By Joshua Barrett, M.D. Candidate, Georgetown University School of Medicine
Years ago in medical school classes, physicians were known to tell medical students that one in three of them would not last through medical school and become a doctor. Given a recent study on depression in medical training in the Journal of the American Medical Association, perhaps the warning should change to one in three medical students will suffer depression.
In the study, nearly one-third of more than 17,000 medical residents were found to experience depression during their residency. Depending on the method of assessment, the prevalence could be cited as high as 43 percent. A related study emphasized the macabre state of medical education by analyzing the drawings of fourth year students when asked to illustrate a formative medical school experience. Almost half of the comics contained imagery related to horror, with many students depicting hospitals as dungeons, patients as ghosts and themselves as sleep-deprived zombies.
As a current medical student, these studies made me highly concerned about the mental health of student physicians. Unfortunately, students in the medical field are not alone in experiencing depression. Poor mental health permeates practicing physicians as well. Depression occurs at least as frequently in practicing physicians as in the general population, affecting about 12% of male and 18% of female doctors. Furthermore, suicide among physicians is 1.4-2.3 times the rate of the general public, depending on gender.
Physician depression and suicide is largely predicated by job stress. In fact, a recent study revealed that workplace stress was three times as likely to contribute to a physician’s suicide as a non-physician’s. The authors of the study suggested that since physicians’ self-identity often revolves around their professional role, workplace problems may trigger more harm in physicians than for someone whose personal and professional identities were less connected.
In fact, for doctors the top four external sources of stress – healthcare reform, Medicare and Medicaid policies, uninsured patients, and income – all revolve around the medical profession. Additionally, specific aspects of the profession, such as administrative demands, long work hours, on-call schedules and concerns about malpractice lawsuits, exacerbate physician stress.
Poor physician mental health has a tremendous effect on patient care. Depression among physicians has been correlated to increased medical errors, ethical lapses, and less compassionate care. Physician job stress even reduces their perceived capacity to take on professional challenges. A recent study suggested that workplace stress explained why only 36% of physicians believed doctors have a major responsibility to reduce healthcare costs, despite their role in prescribing drugs, tests and procedures. For these reasons, physician satisfaction is a necessary concern for both providers and payers.
Health care organizations – including the health systems that employ physicians and the insurers that pay them for services – must recognize the high degree of stress that physicians endure and provide them with appropriate resources and support. It’s a quality of care issue. One-third of physicians have indicated that more flexible work hours with less on-call time and more stable work/life balance would reduce their stress. In the same survey, two-thirds of physicians vouched for ancillary support in the form of nurse practitioners and physician assistants to reduce demands on physicians.
Particularly for non-specialized physicians, healthcare payers greatly contribute to physician stress because of how these doctors are compensated. According to the 2014 Medical Group Management Association’s compensation survey, non-specialized physicians, such as primary care doctors, averaged $220,000 in annual salary compared to $400,000 for specialists and over half a million dollars for cardiologists and orthopedic surgeons. While specialists’ pay is driven by the procedures performed, compensation for primary care physicians is determined by the number of patient visits. Patient management, care coordination and administrative duties, which absorb much of primary care physician’s time, do not generate revenue. If payers reimbursed these important aspects of patient care along with face-to-face visits, primary care physicians would receive fairer compensation. These physicians would feel less pressured to take on more patients to maintain income and less rushed with each patient, ultimately reducing workplace stress and improving care.
Both payers and providers have an important role in reducing physician depression by ameliorating job stress and providing resources to support mental health. After all, for doctors to take care of patients, they must receive appropriate care themselves.
Editor’s Note: This blog post is part of an occasional series by first year Georgetown medical student Joshua Barrett.