As a trained psychiatrist, workaholic, depressive, and (formerly) excellent clinician, I’ve come to the following maxim with apologies to REM: “Everybody needs a little therapy (sometimes)”. As the year winds down and the nights draw in, we are taking time to reflect on 2023. Over the next weeks over the Holidays and after we ring in the new year, Physicians Anonymous will be publishing a series on self-examination.
We will review our achievements in 2023, then cover the importance of an examined life, contrast therapy vs coaching, and explore the role of therapy. In the new year we will dive into a number of self-reflective exercises to help us examine our priorities: watch out for the obituary (or eulogy) exercise and the Ideal day exercise…
“...for the unexamined life is not worth living.”
― Plato, The Trial and Death of Socrates
We are born with these incredible brains with more neuronal connections than stars in the known universe, and no user manual. Therapy saved my life at least once, and taught me a bunch of skills that psychiatry residency did not (although in part, this may be because I was a bad student).
Self-insight and life skills discovered through examining our lives are invaluable and generally not taught to doctors in training. So I am all for an examined life, and I would love it if it were easier for more of us to access career-safe therapy or accredited coaching.
So sometimes a bit of help is needed, and public attitudes to therapy are increasingly positive. I was encouraged to read a US survey finding that 91% of respondents prefer dating partners who have been to therapy. Having been in therapy twice, does that make me doubly attractive?
Prevention, or at least early intervention – before the feces hits the fan – should be the norm for physicians (and, arguably, many high stress life-dependent professions: I’m looking at you, airline pilots and military people).
Investing in these skills is likely to reduce overall stress levels and improve quality of life; there is evidence that structured programs may even prevent the onset of new mental illness or disability, burnout. Therapy should not only be destigmatized but also actively encouraged by our institutions at all levels and protected in law.
In an ideal world, rather than job/residency/licensing/credentialing forms asking “Have you ever had psychiatric treatment”, they would be asking “Why have you not had therapy?” In the (current) real world, far too many institutions ask too many invasive personal questions about physician well-being and “mental health treatment”.
A physician with enough self-awareness (or who listens to their loved ones expressing concern – something I was too arrogant to do) to engage a therapist, make the time, commit the resources, and open the proverbial psychological can of worms, should be lauded and not punished.
However, at present, there are multiple barriers to physicians getting help in many countries. These include our own internal barriers and fears, and regulatory/licensing/career concerns.
Taking a lot of selfies doesn’t mean you live an examined life.” ― Gina Barreca
We have written at length about physician fears of career damage due to getting help. We have tried to debunk some of the myths underlying these fears, but many remain.
Perhaps the most concerning example comes from a system-wide suicide prevention and depression awareness program. Using a risk-tier system, 97% of house-staff met high- or moderate-risk criteria for depression or suicide. However, because of the barriers faced by house-staff, only 8% of house-staff that were invited ultimately participated in the program.
Another aspect that we haven’t covered yet is the “I can fix it myself” approach. Most physicians are creative, can-do, hard-working, and problem-solvers. We need a high degree of self-belief to deliver complex modern healthcare. Yet we also think we can fix ourselves. We self-treat too often, especially with things we can’t. How many of us would attempt our own appendectomies (unless you are stuck in an Antarctic research base during a blizzard)?
In 2014, the US Supreme Court ruled that to be compliant with the Americans with Disabilities Act (ADA) professional licensing boards must limit mental health questions to current diagnoses impairing the applicant’s ability to perform professional duties.
In 2018, the Federation of State Medical Boards (FSMB) released 4 recommendations for medical boards to be compliant with the ADA and promote physician wellness on medical license applications: (1) ask only if impaired, (2) ask only current, (3) allow for safe haven non-reporting, and (4) include supportive language normalizing physician wellness.
Despite a growing body of evidence demonstrating that asking questions about mental health, addiction or substance use history on licensing and other applications deters physicians from seeking care, as of a 2023 study, only 3 (5%) of US states met all 4 recommendations.
As we have already argued, burnout (and, by extension, mental illness) are administrative (systemic) occupational disorders, and not due to defects or a lack of grit in the physicians.
Whilst therapies for individual doctors and students may address some of the processes leading to mental ill-health, interventions that address multiple organizational and professional issues simultaneously are more likely to be successful.
Indeed, a recent review found three important processes leading to physician mental ill-health: significant and complex workload, organizational management, and the professional culture of medicine.
As someone who has been both physician and patient, I can highly recommend investing in a structured form of getting to know yourself.
Whether that is through life/performance coaching (from an experienced, accredited, and recommended coach who understands life as a physician) or a therapist
