Mohit Harsh, MD, a resident at Barnes-Jewish Hospital in St. Louis, prided himself on knowing personal details like the hobbies or hometowns of dozens of intensive care unit (ICU) patients. He often checked patients’ charts on his days off and easily connected with the relatives of those in his care. Then COVID-19 came crashing through the unit’s doors.
Suddenly, nearly every moment was filled with urgent admissions, desperate efforts to battle a strange disease, and struggles to communicate remotely with patients’ terrified family members. During his September rotation, Harsh recalls, it seemed as though not a single ICU patient survived.
Soon, patients became mere bed numbers to him, and some days, he could barely drag himself into work. He knew he needed professional help, but one fear haunted him: What if his co-workers found out?
“I was worried my peer colleagues would see me differently,” says Harsh, who eventually decided he needed treatment. “I worried that the entire leadership would know, and I’d feel like Big Brother was always watching me. I also was concerned that the interns I’d be guiding wouldn’t give me the same level of respect,” he adds. “I just didn’t want to be perceived as weak.”
As COVID-19 cases continue to spike across the country, experts worry that providers will avoid much-needed mental health care for fear of harming their reputations or ruining their careers.
Yet many are not getting the help they need. Only 13% of providers have sought treatment to address pandemic-related mental health concerns. Among emergency physicians — 87% of whom say they’ve been experiencing increased stress — nearly half report not feeling comfortable seeking mental health treatment.
“It’s heartbreaking that you have people who are putting themselves at risk and facing enormous stress without getting the help they need. The strain clinicians are facing is on top of what they were already struggling with even before COVID.”
Liselotte Dyrbye, MD
Physician well-being researcher at Mayo Clinic
Providers’ silent suffering can have dire costs. In perhaps the most well-known recent physician suicide, Lorna Breen, MD, medical director of the emergency department at NewYork-Presbyterian Allen Hospital, died after telling loved ones she felt useless to her patients and desperately feared seeking treatment.
Physicians report numerous worries over seeking mental health care: Losing face. Having their privacy invaded. Paying more for malpractice insurance or not being able to get it at all. Losing their hospital privileges — and possibly even their license to practice medicine. And though efforts are underway to address these concerns, experts say it will take much work to allay them.
That work is essential, argues Liselotte Dyrbye, MD, a Mayo Clinic researcher who specializes in physician well-being.
“It’s heartbreaking that you have people who are putting themselves at risk and facing enormous stress without getting the help they need,” she says. “The strain clinicians are facing is on top of what they were already struggling with even before COVID. As a community, we have to figure out a way to put our arms around them and help them through this very tough period — and beyond it.”
The licensing dilemma
For many providers, the medical licensing process has posed a major barrier to treatment. Nearly 40% of physicians said they’d be reluctant to get mental health care out of concern over receiving or renewing their license, according to a 2017 paper in Mayo Clinic Proceedings.
In fact, for decades, state licensing boards often asked wide-ranging questions about mental health that sometimes included checking on brief treatment long ago. Answering yes could trigger a process that might even threaten one’s ability to practice medicine. Now, though, efforts are underway to reform licensing procedures.
In 2018, the Federation of State Medical Boards (FSMB) released recommendations for updating licensing applications. The document advised asking only about current issues that undermine a physician’s ability to work well. Questions about issues other than current impairment — such as a physician's mental health diagnosis — violate the Americans with Disabilities Act, it said.
Since the document’s release, “most boards that needed to alter their licensing applications have done so. The remainder … recognize the need to do that,” says FSMB President Humayun Chaudhry, DO.
In states that have changed their language to focus on impairment, physicians can seek treatment without risking their license for doing so, experts note. In states that haven’t changed their wording — or changed it in ways that are somewhat murky — worries over licensure remain.
Chaudhry says losing one’s license is not common. “Boards want to work with you to make sure you’re getting the care you need,” he says. “They aren’t looking for ways to remove your license.”
But even if one’s license is safe, other application concerns loom. For one, physicians worry that they could be required to meet with the board about their mental health history or share their most private medical records with members.
“Boards want to work with you to make sure you’re getting the care you need. They aren’t looking for ways to remove your license.”
Humayun Chaudhry, DO
Federation of State Medical Boards president
Michael Privitera, MD, who served on the FSMB recommendation committee, notes that boards have always focused on protecting the public, but he applauds the shift in their approach to doing so. “Boards’ previous ways of thinking … are changing with the recognition that physician well-being affects patient well-being. The two are highly linked,” he says. “Protecting physicians’ privacy so they can get the help they need and get back to being well is in everyone’s interest.”
Meanwhile, significant work remains, experts say. “Defining what’s ‘problematic’ [in applications’ language] is not so clear-cut,” argues University of Kansas Medical Center professor Kimberly Templeton, MD, a past president of Kansas’ medical board who is helping lead a national licensing reform campaign. “Many states still could use some updates to encourage help-seeking. But like so much in medicine, the pandemic is shining a light and increasing momentum.”
The weight of many worries
Though they are quite hefty, licensing concerns aren’t the only barrier to physicians seeking mental health treatment, experts say.
“Even if we get the state’s questions right, there are other obstacles,” says Tait Shanafelt, MD, chief wellness officer at Stanford Medicine. “For example, the credentialing questions that hospitals ask before allowing providers to treat patients are often similar to what licensing boards ask — or have asked in the past. That’s an area where we know much less because each hospital approaches this differently,” he adds. “That dimension is the next frontier.”
Physicians are certainly aware of those questions. A 2019 study of New York doctors found that 65% thought privileging applications would be a barrier to physicians seeking mental health care.
Worries extend far beyond credentialing, though, says Carol Pak-Teng, MD, an emergency physician in Jersey City who had to pronounce patients dead numerous times each day early in the pandemic. “What normal human wouldn’t be emotionally affected?” she says.
Pak-Teng first experienced depression years ago, but she consulted her mentors before pursuing treatment. “I was looking for permission to seek help on the record through my insurance, but they dissuaded me,” she says. They had a range of worries, she recalls, from harming future employment opportunities to having trouble getting malpractice or disability insurance. “I was told I should pay out of pocket for care,” she adds. “That really became a barrier for me to seek any care at all.”
Then there’s also concern that a mental health condition will mean having to prove one’s competency in uncomfortable ways at work. Justin Bullock, MD, MPH, says that’s what happened to him.
Back in March, Bullock’s bipolar disorder struck him hard, and the second-year resident needed treatment following a suicide attempt. Eventually, “multiple providers cleared me to go back to work, but my institution still required their own formal evaluation by the well-being committee despite my never having any workplace issues,” he says. “I had to complete an extensive psychiatric evaluation that included multiple drug tests and personality tests. I was told I couldn’t return to work without agreeing to many conditions, including that I do a specific type of therapy.”
Since then, he says, the institution is working to redesign their competency-related procedures. Still, he worries that his experience could squash others’ willingness to get treatment.
“I recognize that this is a complex issue and that institutions want to keep patients and providers safe,” he adds. “I know it may be challenging to find the best answers. But whatever those answers are, we’re certainly not there yet.”
Silenced by stigma
In April, hoping to help staff deal with the crushing effects of the pandemic, New York’s Icahn School of Medicine at Mount Sinai opened the Center for Stress, Resilience, and Personal Growth. There, all Mount Sinai Health System employees can access a range of mental health services for free.
But a key question in leaders’ minds has been whether staff would avoid the services given the long-standing stigma surrounding mental health care. One study, for example, found that 73% of emergency physicians expect stigma at work for seeking treatment.
And while physicians say getting treatment anywhere risks some stigma, getting help at work can be particularly concerning. That’s unfortunate since accessing care elsewhere can be costlier and more time-consuming, experts say.
“There’s always been a segment of our community that asks questions like, ‘Will my visit be documented in the hospital’s electronic health record?’ Yes, the possibility exists that a colleague could open up your record, but doing that is highly sanctionable,” says Mount Sinai Chief Wellness Officer Jonathan Ripp, MD. “Still, the fear that someone may do that is very real.”
Meanwhile, leaders at Mount Sinai, Stanford, and other institutions are launching communications campaigns designed to chip away at the wall of stigma that can bar doctors from seeking mental health care.
“A number of barriers come from a mindset that physicians are supposed to be superhuman. Instead, we should be setting professional norms that medicine is an emotionally demanding profession and that it’s common at times to need help.”
Tait Shanafelt, MD
Chief wellness officer at Stanford Medicine
As Harsh was considering treatment, he recalled numerous emails from his supervisor urging residents to connect if they were struggling. He also knew his program had a therapist on staff specifically for residents. “[My supervisor] gave me so much incredible support,” he says. “I was very, very relieved that the reception I got was quite the opposite of what I feared.”
That response was so important, Harsh says, because trainees too often absorb subtle messages that weakness is simply unacceptable.
“In small interactions throughout medical school, even just in body language, you learn that you need to handle stressful situations flawlessly,” he says. “Most of the time, it’s not explicitly stated. You just know that when it comes to mental health, keep it quiet.”
Shanafelt highlights the need to alter some crucial elements of the medical culture.
“While important, we can’t blame all obstacles to treatment on issues like licensing questions,” he says. “A number of barriers come from a mindset that physicians are supposed to be superhuman.”
“Instead, we should be setting professional norms that medicine is an emotionally demanding profession and that it’s common at times to need help. When you experience one of those seasons in your career, it’s normal, it’s supported, it’s expected that you get help,” Shanafelt says. “Changing that mindset is crucial work we have to do in the house of medicine,” he adds. “No one can fix that but ourselves.”