose my license.”
Given this punitive context, Dr Bullock said: “I didn't feel like I could be truly honest about when I was struggling, and to me, that feels dangerous.” Like many in this position, he actually didn’t feel safe asking for additional help through this mechanism. These requirements — far from protecting his mental health — took dozens of hours away from preventive care, treatment, education, and patient care.
Bright spots: Clinician stories
Mental illness stigma is still strong in medicine:
In 2023, nearly eight in 10 US physicians, residents, and medical students agree there is stigma around clinician mental health and around seeking care.
Approximately half of US physicians, residents, and students said they know a colleague who would not seek care for mental health for one reason or another.
Research shows that the single best way to challenge mental illness stigma and stereotypes is to share stories of illness and recovery — contextualizing, normalizing, and humanizing mental illness. And there’s been a recent rising tide of clinicians sharing their mental health stories, ranging from online communities like Medical Minds Matter where stories can be anonymous to those shared publicly — including by several of those interviewed here.
“There really does seem to be a whole movement happening… toward just a greater transparency about our humanness,” said Dr Myers. “It’s revolutionizing medicine.”
Corey Feist, JD, MBA, CEO of the Dr Lorna Breen Heroes Foundation, said of the domino effect of stories: “When you speak of the unspeakable, it gives permission to others to speak about it, too.” And in time, it normalizes and increases help-seeking.
Bright spots through the pandemic
As we now only know too well, the pandemic strained the healthcare workforce to breaking and beyond. And also — out of necessity, 2020 saw the formation of several physician- and family-led initiatives that have ushered in meaningful change since — alongside multi-layered investments in clinician well-being around the world.
Corey Feist, JD, MBA, and his wife, Jennifer Feist, JD, co-founded the Dr Lorna Breen Heroes Foundation in 2020 after Ms Feist’s sister, Dr Lorna Breen, an emergency doctor and COVID frontliner, died by suicide.
In just three years, their work has fundamentally changed the landscape of US clinician health — and was recognized this week by the US Surgeon General’s Medallion, the highest civilian award of its kind.
The Foundation has worked with licensing and credentialing bodies throughout the country to reform the intrusive, often punitive way mental health has been probed, in violation of the Americans with Disabilities Act (ADA) — often deterring clinicians from seeking help for mental health conditions.
In 2020, licensing in 17 states was ADA-compliant; and now, 25 states meet at least one of these standards and 11 others are on their way:
Ask one question that addresses all mental and physical health conditions as one, with no added explanations, asterisks, or fine print. (Of note, this was not the case when I first applied for a license in Maryland or California — then, both applications had additional time- and cost-intensive requirements for anyone with mental illness, including letters from every treating provider I’d seen for my California license).
Refrain from asking probing questions about an applicant’s health altogether.
Use an Attestation Model with supportive language around mental health and offer “safe haven” non-reporting options to physicians who are receiving care.
“Removing barriers and penalties to mental health access is one of our biggest feathers in our cap,” said Mr Feist. Ensuring that clinicians are aware of these changes and their legal entitlements — so they no longer fear seeking care — is the next hurdle.
The Foundation also spearheaded the first federal legislation designed to safeguard clinician mental health — the 2022 Dr Lorna Breen Healthcare Provider Protection Act, which provides $135 million towards clinician suicide and burnout prevention efforts, including training, an awareness campaign, and improved access to treatment.
Further, they’ve brought over a dozen practice associations together for the ALL IN: Wellbeing First for Healthcare initiative, a hub of organizational resources to support healthcare worker well-being that serves as “a starter kit for hospitals and health systems,” said Mr Feist.
In March of 2020, psychiatrist Mona Masood, DO, found there to be “a deafening silence” in online communities with respect to clinicians talking about their feelings about the pandemic — she instead found them over-intellectualizing it, focusing on clinical presentations and case numbers. “This was a big red flag,” she said.
When Dr Masood put up a Facebook post in March 2020 asking for peer interest in supporting physician emotional well-being, she hit a chord. Within a week, 500 volunteer psychiatrists had raised their hands. Shortly thereafter, the Physician Support Line (PHL) was launched.
Today, the line has provided tens of thousands of anonymous clinician and student callers with free, therapeutic peer support. The 800 volunteer psychiatrists who staff it engage in a weekly debrief, alongside educational sessions on physician well-being and related topics.
Something that’s surprised them: Even though this line was created expressly for support, many calls start with an apology. “‘I’m so sorry for calling — I know that there’s people who could use this more than me,’” said Dr Masood.
PHL has allowed clinicians to finally feel entitled to claim support at scale, starting from their initial fears relating to COVID to all stripes of human angst since then.
The Sharp Index was founded in 2018 by Janae Sharp after the suicide of her physician husband, John Madsen (in 2015), to reduce clinician suicide and improve mental health — and make health care “the healthiest place to work,” said Ms Sharp.
Alongside scholarships, childcare subsidies, and other programs, “I’m most proud of the work we’ve done for people who are in crisis or have lost someone — the people who have come back and said, you know, we could have ended up like John,” Ms Sharp said.
Dr Gold and Dr Myers both spoke of a future where we have more open peer and supervisor support, flexibility, and systems that allow for prevention of clinician mental health needs, not just amplifying access to interventions after the fact to “[stop] the bleed,” as Dr Gold said.
At the individual, community, and organizational levels, being more attuned to red flags and knowing what flexibility and well-being tools to implement when they occur to prevent burnout or an illness episode is key:
“I think that we need to be in a place where friends and colleagues and supervisors feel safe talking about this stuff… noticing behavioral changes [that indicate early warning signs] — and having earlier conversations with people,” and then providing targeted preventive supports, like allowing a student to turn in a paper late or allowing an employee to work from home.
All in all, my interviewees and I agreed that though there’s much left to be done, the pandemic has palpably ushered in more awareness, commitment (financial and cultural), and meaningful, though incremental, systemic change towards ensuring that healers, too, can be healed. What are your thoughts?
Mental illness and the stigma around it is a huge issue in the house of medicine. I am not proud to say that I was taking care of a teen with severe anxiety in the ED. Her mom mentioned letting her take the day off school. My internal monologue was harsh and along the lines of, "that is not a valid reason to miss school". Of course, that monologue has been used on myself more than anyone. I think one of the contributors to unwellness and suicide in medicine is the attitude that experiencing emotions during or because of our work is "unprofessional". There is so much fear, anger, and grief we carried around before COVID and COVID compounded that. And then there's the shame. Medical education was, frankly, traumatic for me because of how much shame was a tool in training. I wrote about it in my substack a little while ago, but I had a patient death in training that was also a very shame filled experience, the message I took from my attendings was, "You're fine, and if you're not fine you better f-ing figure it out." Anyway, greatly appreciate this conversation and hope it continues.
Thank you for this informative summary of where we are, what’s been done, and where we need to go. As a group, we do not talk and write enough about clinician wellbeing. The very notion that mental illness is a factor considered in licensure, and medical illnesses are not, is ludicrous. Your efforts to highlight these stories are greatly appreciated.