By Sandeep P. Kishore
The NAM Perspectives paper “Breaking the Culture of Silence on Physician Suicide”  brought together four unique voices from surgery, nursing, medical training, and the clergy to consider what led Kaitlyn, a young medical student, to take her own life on April 11, 2013. Drawing from personal experiences, the authors exposed what they thought was a culture of silence under intense pressure that pushes physicians, health professionals, and trainees to experience depression and in some cases to tragically end their lives. But these are just four opinions based on four experiences. The authors hope to bring more voices into the conversation by asking others who are comfortable doing so to share their own reactions to situations they have been forced to navigate throughout their education and careers as health care providers.
Dr. Arthur Hengerer, past chair of the Federation of State Medical Boards (FSMB), has taken up that charge. What follows is a powerful narrative, given the experience of the author and the personal commitment he is making to breaking—and rectifying—the culture of silence around burnout in our workforce. Anyone can join this movement by sending their written thoughts, opinions, or personal accounts relating to the culture of silence to firstname.lastname@example.org. These written comments will be shared only if the writer and those easily identified in the remarks provide explicit permission to do so.
By Arthur Hengerer
Over the course of my 40 years of work in the field of medicine, I have witnessed many mental health challenges among my physician colleagues at all stages of their careers. Frequently, the source of their struggles stems from unaddressed stress that often begins during medical training in academic institutions, where I spent more than 25 years as a medical educator.
This early stress does not subside post-graduation, and I would argue it intensifies due to the culture of medicine that discourages any open acknowledgment of mental health challenges like depression. It is this unrelenting stress that can eventually lead to burnout, addictive behaviors, fraudulent practices, or aberrant social or sexual indiscretions. If stress, burnout, and dysfunctions are left to fester, they could have implications for career advancement, not to mention the safety of patients under the care of an exhausted or dysfunctional physician. I know this firsthand because fifteen years ago, I started getting involved with regulatory aspects of medicine by serving on the State Board for Professional Medical Conduct in New York State (the Board). It was then that I began to understand how a cascade of events could, on occasion, lead to a report to regulatory bodies, whose responsibility it is to protect the public.
I further solidified my thinking about the intersection of regulation, mental health, and patient safety in my next position as chair of the Board, before joining the FSMB and becoming the chair of that board. I believe state medical boards have a crucial role in encouraging wellness during a medical professional’s career, since they exist as stewards of individuals’ career paths. However, I also see a role for educational and professional organizations in addressing mental health challenges earlier in the practitioner’s training, to avoid potential pitfalls throughout one’s career, which could include problems at the regulatory and licensure stage.
Here, I lay out three areas for discussion.
First, there is the critical role of state medical boards in identifying mental health challenges and physical impairments, particularly during licensure and re-licensure. Through my experience, I have realized that more knowledge is needed upstream to identify physicians who are struggling and get them help earlier, before their challenge becomes a safety issue and the physician risks losing his or her license. I have been intimately involved in these kinds of cases for many years, and truly see the process of identifying and treating mental health challenges as a continuum.
The continuum starts when physicians are young, stressed, and newly licensed. Stress and burnout continue to build as the same physicians seek to renew their licenses with the state boards to remain in practice. While most are able to function adequately as physicians, some cannot and end up being reviewed by a conduct board, which is forced to suspend or revoke their licenses. I have seen this far too many times, but I have also seen many physicians helped through physician health programs.
How might we proactively address these challenges? One option is to ask physicians about the symptoms, signs, and cues to burnout in licensure questionnaires by state medical boards or by some other methodology. However, there is often great stigma surrounding mental health issues, and that is playing out within the medical profession. As a result, physicians experiencing depression or any mental health challenge do not feel their confidentiality would be protected if they were honest about what they are experiencing. Similarly, medical students and trainees fear that admitting to mental health struggles will compromise their chances of getting into a residency program. One must wonder, are licensing requirements actually causing physicians to hide their own burnout?
Second, the FSMB and state medical boards are experiencing a tension of needing to prioritize wellness and health of physicians—to reduce clinical errors—and also balancing this with concerns of transparency with patients and ensuring a robust health workforce. How open should we be?
There are no clear answers, but the FSMB is examining a variety of options and interventions. I’m involved with a wellness and burnout work group that is looking at the licensure application process and asking how best to handle questions about mental health. There is debate about whether to ask about mental health and how to do so respectfully and carefully. We are also looking at other factors that affect physician satisfaction—such as the electronic health record (EHR), practice autonomy, and system environmental operations—to be included in the recommendations of the work group’s final report. We are learning that there is great variability, and research efforts will be needed to study the impact that different approaches might have on reporting, stigma, and resulting wellness. We are examining how we can best provide support for those at risk, both to risk stratify and identify individuals—all within the parameters of the Americans with Disabilities Act—while ensuring respect for their privacy.
Third, there is the issue of self-regulation. In the medical profession, it is our duty to report and self-regulate. However, it is very clear that the medical profession does not do this effectively. Our professionalism and social contract with society expects us to accept that duty. It is the responsibility of the profession as a whole to assist physicians who need help early on and to provide them with the tools and support to get help. At FSMB, we are trying to address this issue head on.
There are known drivers of burnout reviewed elsewhere . These can occur at any time from early medical school through training and clinical practice. Thus, medical students and physicians should work hard to have a balanced life and should seek help when struggling with emotional well-being. A common concern with seeking help is that the medical student or physician will be reported and that reporting will adversely affect their career. According to Gold et al. , roughly half of the 2,100 female physicians surveyed by her team responded affirmatively to the “mental illness” question but did not seek treatment. Only 6 percent of those who reported a mental illness in the survey disclosed the information on a licensing application. While there is substantial variation in reporting requirements among state medical boards, the majority continue to ask applicants questions about past and current mental illnesses . Many of us wonder whether the disclosure of such information for medical licensure is a deterrent to seeking treatment. I have seen the benefit of professional help on multiple occasions, and it has protected both patients and physicians from harm.
Physicians at all levels of their careers must be mindful of the effects of stress and burnout in their practice, and remember the importance of developing a healthy work-life balance, practicing mindfulness, and seeking help when experiencing symptoms of burnout or depression.
I am focusing the rest of my career on these issues to ensure the regulatory and licensure environment promotes physician health and wellness, and helps minimize—not drive—burnout.
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- Kishore, S., D. E. Dandurand, A. Mathew, and D. Rothenberger. 2016. Breaking the culture of silence on physician suicide. Discussion Paper, National Academy of Medicine, Washington, DC. http://nam.edu/wp-content/uploads/2016/06/Breaking-the-Culture-ofSilence-on-Physician-Suicide.pdf.
- Shanafelt, T. D., O. Hasan, L. N. Dyrbye, C. Sinsky, D. Satele, J. Sloan, and C. P. West. 2015. Changes in burnout and satisfaction with work-life balance in physicians and the general US working population between 2011 and 2014. Mayo Clinic Proceedings 90(12):1600-1613.
- Gold, K. J., L. B. Andrew, E. B. Goldman, and T. L. Schwenk. 2016. “I would never want to have a mental health diagnosis on my record”: A survey of female physicians on mental health diagnosis, treatment, and reporting. General Hospital Psychiatry 43:51-57, doi:10.1016/j.genhosppsych.2016.09.004.
- Gold, K.J., E.R. Shih, E.B. Goldman, and T.L. Schwenk. 2017. Do US medical licensing applications treat mental and physical illness equivalently? Family Medicine 49(6):464-467.