Physician well-being is increasingly being recognized as an ethical issue, but mental health stigma remains an obstacle. Ethicists can:
• identify physicians who may be experiencing distress;
• partner with clinical leaders to identify resources;
• participate in wellness committees or task forces.
A physician feels depressed, overwhelmed, or even suicidal. He or she might not seek help due to worries over future ability to obtain a medical license, or other repercussions.
“Medicine and all of the healthcare professions have always been very high-stress occupations. We’ve known that takes a toll on people,” says Darrell G. Kirch, MD, president of the Washington, DC-based Association of American Medical Colleges.
What’s changed is that there finally is evidence showing the true extent of physician distress. “That has raised our consciousness of the problem,” says Kirch. “It has long been an issue, but is finally getting the attention it deserves.”
Physician well-being is a necessary component of an effective and ethical healthcare delivery system, says Claire Zilber, MD, DFAPA, ethics committee chair for the Lakewood-based Colorado Psychiatric Society.
“If a physician is struggling under the weight of anxiety, depression, or burnout, he or she is not at their best,” says Zilber. The quality of patient care can suffer.
“We are held to such high standards in our complex and demanding profession, yet there is little time or encouragement for self-care,” says Zilber.
The principles of clinical ethics are focused on the patient. Physicians strive to do what is in the patient’s best interest, and avoid harm. Yet there is increasing evidence that physician burnout and distress negatively affect patients.
This is true not just for satisfaction, but also outcomes and even potentially medical errors, says Kirch: “So from an ethical perspective, a duty to our patient really creates a duty to take care of ourselves.”
Ethicists can do these two things to promote physician well-being, says Kirch:
• When consulting on emotionally charged, difficult cases, ethicists can identify clinicians who may be experiencing distress.
• Ethicists can point out that physicians have an ethical obligation for self-care because it affects their ability to practice.
The ethical principle of beneficence is promoted when physicians are functioning at their best, able to interact with professionalism, and make well-considered treatment decisions, says Zilber.
“Justice — the notion that healthcare resources will be distributed in a fair manner — may be compromised if physicians experience unique obstacles to accessing health-care for themselves,” adds Zilber.
Increased awareness isn’t enough, says Kirch: “We really need to take action on a number of fronts.” Some examples include the following:
• Medical schools and residency training programs are emphasizing maintaining personal well-being, fostering resilience, and managing fatigue.
“I’ve really been impressed that at many schools, the students themselves have created programs to build their sense of community and foster mutual support,” says Kirch.
• Efforts are underway to make mental health services more accessible and more confidential for physicians.
A 2017 American Medical Association policy aims to improve physician and medical student access to mental healthcare and reduce stigma associated with mental illness.1
“We need to make it clear at the very beginning of their medical training that they themselves need care, and there shouldn’t be any stigma against seeking that care,” says Kirch, co-chair of the National Academy of Medicine’s Action Collaborative on Clinician Well-Being and Resilience.
Physicians seeking mental healthcare have valid concerns about confidentiality. Some are reluctant to use their health insurance to pay for treatment, fearing their employer will find out the physician is accessing psychiatric services, says Zilber. Likewise, physicians are concerned about the confidentiality of the electronic medical record if they seek services within their own healthcare system.
“As long as stigma about psychiatric care exists, there will be reluctance to receive treatment,” says Zilber.
• State medical boards are eliminating inappropriate questions regarding past mental health treatment.
“Those questions aren’t appropriate. The appropriate question is whether the physician has any type of problem that might impact their ability to practice currently,” says Kirch.
Many state applications for medical licensure inquire about a history of psychiatric or neurological disorders. “An affirmative response requires an explanation, thus revealing to the licensing board one’s diagnosis and treatment history,” says Zilber. This creates an ethical dilemma. “The physician can disclose highly personal information to the organization that controls medical licensure or falsify the answer on the application — which is fraud, and could result in disciplinary action if discovered,” says Zilber.
In a small number of states, including Colorado, the licensing board and physician health program (PHP) have an agreement that if physicians are enrolled with and monitored by the PHP, they’re permitted to answer “no” to the licensing question about having a psychiatric or neurological condition.
“This removes one obstacle to accessing treatment,” says Zilber. “Unfortunately, most states have not yet adopted this kind of arrangement.” Even in the states where it exists, it isn’t necessarily known or understood by the average physician.
• Hospitals are creating the position of chief wellness officer.
Even if the position doesn’t exist at the institution, ethicists can partner with clinical leaders such as the chief medical officer and chief nursing officer to raise awareness of the problem. The group can work together to identify resources that clinicians can be referred to.
“In some places, key leaders have come together and formed a wellness committee or task force,” says Kirch. “Ethicists could certainly be a vital partner in that effort.”
• Hospitals are reversing stigma by creating a culture that embraces mental healthcare.
One way of doing this is for hospital leaders to make public statements about the benefits of psychiatric treatment.
“This helps to change the perception that we should be keeping secret our struggles with burnout, depression, anxiety, substance use disorders, or other mental illness,” says Zilber.
1. American Medical Association. AMA Adopts Policy to Improve Physician Access to Mental Health Care. June 14, 2017. Available at: https://bit.ly/2tbCl3l.
• Claire Zilber, MD, DFAPA, Ethics Committee Chair, Colorado Psychiatric Society, Lakewood. Email: firstname.lastname@example.org.