Although the physical health of physicians is better than the general population, physicians suffer from significantly higher rates of mental health disorders. Studies in the United States show that reported suicide rates among physicians range between 30 to 40 per 100,000, compared to an average of 13.0 for the American general population. Although Canada's suicide rate is slightly lower (11.3 per 100,000), the prevalence of physician suicide appears to be at the low range of the reported American rate or higher. This article examines how and why physicians may be more vulnerable to mental health disorders than the general population. What are the possible factors related to the development of these disorders in physicians and what are the solutions to improve physician care.
“ This article examines how and why physicians may be more vulnerable to mental health disorders than the general population.
The overall physician suicide rate cited by most studies is two to four times higher than the general population. In the United States, this translates to an equivalent of one to two average-sized Medical school graduating classes needed every year just to replace the number of physicians who commit suicide. This phenomenon is not new and has been studied since the 1960s. Earlier studies suggested that psychiatrists have the highest suicide rate and pediatricians had the lowest rate, however, later studies have reported no statistical significance in the differences of suicide rates among specialties. Moreover, studies have also concluded that suicide is the most common cause of death for young physicians (26% of deaths). Male physicians commit suicide at a rate about 1.4 times greater than the general population, whereas female physicians have suicide rates about 3 times higher than the general population. Unlike the general population, where males complete suicide four times more often than females, male and female physicians have approximately equal suicide rates.
The causes of suicide amongst physicians appear to be the same as the general population, with between 70% and 90% of suicides being linked to mental health disorders. Suicide rates are higher among physicians who are divorced, widowed, or never married. Physicians who are more vulnerable to suicide are driven, competitive, compulsive, individualistic, and ambitious. They have slightly more difficult or emotionally draining patients than their peers and they are typically graduates of a well-regarded medical school. They often have mood swings, dependency on alcohol or other drugs, and sometimes a non- life-threatening physical illness. Depression is a major contributor to suicide, and other factors include bipolar disorder and alcohol and substance abuse. Overall, physicians have the same vulnerabilities to mental illness as the general population. Contributing to the problem is the higher completion to attempt ratio for physicians, which may result from greater knowledge of lethality of drugs and easy access to means.
A recent survey of Canadian physicians found that over 20% of physicians had felt unable to experience joy or had felt depressed for at least two weeks in the preceding year. In addition, over a quarter (26%) stated that their mental health made it difficult to work at least some of the time in the past year. Although both male and female physicians suffer from the disease, the prevalence of depression and sadness were higher among female physicians than males.
High rates of depression are not limited to practising physicians but evidence suggests that medical students and residents also demonstrate higher rates of depression. Depression affects an estimated 12% of males and 18% of females of the general population while 15-30% of medical students and residents are affected by it. A study of female physicians found that 51% had a history of depression: among female physicians, 73% of female psychiatrists had a history of depression compared to 46% of other female physicians with similar histories. However, results of this study were recently contradicted by another study which concluded that prevalence rates of depression among female physicians may be similar to those in the general population. This contradiction suggests that depression among female physicians needs to be studied further.
It has been estimated that 40% of physician suicides are associated with alcoholism, and 20% with drug abuse. More attention has been given to substance abuse amongst physicians than depression. Recent studies have concluded that alcoholism and illicit drug abuse by physicians is comparable to the general population, but physicians are at increased risk for prescription drug abuse. Higher familiarity and availability of addictive drugs are likely to play a role in the increased rates of drug addiction among physicians. There also exists the possibility of physicians self-medicating themselves rather than consulting other physicians. In addition, physicians are more knowledgeable about the lethal doses of medications, which may play a role in the increased rates of successful suicide.
Divorce rates among physicians are 10% to 20% higher than the general population. Through medical school, residency, and professional practice, physicians tend to be more focused on their professional goals than personal relationships. It is believed that this deferral of personal relationships may be the cause of distant and estranged relations with their families and friends, and sadly, unhappy marriages.
An in-depth study of mental disorders amongst physicians points to the personal trait of perfectionism to be a very important cause. Perfectionism may lead to a thorough clinical approach, but it also breeds an unforgiving attitude towards oneself. When mistakes occur, the fear of medico-legal consequences exacerbates the distress. Studies have shown that physicians are less likely to disclose their mistakes to colleagues and experience a lack of support from colleagues in addressing their concerns. Perfectionism and the competitiveness engendered in medical training are cited as key reasons for experiencing distress about clinical errors.
A December 2015 CBC News article contained two insightful quotes from Canadian physicians: "[we need to] Change the culture that depicts doctors as super heroes who don't get sick when in reality they're just as vulnerable to depression as everyone else" and "the training of medical professionals is like a boot camp where residents are left to sink or swim."
Some studies hypothesize the adjustment of life before and after medical school to be a strong predictor of mental disorders. Medical students are often not prepared for the stress and hard work of the medical profession. While going through training, physicians endure a high degree of stress and sleep deprivation, which can result in both cognitive impairment and emotional fragility. In addition, during both medical school and residency, physicians become introduced to the mentality of distancing from patients, taking on more and more work without complaint, and learning to compartmentalize feelings.
“ [we need to] Change the culture that depicts doctors as super heroes…
In their working lives, physicians are often rewarded for long hours, which results in self-neglect. The medical practice brings with it unique stresses, including coping with intense emotions of suffering, fear, mortality, demanding patients, and uncertainty due to limits of medical science. Physicians often struggle during training and in later years to harden themselves to these issues.
Although physicians are accustomed to hearing and protecting the confidences of others, it may be hard for them to let their own guard down and trust another. Many physicians believe that it is not acceptable to reveal their own weaknesses and vulnerabilities to others. This difficulty with trust may also be part of the problem.
Difficulty setting appropriate limits on time is another characteristic common among physicians. There is an expectation that physicians must be available whenever needed, and this can lead to a sense of obligation that makes it difficult to set limits without guilt. Physicians often internalize this concept of perpetual availability and perceive limits as a lack of professional commitment.
While acute stress, social isolation, pre-existing mental illness and substance abuse may be obvious factors to consider, we must also ask if there are aspects of medical culture that might push suffering physicians beyond their limit of emotional resilience.
In a publically funded healthcare system (such as Ontario's Health Insurance Plan), the reward to physicians is not only determined by their commitment to their practice and hard work but also by budgetary constraints of the Plan's sponsor (i.e. the Ontario Government). This means that physicians are impacted by decisions out of their direct control. For example, the Ontario Government's unilaterally-imposed cutbacks reduced physician billings to the Plan by almost seven percent. Given the overall increase in the Ontario population and patient aging that has continued, this has clearly affected the lives of both physicians and their patients: it's not the monetary hit per se but rather the stress of not being able to give the appropriate amount of care to their patients. This situation contributes to burnout and increased susceptibility to mental disorders.
Mental health of physicians is a serious issue that does not only affect the health of physicians but the sustainability of the health care system at large. Therefore, addressing these problems should be a priority for educational institutions, professional associations, and the government.
Although physician well-being, self-awareness, and personal growth have received more attention in recent years, much more can be done:
Fortunately, there are resources available to support physicians while the system waits to change.
Operated by the OMA, the
Physician Health Program provides a range of direct services for physicians, residents, medical students, veterinarians as well as supportive services to family members of our clients. It will serve the needs of physicians and veterinarians at risk of, or suffering from substance use disorders, and/or psychiatric disorders through prompt intervention, referral to treatment, monitoring and advocacy while maintaining the highest standards of quality, confidentiality, responsibility and accountability to the physicians and veterinarians of Ontario.
Ontario Mental Health Helpline – 1-866-531-2600 – is staffed all day every day to help with every mental health related issue. They also have a
web chat feature and
smartphone app available.
Royal College of Physicians & Surgeons of Canada published
"CanMEDS physician health guide: A practical handbook for physician health and well-being" back in 2009 covering topics as diverse as poor nutrition to problems with finances to stress management, this handbook provides practical information for understanding the issue and also presents easy-to-follow solutions to many of the issues surrounding physician health.
time management guide is a practical resource for enhancing physician capabilities helps busy physicians manage their time more efficiently and effectively.
Ontario Association for Suicide Prevention does not focus on physicians specifically, but is designed as a resource to prevent suicides.
"Depression burden weighs heavily on resident physicians" CBC News, December 8, 2015.
ePhysicianHealth Free online physician health and wellness resource. Developed by Canada's leading physician health and eLearning experts to provide cutting edge, evidence-based information and innovative tools.
In many provinces – all except Manitoba, Newfoundland & Labrador, and Prince Edward Island –
calling 211 will give you access to community health services.
Ontario's doctors respond to Minister of Health's most recent comments about negotiations, Ontario Medical Association, March 2016
Physician Health Matters: A mental health strategy for physicians in Canada, Canadian Medical Association, February 2010
The suffering of Physicians, Thomas R Cole and Nathan Carlin, The Lancet, October 2009
29% of Young Doctors Are Depressed: Study, Mandy Oaklander, Time, December 2015
When Doctors Get Depressed, Tara Parker-Pope, The New York Times, October 2010
The Painful Truth: Physicians Are Not Invincible, Merry N. Miller, K. Ramsey Mcgowen, and James H. Quillen, Southern Medical Journal, 2000