Acad Psychiatry DOI 10.1007/s40596-014-0033-y
IN DEPTH ARTICLE: COMMENTARY
Philosophy in Medical Education: A Means of Protecting Mental Health Eric J. Keller
Received: 25 August 2013 / Accepted: 3 January 2014 # Academic Psychiatry 2014
Abstract Objective This study sought to identify and examine less commonly discussed challenges to positive mental health faced by medical students, residents, and physicians with hopes of improving current efforts to protect the mental health of these groups. Additionally, this work aimed to suggest an innovative means of preventing poor mental health during medical education. Methods Literature on medical student, resident, and physician mental health was carefully reviewed and a number of psychiatrists who treat physician-patients were interviewed. Results The culture of medicine, medical training, common physician psychology and identity, and conflicting professional expectations all seem to contribute to poor mental health among medical students, residents, and physicians. Many current efforts may be more successful by better addressing the negative effects of these characteristics of modern medicine. Conclusions Programs aimed at promoting healthy mental lifestyles during medical education should continue to be developed and supported to mitigate the deleterious effects of the challenging environment of modern medicine. To improve these efforts, educators may consider incorporating philosophical discussions on meaning and fulfillment in life between medical students and faculty. Through medical school faculty members sharing and living out their own healthy outlooks on life, students may emulate these habits and the culture of medicine may become less challenging for positive mental health. Keywords Mental health . Medical education . Preventive therapy E. J. Keller (*) Northwestern University, Chicago, IL, USA e-mail: [email protected]
Over the last few decades, studies have continued to report a high prevalence of burnout, depression, and suicide ideation among medical students and residents as well as significantly higher suicide rates among physicians than the general population [1–4]. Although efforts have been made to identify and reduce common stressors and barriers to treatment, raise awareness of this issue, and provide better access to mental health services, the prevalence of poor mental health in these groups has remained high. To better understand the aspects of modern medicine which may be impeding these efforts, literature on medical student, resident, and physician mental health was reviewed and a number of psychiatrists who treat physician-patients were interviewed. This investigation highlighted the need to further develop and support programs aimed at promoting positive mental health during medical education as well as a possible means of improving current efforts.
Current Status of Medical Student and Physician Mental Health According to the CDC, the prevalence of current depression (major or other depression) and suicidal ideation among adults in the USA is 9.1 and 3.7 %, respectively [5, 6]. A 2003–2004 study of 1,184 medical students and 532 residents from six US medical schools found symptoms of major depression in 12 % and mild/moderate depression in 9.2 % of these medical trainees [7]. In a study of 4,287 medical students from seven US medical schools conducted from 2006 to 2007, 49.6 % of students had experienced burnout and 11.2 % reported suicide ideation [2]. Research concerning the mental health of practicing physicians is less common, though studies have shown a higher prevalence of suicide. In a 2004 meta-analysis of 25 articles estimating age-standardized suicide rates among physicians, male and female physicians had aggregate suicide risk
Acad Psychiatry
ratios of 1.41 and 2.27, respectively, compared to the general population [8]. Interestingly, a 2003 consensus statement prepared by 15 experts on the subject found physicians to have a similar lifetime prevalence of depression to the general population [9]. This discrepancy may be the result of physicians’ tendency to minimalize their illnesses, as discussed later. Much of the blame for poor mental health during medical education has been placed on the demanding nature of medical school and residency programs. Commonly reported stressors included lack of sleep, financial debt, large work load, high competition, and lack of sexual activity [3]. For practicing physicians, less blame has been placed on long work hours compared to changes in professional demands. Studies reporting decreased physician satisfaction point to rises in malpractice lawsuits, diminished prestige, constraints on time with patients, disputes over income, and disparities between physicians’ expectations and those of patients, insurance agencies, and administration [1, 9–12]. Although dissatisfaction does not necessarily equate to mental illness, these sources of dissatisfaction likely represent major stressors in combination with other life problems (e.g., marital disputes, financial losses). Commonly identified barriers to treatment have centered on fear of stigmas [9, 13–15]. Medical students and residents fear that admission of a mental illness will negatively affect their evaluations and academic records whereas physicians worry about intrusive investigations by state licensing boards, professional consequences such as reduction of hospital privileges, and a loss of their colleagues’ respect [15]. Psychiatrists who have treated medical students and physicians with mental illnesses suggest that improvements have been made [16–19]. For example, the American Foundation for Suicide Prevention produced two short films, one on physicians and one on a medical student with mental illnesses, to reduce perceived stigmas. Furthermore, more mental health programs are being made available to students and many medical schools have implemented programs to support student well-being [3, 20, 21].
Culture of Medicine and Medical Training Various aspects of medical culture make it a particularly challenging environment for those struggling with their mental health. The competitive nature of the medical field often pushes students and residents to neglect their personal health in efforts to get ahead and gain respect, while physicians do so trying to meet the demands of their patients, employers, and families [15]. Furthermore the term “mental illness” still carries negative connotations of being blameworthy and dangerous to one’s self or others [22]. A 2009 survey partially illustrated this point, reporting that 38 % of 284 non-depressed medical students felt those students with depression were to blame for their problems [14]. These attitudes contribute to an underlying message that physicians either have what it takes to make it in medicine or not. Although physicians surely care for their colleagues, they tend to hold them to higher expectations than their patients, trusting them to work matters out on their own and not wanting to ask and offend their colleagues [22]. Much of the culture of medicine stems from medical training. Due to modern medicine’s heavy use of science, its practice is often mistakenly considered or approached as a science, creating an expectation of objectivity. As students transition from uninformed outsiders to clinicians, their certainty in medical theory is challenged by the variability of clinical practice. They learn to go on best guesses, and uncertainty is thus “ritualized and professionalized” [23]. Previous internal uncertainties are pushed aside as students begin to dissociate themselves from the patients they see. By the end of their training, their focus has often turned entirely outward to the patient rather than inward, making it difficult to “identify subjective subtext” [24]. The underlying lesson seems to be one of control: knowing is control, the anatomically invisible is an afterthought if a thought at all, and control of one’s emotions becomes a virtue [23, 24]. Thus, the mentally ill student or physician can feel the need to control his/her emotions, fear being judged as weak and unfit for medicine, and struggle to re-identify with the uncertainties of being a patient [20]. Physician Psychology and Identity
Additional Challenges for Positive Mental Health In addition to the challenges for positive mental health commonly discussed, it seems likely that other aspects of the medical profession, which tend to receive less attention in the literature, are impeding efforts to improve and support medical student, resident, and physician mental health. Three important additional challenges for positive mental health include the culture of medicine and medical training, common physician psychology, and conflicting professional expectations.
Myers and Gabbard have observed that the medical field tends to attract individuals with personality types predisposed to poor mental health, such as rigidity, perfectionism, and excessive devotion to work and perceived responsibilities [15]. On one hand, these traits can work to one’s advantage, and to an extent, physicians are selected for these very qualities when applying to medical school. Problems arise when a medical student or physician encounters the array of stressors mentioned previously and begins to experience the symptoms of a mental illness. These same personality traits can then
Acad Psychiatry
exacerbate the issue. For instance, the same perfectionism valued as attention to detail can often work against selfacceptance. At first, symptoms are often minimalized and work is used as a distraction [13]. Unwanted and confusing emotions are repressed and pushed aside as vulnerability and selfishness, which may work until these emotions become overwhelming [15]. At a deeper level, mental illness may threaten some physicians’ concepts of self. Elliot noted that the meaning in life, for some Americans, is closely tied to psychological well-being. Some Americans seek jobs which are fulfilling, relationships which are healthy, so that their work is not just a job so much as a part of who they are [25]. If this is the case, those physicians are not just physicians to pay the bills; those roles are a large part of who they are and how they gain fulfillment in life. Regardless of one’s opinions about sources of fulfillment, a number of writers have suggested that being ill conflicts with physicians’ professional roles as healers [22, 26, 27]. Since physicians strive to control and remove uncertainty through understanding, diseases of the mind would seem to be particularly challenging. Mental illnesses are not only subjective and often difficult to understand but they threaten a tool essential to the physician’s professional role: the mind. As he/ she grapples with this loss of control, perhaps even an identity crisis of sorts, suicide can become a means of escape and ultimate control. Conflicting Professional Expectations Many sources of physician dissatisfaction commonly discussed concerned differences in expectations. Previous studies seem to convey a similar message: dissatisfied physicians desire more autonomy and time with patients yet they must meet the demands of a medical system “dominated by managed care and physician organizations” [1, 12, 28]. Holsinger and Beaton have thus suggested that the failure of “professional values and practices of physicians” to adapt to changes in the American healthcare system contributes to physician dissatisfaction [10]. Although future changes may address these concerns, growth in medical technology and healthcare systems will likely continue to place additional professional demands and ethical complexity in the physician’s role. Many bioethical dilemmas and discrepancies in professional expectations faced by physicians seem to be part of a more general question: what is the proper place or role of medicine in our societies? Physicians must seek a balance between the expectations of administrators, such as paperwork, moreinformed patients, and their personal lives. The past days of hard paternalism and predominantly autonomous physicians were surely not without sources of dissatisfaction and uncertainty, but it was arguably easier to put aside differences in opinions about the proper goals of medicine, and its limits were
less obscure without the current abilities of technology. Attempts to balance often competing expectations of modern physicians will likely remain challenging, adding to the stress and conflict to physicians’ lives.
Discussion and Future Directions The culture of medicine will likely continue to be one of high expectations and competition to protect the quality of care patients receive. To be a servant to something as complex as human health requires physicians that are willing to push themselves and sacrifice some of their personal freedom. Although it may sound blunt, not everyone can be a physician, and when the health of a loved one is on the line, one expects his/her physician to be somewhat perfectionistic and exacting. However, promoting physician mental health also protects the quality of patient care without contributing to the less favorable aspects of medical culture. Dissatisfied, burnt-out, or depressed medical students, residents, and physicians have been shown to deliver a lower quality of care, tending to make more errors and have less altruistic attitudes toward patients [29–32]. The stressors, barriers, and additional challenges discussed above all seem to contribute to a perfect storm for poor mental health. Efforts to raise awareness and reduce stigmas should help pacify the fury of this storm while support programs provide life preservers for those drowning in its wake. But this storm will likely persist; therefore, it seems reasonable to equip future physicians with tools to brave this storm. Some medical schools have implemented programs with this direction in mind. Much like current efforts to reduce the prevalence of noninsulin-dependent (type II) diabetes mellitus by focusing on prevention, there may be more benefits in promoting a healthy mental lifestyle in addition to treatment. Some examples include The David Geffen School of Medicine at UCLA where students participate in well-being groups led by faulty advisers. Groups of interns and residents at Johns Hopkins Bayview Medical Center participate in lunchtime support groups which provide them with a safe place to reflect and share concerns, supporting personal growth. Many similar programs exist at other institutions, but these programs could be more widely implemented and perhaps even improved through the implementation of more philosophical discussions on the meaning and fulfillment in life among medical students, residents, and physician-faculty. The utility of this approach is strongly based on the theory that one’s lifestyle can have a significant impact on his/her mental health. Some professionals have argued that modern medicine has “medicalized the soul,” treating internal dysfunctions which are judged as socially inappropriate like other diseases of the body [33, 34]. Conversely, Kramer has suggested that sadness, melancholy, and other characteristics
Acad Psychiatry
are often confused with full-blown depression, a dangerous disease distinctly different from these characteristics [35]. Mental health may instead be understood as a continuum similar to many more objectively definable physical characteristics. Life is often difficult and one may experience symptoms similar to a mental illness without entering into the mental illness end of the continuum. Over time, difficulties may persist, causing one’s mental health to worsen and be diagnosed as a mental illness. Whether the individual was genetically prone to develop a mental illness or chose to put him/herself in a mentally unhealthy environment, it should not affect the fact that his/her mental functioning is now in the mental illness end of the continuum. If one accepts that problems in life can exacerbate and perhaps even cause poor mental health, the mental health issues of some individuals may be prevented by equipping them with tools to better face life’s problems. The question of how to best promote personal well-being in medical education seems to have two primary complicating factors for programs to address: there is a vast array of theories on what makes life go well and the hierarchy of the medical education may undermine efforts to promote healthy mental lifestyles. The former concern is a philosophical one which may not demand a single set of solutions rather than the right kinds of questions. By facilitating thoughtful discussions during which important questions about meaning and fulfillment in life are asked and personal narratives are shared and considered, an array of healthy mental lifestyles can be explored, allowing diverse groups of students and faculty to select techniques which best support their personal growth. The second concern is more difficult to address. Even if medical students are instructed on various ways to promote their well-being, these students will likely emulate the lifestyles of the student or physician-mentors they respect and train under. If those role models are not practicing healthy habits, efforts to encourage medical students to live healthy lifestyles will likely be undermined. A potential benefit of the discussion-based format is that the learning is self-directed and individualized. This educational approach may encourage students to take more ownership of the healthy mental lifestyles they develop. Such an approach to the prevention of poor mental health among medical students, residents, and physicians during medical education requires support from all levels of administration within the institution as well as a dedicated department to implement such a program. To expand upon this approach, further research focusing on the history, sociology, and philosophy of medicine will be required to better understand what these philosophical discussions should entail and how they can best be implemented into medical school curricula. It is clear from the literature reviewed and psychiatrists interviewed for this investigation that the mental health of medical students, residents, and physicians is still an important
issue facing the medical field. Great work has been done, but studies continue to suggest that there is more to do. In addition to current efforts, medical schools may consider implementing philosophical discussions among students and faculty. This approach may encourage students to look both outward toward patients and inward toward themselves during their training and later in life. As these self-reflective medical students become faculty members and practicing physicians, they would hopefully maintain their healthy outlooks on life discussed with and influenced by their mentors. Thus, this approach to prevention in concert with other efforts to help medical students and physicians currently struggling with mental illnesses may gradually change the culture of medicine to support better mental health while maintaining its high standards for quality patient care. Implications for Academic Leaders & The prevalence of mental health issues among medical students, residents, and physicians has remained an important concern for quality healthcare & Programs aimed at preventing these issues by promoting mental wellbeing should be supported at all levels of administration & Medical schools should consider implementing innovative means of promoting student and faculty well-being
Implications for Educators & Medical students and residents continue to face a challenging environment for positive mental health & Programs aimed at promoting mental well-being should continue being developed and implemented & Philosophical discussions among students and faculty members should be considered as a valuable means of promoting mental wellbeing & Educators should be careful to practice healthy habits in their own lives as students are likely to emulate these habits whether positive or negative
Acknowledgments The author wishes to thank Dr. Alice Dreger, Dr. Tod Chambers, Dr. Charles Reynolds III, and Dr. Joel Frader for their support and guidance in preparing this article. Disclosures The author has no other affiliations or conflicts of interest to disclose.
References 1. Zuger A. Dissatisfaction with medical practice. N Engl J Med. 2004;350(1):69–75. 2. Dyrbye LN, Thomas MR, Massie FS, Power DV, Eacker A, Harper W, et al. Burnout and suicidal ideation among U.S. medical students. Ann Intern Med. 2008;149(5):334–41. 3. Myers MF. The support and welfare of the student. In: Gask L, Coskun B, Baron D, editors. Teaching psychiatry: putting theory into practice. Chichester: John Wiley & Sons Ltd; 2011.
Acad Psychiatry 4. Dyrbye LN, Thomas MR, Shanafelt TD. Systematic review of depression, anxiety, and other indicators of psychological distress among U.S. and Canadian medical students. Acad Med J Assoc Am Med Coll. 2006;81(4):354–73. 5. CDC. Current depression among adults—United States, 2006 and 2008. MMWR. 2010;59(38):1229–35. 6. CDC. Suicidal thoughts and behaviors among adults aged ≥18 years—United States, 2008-2009. MMWR. 2011;60(SS13):1–22. 7. Goebert D, Thompson D, Takeshita J, Beach C, Bryson P, Ephgrave K, et al. Depressive symptoms in medical students and residents: a multischool study. Acad Med J Assoc Am Med Coll. 2009;84(2): 236–41. 8. Schernhammer ES, Colditz GA. Suicide rates among physicians: a quantitative and gender assessment (meta-analysis). Am J Psychiatr. 2004;161(12):2295–302. 9. Center C, Davis M, Detre T, Ford DE, Hansbrough W, Hendin H, et al. Confronting depression and suicide in physicians: a consensus statement. JAMA J Am Med Assoc. 2003;289(23):3161– 6. 10. Holsinger Jr JW, Beaton B. Physician professionalism for a new century. Clin Anat. 2006;19(5):473–9. 11. Pathman DE, Konrad TR, Williams ES, Scheckler WE, Linzer M, Douglas J. Physician job satisfaction, dissatisfaction, and turnover. J Fam Pract. 2002;51(7):593. 12. Leigh JP, Tancredi DJ, Kravitz RL. Physician career satisfaction within specialties. BMC Health Serv Res. 2009;9:166. 13. Myers MF. Physician suicide and resilience: diagnostic, therapeutic and moral imperatives. World Med J. 2011;57:90–7. 14. Schwenk TL, Davis L, Wimsatt LA. Depression, stigma, and suicidal ideation in medical students. JAMA J Am Med Assoc. 2010;304(11): 1181–90. 15. Myers MF, Gabbard GO. The physician as patient: a clinical handbook for mental health professionals. Washington: American Psychiatric Publishing, Inc; 2008. 16. Personal communication with Reynolds III C. (used with permission), June 14, 2013. 17. Personal communication with Anzia J. (used with permission), June 12, 2013. 18. Personal communication with Myers M. (used with permission), June 10, 2013. 19. Personal communication with Sen S. (used with permission), June 17, 2013.
20. Reynolds 3rd CF, Clayton PJ. Commentary: out of the silence: confronting depression in medical students and residents. Acad Med J Assoc Am Med Coll. 2009;84(2):159–60. 21. System UoCSDH. Healer Education Assessment and Referral Program. [cited 2013 July 21]; Available from: http://health.ucsd. edu/specialties/wellbeing/Pages/default.aspx. 22. Wallace JE. Mental health and stigma in the medical profession. Health (Lond). 2012;16(1):3–18. 23. Montgomery K. How doctors think: clinical judgment and the practice of medicine. New York: Oxford University Press, Inc.; 2006. 24. Billing C. Dangerous fearlessness: the formation of physicians. A condition of doubt: the meanings of hypochondria. New York: Oxford University Press, Inc; 2012. p. 106–26. 25. Elliot C. Better than well: American medicine meets the American dream. New York: W. W. Norton & Company, Inc.; 2004. 26. Edelstein EL, Baider L. Role reversal: when doctors become patients. Psychiatr Clin. 1982;15(4):177–83. 27. Klitzman R. When doctors become patients. New York: Oxford University Press; 2008. 28. Landon BE, Reschovsky JD, Pham HH, Blumenthal D. Leaving medicine: the consequences of physician dissatisfaction. Med Care. 2006;44(3):234–42. 29. Fahrenkopf AM, Sectish TC, Barger LK, Sharek PJ, Lewin D, Chiang VW, et al. Rates of medication errors among depressed and burnt out residents: prospective cohort study. BMJ. 2008;336(7642):488–91. 30. West CP, Tan AD, Habermann TM, Sloan JA, Shanafelt TD. Association of resident fatigue and distress with perceived medical errors. JAMA J Am Med Assoc. 2009;302(12):1294–300. 31. Dyrbye LN, Massie Jr FS, Eacker A, Harper W, Power D, Durning SJ, et al. Relationship between burnout and professional conduct and attitudes among US medical students. JAMA J Am Med Assoc. 2010;304(11):1173–80. 32. Dyrbye LN, Harper W, Moutier C, Durning SJ, Power DV, Massie FS, et al. A multi-institutional study exploring the impact of positive mental health on medical students’ professionalism in an era of high burnout. Acad Med J Assoc Am Med Coll. 2012;87(8):1024–31. 33. Horwitz AV. Creating mental illness. Chicago: The University of Chicago Press; 2002. 34. Szasz TS. The myth of mental illness. Perennialth ed. New York: HarperCollins Publishers; 2010. 35. Kramer P. Myths of the blues. Why it’s a bad idea to romanticize depression. US News World Rep. 2005;138(19):62.
IN DEPTH ARTICLE: COMMENTARY
Philosophy in Medical Education: A Means of Protecting Mental Health Eric J. Keller
Received: 25 August 2013 / Accepted: 3 January 2014 # Academic Psychiatry 2014
Abstract Objective This study sought to identify and examine less commonly discussed challenges to positive mental health faced by medical students, residents, and physicians with hopes of improving current efforts to protect the mental health of these groups. Additionally, this work aimed to suggest an innovative means of preventing poor mental health during medical education. Methods Literature on medical student, resident, and physician mental health was carefully reviewed and a number of psychiatrists who treat physician-patients were interviewed. Results The culture of medicine, medical training, common physician psychology and identity, and conflicting professional expectations all seem to contribute to poor mental health among medical students, residents, and physicians. Many current efforts may be more successful by better addressing the negative effects of these characteristics of modern medicine. Conclusions Programs aimed at promoting healthy mental lifestyles during medical education should continue to be developed and supported to mitigate the deleterious effects of the challenging environment of modern medicine. To improve these efforts, educators may consider incorporating philosophical discussions on meaning and fulfillment in life between medical students and faculty. Through medical school faculty members sharing and living out their own healthy outlooks on life, students may emulate these habits and the culture of medicine may become less challenging for positive mental health. Keywords Mental health . Medical education . Preventive therapy E. J. Keller (*) Northwestern University, Chicago, IL, USA e-mail: [email protected]
Over the last few decades, studies have continued to report a high prevalence of burnout, depression, and suicide ideation among medical students and residents as well as significantly higher suicide rates among physicians than the general population [1–4]. Although efforts have been made to identify and reduce common stressors and barriers to treatment, raise awareness of this issue, and provide better access to mental health services, the prevalence of poor mental health in these groups has remained high. To better understand the aspects of modern medicine which may be impeding these efforts, literature on medical student, resident, and physician mental health was reviewed and a number of psychiatrists who treat physician-patients were interviewed. This investigation highlighted the need to further develop and support programs aimed at promoting positive mental health during medical education as well as a possible means of improving current efforts.
Current Status of Medical Student and Physician Mental Health According to the CDC, the prevalence of current depression (major or other depression) and suicidal ideation among adults in the USA is 9.1 and 3.7 %, respectively [5, 6]. A 2003–2004 study of 1,184 medical students and 532 residents from six US medical schools found symptoms of major depression in 12 % and mild/moderate depression in 9.2 % of these medical trainees [7]. In a study of 4,287 medical students from seven US medical schools conducted from 2006 to 2007, 49.6 % of students had experienced burnout and 11.2 % reported suicide ideation [2]. Research concerning the mental health of practicing physicians is less common, though studies have shown a higher prevalence of suicide. In a 2004 meta-analysis of 25 articles estimating age-standardized suicide rates among physicians, male and female physicians had aggregate suicide risk
Acad Psychiatry
ratios of 1.41 and 2.27, respectively, compared to the general population [8]. Interestingly, a 2003 consensus statement prepared by 15 experts on the subject found physicians to have a similar lifetime prevalence of depression to the general population [9]. This discrepancy may be the result of physicians’ tendency to minimalize their illnesses, as discussed later. Much of the blame for poor mental health during medical education has been placed on the demanding nature of medical school and residency programs. Commonly reported stressors included lack of sleep, financial debt, large work load, high competition, and lack of sexual activity [3]. For practicing physicians, less blame has been placed on long work hours compared to changes in professional demands. Studies reporting decreased physician satisfaction point to rises in malpractice lawsuits, diminished prestige, constraints on time with patients, disputes over income, and disparities between physicians’ expectations and those of patients, insurance agencies, and administration [1, 9–12]. Although dissatisfaction does not necessarily equate to mental illness, these sources of dissatisfaction likely represent major stressors in combination with other life problems (e.g., marital disputes, financial losses). Commonly identified barriers to treatment have centered on fear of stigmas [9, 13–15]. Medical students and residents fear that admission of a mental illness will negatively affect their evaluations and academic records whereas physicians worry about intrusive investigations by state licensing boards, professional consequences such as reduction of hospital privileges, and a loss of their colleagues’ respect [15]. Psychiatrists who have treated medical students and physicians with mental illnesses suggest that improvements have been made [16–19]. For example, the American Foundation for Suicide Prevention produced two short films, one on physicians and one on a medical student with mental illnesses, to reduce perceived stigmas. Furthermore, more mental health programs are being made available to students and many medical schools have implemented programs to support student well-being [3, 20, 21].
Culture of Medicine and Medical Training Various aspects of medical culture make it a particularly challenging environment for those struggling with their mental health. The competitive nature of the medical field often pushes students and residents to neglect their personal health in efforts to get ahead and gain respect, while physicians do so trying to meet the demands of their patients, employers, and families [15]. Furthermore the term “mental illness” still carries negative connotations of being blameworthy and dangerous to one’s self or others [22]. A 2009 survey partially illustrated this point, reporting that 38 % of 284 non-depressed medical students felt those students with depression were to blame for their problems [14]. These attitudes contribute to an underlying message that physicians either have what it takes to make it in medicine or not. Although physicians surely care for their colleagues, they tend to hold them to higher expectations than their patients, trusting them to work matters out on their own and not wanting to ask and offend their colleagues [22]. Much of the culture of medicine stems from medical training. Due to modern medicine’s heavy use of science, its practice is often mistakenly considered or approached as a science, creating an expectation of objectivity. As students transition from uninformed outsiders to clinicians, their certainty in medical theory is challenged by the variability of clinical practice. They learn to go on best guesses, and uncertainty is thus “ritualized and professionalized” [23]. Previous internal uncertainties are pushed aside as students begin to dissociate themselves from the patients they see. By the end of their training, their focus has often turned entirely outward to the patient rather than inward, making it difficult to “identify subjective subtext” [24]. The underlying lesson seems to be one of control: knowing is control, the anatomically invisible is an afterthought if a thought at all, and control of one’s emotions becomes a virtue [23, 24]. Thus, the mentally ill student or physician can feel the need to control his/her emotions, fear being judged as weak and unfit for medicine, and struggle to re-identify with the uncertainties of being a patient [20]. Physician Psychology and Identity
Additional Challenges for Positive Mental Health In addition to the challenges for positive mental health commonly discussed, it seems likely that other aspects of the medical profession, which tend to receive less attention in the literature, are impeding efforts to improve and support medical student, resident, and physician mental health. Three important additional challenges for positive mental health include the culture of medicine and medical training, common physician psychology, and conflicting professional expectations.
Myers and Gabbard have observed that the medical field tends to attract individuals with personality types predisposed to poor mental health, such as rigidity, perfectionism, and excessive devotion to work and perceived responsibilities [15]. On one hand, these traits can work to one’s advantage, and to an extent, physicians are selected for these very qualities when applying to medical school. Problems arise when a medical student or physician encounters the array of stressors mentioned previously and begins to experience the symptoms of a mental illness. These same personality traits can then
Acad Psychiatry
exacerbate the issue. For instance, the same perfectionism valued as attention to detail can often work against selfacceptance. At first, symptoms are often minimalized and work is used as a distraction [13]. Unwanted and confusing emotions are repressed and pushed aside as vulnerability and selfishness, which may work until these emotions become overwhelming [15]. At a deeper level, mental illness may threaten some physicians’ concepts of self. Elliot noted that the meaning in life, for some Americans, is closely tied to psychological well-being. Some Americans seek jobs which are fulfilling, relationships which are healthy, so that their work is not just a job so much as a part of who they are [25]. If this is the case, those physicians are not just physicians to pay the bills; those roles are a large part of who they are and how they gain fulfillment in life. Regardless of one’s opinions about sources of fulfillment, a number of writers have suggested that being ill conflicts with physicians’ professional roles as healers [22, 26, 27]. Since physicians strive to control and remove uncertainty through understanding, diseases of the mind would seem to be particularly challenging. Mental illnesses are not only subjective and often difficult to understand but they threaten a tool essential to the physician’s professional role: the mind. As he/ she grapples with this loss of control, perhaps even an identity crisis of sorts, suicide can become a means of escape and ultimate control. Conflicting Professional Expectations Many sources of physician dissatisfaction commonly discussed concerned differences in expectations. Previous studies seem to convey a similar message: dissatisfied physicians desire more autonomy and time with patients yet they must meet the demands of a medical system “dominated by managed care and physician organizations” [1, 12, 28]. Holsinger and Beaton have thus suggested that the failure of “professional values and practices of physicians” to adapt to changes in the American healthcare system contributes to physician dissatisfaction [10]. Although future changes may address these concerns, growth in medical technology and healthcare systems will likely continue to place additional professional demands and ethical complexity in the physician’s role. Many bioethical dilemmas and discrepancies in professional expectations faced by physicians seem to be part of a more general question: what is the proper place or role of medicine in our societies? Physicians must seek a balance between the expectations of administrators, such as paperwork, moreinformed patients, and their personal lives. The past days of hard paternalism and predominantly autonomous physicians were surely not without sources of dissatisfaction and uncertainty, but it was arguably easier to put aside differences in opinions about the proper goals of medicine, and its limits were
less obscure without the current abilities of technology. Attempts to balance often competing expectations of modern physicians will likely remain challenging, adding to the stress and conflict to physicians’ lives.
Discussion and Future Directions The culture of medicine will likely continue to be one of high expectations and competition to protect the quality of care patients receive. To be a servant to something as complex as human health requires physicians that are willing to push themselves and sacrifice some of their personal freedom. Although it may sound blunt, not everyone can be a physician, and when the health of a loved one is on the line, one expects his/her physician to be somewhat perfectionistic and exacting. However, promoting physician mental health also protects the quality of patient care without contributing to the less favorable aspects of medical culture. Dissatisfied, burnt-out, or depressed medical students, residents, and physicians have been shown to deliver a lower quality of care, tending to make more errors and have less altruistic attitudes toward patients [29–32]. The stressors, barriers, and additional challenges discussed above all seem to contribute to a perfect storm for poor mental health. Efforts to raise awareness and reduce stigmas should help pacify the fury of this storm while support programs provide life preservers for those drowning in its wake. But this storm will likely persist; therefore, it seems reasonable to equip future physicians with tools to brave this storm. Some medical schools have implemented programs with this direction in mind. Much like current efforts to reduce the prevalence of noninsulin-dependent (type II) diabetes mellitus by focusing on prevention, there may be more benefits in promoting a healthy mental lifestyle in addition to treatment. Some examples include The David Geffen School of Medicine at UCLA where students participate in well-being groups led by faulty advisers. Groups of interns and residents at Johns Hopkins Bayview Medical Center participate in lunchtime support groups which provide them with a safe place to reflect and share concerns, supporting personal growth. Many similar programs exist at other institutions, but these programs could be more widely implemented and perhaps even improved through the implementation of more philosophical discussions on the meaning and fulfillment in life among medical students, residents, and physician-faculty. The utility of this approach is strongly based on the theory that one’s lifestyle can have a significant impact on his/her mental health. Some professionals have argued that modern medicine has “medicalized the soul,” treating internal dysfunctions which are judged as socially inappropriate like other diseases of the body [33, 34]. Conversely, Kramer has suggested that sadness, melancholy, and other characteristics
Acad Psychiatry
are often confused with full-blown depression, a dangerous disease distinctly different from these characteristics [35]. Mental health may instead be understood as a continuum similar to many more objectively definable physical characteristics. Life is often difficult and one may experience symptoms similar to a mental illness without entering into the mental illness end of the continuum. Over time, difficulties may persist, causing one’s mental health to worsen and be diagnosed as a mental illness. Whether the individual was genetically prone to develop a mental illness or chose to put him/herself in a mentally unhealthy environment, it should not affect the fact that his/her mental functioning is now in the mental illness end of the continuum. If one accepts that problems in life can exacerbate and perhaps even cause poor mental health, the mental health issues of some individuals may be prevented by equipping them with tools to better face life’s problems. The question of how to best promote personal well-being in medical education seems to have two primary complicating factors for programs to address: there is a vast array of theories on what makes life go well and the hierarchy of the medical education may undermine efforts to promote healthy mental lifestyles. The former concern is a philosophical one which may not demand a single set of solutions rather than the right kinds of questions. By facilitating thoughtful discussions during which important questions about meaning and fulfillment in life are asked and personal narratives are shared and considered, an array of healthy mental lifestyles can be explored, allowing diverse groups of students and faculty to select techniques which best support their personal growth. The second concern is more difficult to address. Even if medical students are instructed on various ways to promote their well-being, these students will likely emulate the lifestyles of the student or physician-mentors they respect and train under. If those role models are not practicing healthy habits, efforts to encourage medical students to live healthy lifestyles will likely be undermined. A potential benefit of the discussion-based format is that the learning is self-directed and individualized. This educational approach may encourage students to take more ownership of the healthy mental lifestyles they develop. Such an approach to the prevention of poor mental health among medical students, residents, and physicians during medical education requires support from all levels of administration within the institution as well as a dedicated department to implement such a program. To expand upon this approach, further research focusing on the history, sociology, and philosophy of medicine will be required to better understand what these philosophical discussions should entail and how they can best be implemented into medical school curricula. It is clear from the literature reviewed and psychiatrists interviewed for this investigation that the mental health of medical students, residents, and physicians is still an important
issue facing the medical field. Great work has been done, but studies continue to suggest that there is more to do. In addition to current efforts, medical schools may consider implementing philosophical discussions among students and faculty. This approach may encourage students to look both outward toward patients and inward toward themselves during their training and later in life. As these self-reflective medical students become faculty members and practicing physicians, they would hopefully maintain their healthy outlooks on life discussed with and influenced by their mentors. Thus, this approach to prevention in concert with other efforts to help medical students and physicians currently struggling with mental illnesses may gradually change the culture of medicine to support better mental health while maintaining its high standards for quality patient care. Implications for Academic Leaders & The prevalence of mental health issues among medical students, residents, and physicians has remained an important concern for quality healthcare & Programs aimed at preventing these issues by promoting mental wellbeing should be supported at all levels of administration & Medical schools should consider implementing innovative means of promoting student and faculty well-being
Implications for Educators & Medical students and residents continue to face a challenging environment for positive mental health & Programs aimed at promoting mental well-being should continue being developed and implemented & Philosophical discussions among students and faculty members should be considered as a valuable means of promoting mental wellbeing & Educators should be careful to practice healthy habits in their own lives as students are likely to emulate these habits whether positive or negative
Acknowledgments The author wishes to thank Dr. Alice Dreger, Dr. Tod Chambers, Dr. Charles Reynolds III, and Dr. Joel Frader for their support and guidance in preparing this article. Disclosures The author has no other affiliations or conflicts of interest to disclose.
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