From the Editor

The days have been long. As we enter the third year of the pandemic, many are feeling it. 

What has the impact been on the mental health of us physicians? We have anecdotal evidence, but data has been lacking. In the first selection, we consider a new paper by Dr. Daniel T. Myran (of the University of Ottawa) and his co-authors. Drawing on data from 34,000 Ontario doctors, the authors considered MD visits for mental health and substance (in other words, doctors visiting their doctors), finding that such appointments were up 27% during the first year of the COVID-19 pandemic. “These findings may signal that the mental health of physicians has been negatively affected by the pandemic.” We look at the paper and the invited commentary that accompanies it.

In the second selection, Agnes Arnold-Forster (of the London School of Hygiene and Tropical Medicine) and her co-authors consider the evolving understanding of physician health by looking to history. They argue that three concepts – medical exceptionalism, medicalization, and an emphasis on individual responsibility – have harmed physicians, creating “excessive commitment and complete personal sacrifice.” They suggest an alternative. “By attending to the lessons of the past, we can envision a better future for patients and their physicians.”

DG


Selection 1: “Physician Health Care Visits for Mental Health and Substance Use During the COVID-19 Pandemic in Ontario, Canada”

Daniel T. Myran, Nathan Cantor, Emily Rhodes, et al.

JAMA Network Open, 21 January 2022

Studies have documented high levels of mental health and substance use concerns among physicians. The emergence of the COVID-19 pandemic poses additional risks to the mental health of physicians. In addition to the general societal disruption from the COVID-19 pandemic, physicians face specific occupational stressors, including a potentially greater risk of exposure to SARS-CoV-2, with consequent concerns over personal health and infecting family, friends, and colleagues; inadequate personal protective equipment; rapid practice changes including loss of income; and high, and at times overwhelming, workloads. There are additional concerns about trauma arising from moral distress when physicians face difficult decisions regarding the allocation of scarce resources or balancing their needs and those of their patients.

During the pandemic, health care workers, including physicians, have self-reported high levels of stress, anxiety, and depression. Surveys of physicians in China (n = 493) and New York (n = 282) during the first months of the COVID-19 pandemic found that 42.8% of respondents had at least mild symptoms of depression and 41% screened positive for depression. A survey of approximately 1300 Canadian physicians during late 2020 found that 62% reported being quite or extremely stressed most days. Two cross-sectional surveys (n = 1407 and n = 2649) of Ontario physicians found that the proportion of respondents reporting being completely burned-out (a strong correlate of mental health issues) increased from 10.6% in March 2020 to 14.0% in March 2021. However, to date, studies on physicians’ mental health during the pandemic have used small cross-sectional samples that, combined with low response rates (eg, <10% in the Ontario surveys), raise concerns of whether they represent all physicians…

So begins a paper by Myran et al.

Here’s what they did:

  • “We conducted a cohort study of practicing physicians in Ontario, the most populous province in Canada (n = 14.7 million in 2020)…”
  • They drew on health administrative data from March 1, 2017, to March 10, 2021 that “captured nearly all outpatient visits to physicians in Ontario.”
  • “Our primary outcome was an outpatient visit (including virtual care and telemedicine) by a physician to another physician related to mental health or substance use.”
  • Statistical analyses were done, including “autoregressive integrated moving average models and generalized estimating equations…”

Here’s what they found:

  • “Our study included 34 055 physicians practicing in Ontario between 2017 and 2021…”
  • Demographics. The majority were men (52.6%) with a mean age was 41.7 years; 96.4% lived in an urban region. 
  • Practice. A wide variety of physician specialties was represented, with the most common specialty being family medicine (31.0%).
  • COVID. “During the first year of the pandemic, 11.1% of physicians (residents and fellows not examined) cared for at least 1 patient with suspected or confirmed COVID-19 in the ED or inpatient setting…”
  • Problems. Over 65% of mental health and substance use visits were due to anxiety; 15% were related to a mood disorder. That was true before and during the pandemic.
  • Increase. “The annual crude number of visits per 1000 physicians increased by 27%, from 816.8 before the COVID-19 pandemic to 1037.5 during the pandemic (adjusted incident rate ratio per physician, 1.13…). The absolute proportion of physicians with 1 or more mental health and substance use visits within a year increased from 12.3% before to 13.4% during the pandemic (adjusted odds ratio, 1.08…).”
  • Specialties. “Psychiatrists had the highest rate of annual visits (3441.5 per 1000 physicians), and surgeons had the lowest rates of visits (370.9 visits per 1000 physicians).
  • History. “Most visits (86.3%) before the pandemic were by physicians with a history of a mental health visit in the preceding 2 years.” And after: “The relative increase in the rate of visits by physicians without a mental health and substance use history was significantly greater (aIRR, 1.72…) than by physicians with a mental health and substance use history (aIRR, 0.98…).”

A few thoughts:

1. This is a good study.

2. Wow.

3. The result in a nutshell: “After adjusting for demographic and physician characteristics and a history of health care use related to mental health, visits increased on average by 13% per physician (aIRR, 1.13…).”

4. Interestingly, there was no statistical difference between men and women. (!)

5. Even more interestingly, there was no statistical difference between those who worked with COVID-19 patients and those who didn’t. (!!)

6. Is it all bad news? The authors note that access has changed: “In response to the pandemic there was a large expansion of virtual care options in Ontario. It is possible that physicians with both physical and mental health concerns that predated the pandemic increased their health services use owing to this change (eg, appointments are easier to schedule and less visible and thus less stigmatized).”

7. Like all studies, there are limitations. The authors write: “physicians have low levels of care-seeking behaviors related to mental health and substance use, and encounters related to mental health and substance use by physicians may be incorrectly coded as due to other reasons by providers owing to concerns over discrimination from regulatory bodies and stigma. Consequently, our study has likely only captured more severe outcomes and may miss other patterns of changes in important outcomes, such as physician burnout…”

8. The paper runs with a commentary by Dr. Bernard P. Chang (of Columbia University), “The Health Care Workforce Under Stress – Clinician Heal Thyself.

He offers an optimistic assessment: “Their results are somewhat encouraging insofar as we are now seeing more clinicians seeking professional help and guidance for mental health concerns.” 

Bernard P. Chang

He points a way forward: “Creating additional avenues or opportunities for health care professionals to obtain mental health services will be paramount, while cognizant of the unique challenge surrounding reticence in seeking care within the profession. In addition to providing and encouraging the use of local mental health resources for health care workers, the use of digital care programs (eg, digital health) as a means to scale and encourage adoption of mental health programs among health care professionals may show promise. The use of platforms such as telemedicine and guided/unguided digital programs offers novel avenues to increase adoption and support for mental health services in physicians, while also offering discretion and scheduling flexibility, thus potentially reducing traditional barriers to seeking mental health services among health care professionals.”

The commentary can be found here:

https://jamanetwork.com/journals/jamanetworkopen/fullarticle/2788293

The full JAMA Network Open paper can be found here:

https://jamanetwork.com/journals/jamanetworkopen/fullarticle/2788289


Selection 2: “Obstacles to Physicians’ Emotional Health – Lessons from History”

Agnes Arnold-Forster, Jacob D. Moses, Samuel V. Schotland

The New England Journal of Medicine, 6 January 2022

Beyond its obvious and devastating effects on patients, the Covid-19 pandemic has exacerbated deep-seated vulnerabilities in health care systems and revealed the challenges they face in protecting the mental health and well-being of physicians. Even before the pandemic, physician burnout was a concern for the medical community and, increasingly, for policymakers. And although the conditions of the current crisis are unique, medical professionals have been known to struggle in the past, and remedies have been tried. Insights from the history of medicine may help us craft solutions to these problems; history may not only explain why physicians are under such strain but also reveal why so many proposed solutions have fallen short.

So begins an essay by Arnold-Forster et al.

They argue that there are “three key obstacles have historically prevented improvements to physicians’ emotional health. Medical exceptionalism, medicalization, and an emphasis on individual responsibility are overlapping issues that have shaped our approaches to the well-being of health care professionals.”

Medical exceptionalism

“One of the central tenets of medical professional identity is the exceptional status of physicians and their work. Such exceptionalism has not always held sway. In the 18th century, though some physicians were associated with elite institutions and held in high regard as well-educated gentlemen, medicine overall was a busy marketplace populated as well by ‘mere retailers of physic,’ ‘quacks,’ and ‘nostrum sellers.’ Over the course of the 19th century, owing to a protracted and deliberate process of professionalization, physicians improved their reputation and became associated with humanitarianism, benevolence, and commitment to the public good.

“As a result, physicians were believed to be driven by vocation and a sense of duty. Medicine was not just a job like any other, but a calling or commitment… Such devotion may seem like an admirable asset that has secured U.S. physicians their high social and economic status. But notions of medical exceptionalism have also had profoundly negative consequences: physicians are frequently denied basic workplace rights and protections, and their exploitation is rationalized on the basis of the belief that medicine requires self-sacrifice.”

Medicalization and Individual Responsibility

“In the second half of the 20th century, physicians’ mental health and well-being were increasingly scrutinized and deemed a problem worthy of attention. Waves of studies and books from the mid-1950s onward examined the unhappy physician. Works including The Emotional Health of Physicians (1967)… discussed depression, substance use, and death by suicide.

“As physicians paid greater attention to these issues, medical societies concentrated on the problem of ‘impaired physicians’ – doctors deemed to be compromised by psychological, emotional, or substance use disorders. Impaired physicians were depicted as a threat to themselves, public health, and the profession’s reputation. By focusing on mental illness, organized medicine brought attention to the deleterious effects that physicians’ emotional states could have on patients – but in the process, it stigmatized physicians’ mental health issues.”

They discuss laws aimed at “sick doctors” and greater regulation of the profession. “Although this medicalization brought much-needed attention to physicians’ mental health and legitimized a serious problem endemic to the medical workforce, it also stigmatized unwell physicians as the source of the problem. This deflection allowed organizations to neglect structural problems, such as working hours and conditions, and to focus narrowly on individual blame.”

They note the rise of the wellness movement. “The modern wellness movement initially positioned itself as an alternative to biomedicine, but by the 1970s, mainstream medical centers began establishing wellness programs.” Still, they note the bias: “Wellness promotion and burnout prevention did not simply happen simultaneously: they were tied together by a belief in individual responsibility. Today, self-care programs have become fixtures in many health systems.”

They argue: “When physicians have been expected to be self-negating, have been stigmatized for being sick, and have been held personally responsible for their wellness, efforts to address emotional health have targeted individual clinicians.”

A few thoughts:

1. This paper offers a good historical perspective on today’s discussions about physician wellness.

2. The triad of beliefs – medical exceptionalism, medicalization, and an emphasis on individual responsibility – isn’t original, but it is thoughtful.

3. They argue for a way forward: “An alternative is to recognize physicians as workers who, like others in health care, deserve basic rights and adequate conditions. The historical obstacles have allowed health care to subsist on the goodwill of its employees rather than reckoning with structural problems. Recognition of these persistent barriers can spur structural policy innovations that numerous North American and European groups have identified, such as adopting work-limit protections, making occupational health a top-level priority on par with patient safety, and addressing social determinants of both patient illness and clinician burnout…”

4. Burnout is a topic explored in past Readings. In December, we considered a podcast interview with Dr. Jillian Horton:

https://www.porticonetwork.ca/web/podcasts/quick-takes/combating-burnout

The full NEJM paper can be found here:

https://www.nejm.org/doi/full/10.1056/NEJMp2112095

Reading of the Week. Every week I pick articles and papers from the world of Psychiatry.