Carol A. Bernstein, MD, and colleagues recently published a commentary in JAMA Psychiatry on the importance of differentiating burnout from major depressive disorder among physicians. “It is critical that burnout not become the catchall term for emotional distress experienced by physicians,” the authors highlighted in their Viewpoint. Dr. Bernstein is the Vice Chair for Faculty Development and Wellbeing, Departments of Psychiatry and Behavioral Science and Obstetrics and Gynecology, Montefiore Medical Center/Albert Einstein College of Medicine, Bronx, NY. She is also a Past-President of the American Psychiatric Association. Take Note “If physicians feel valued and they sense that their values are being reflected in what’s going on, if the leadership in institutions cares about their well-being as well as the well-being of patients, it can go a long way.” –Carol A. Bernstein, MD In an interview with MedPage Today, Dr. Bernstein discusses the entrenched problem of conflating burnout and depression among physicians, emphasizing the issues of stigma and barriers to appropriate mental healthcare access. She points out that the system needs to transform in order to help reduce the tremendous stress and distress physicians face as they care for their patients and to help properly identify and treat psychiatric illness in the medical profession. Here are excerpts from the interview, which have been lightly edited for clarity. MedPage Today: Burnout is considered a risk factor for depression, people experiencing burnout can eventually develop depression? Dr. Bernstein: Absolutely. In susceptible people, burnout can contribute to the development of depression without question. Burnout and depression are complexly inter-related. Yet, at the same time, burnout can be confused with depression and vice versa? That’s what so tricky about this. You want to be sure that you aren’t mistaking burnout for depression or depression for burnout because the remedies are different. And symptoms are similar so that makes it very hard. Part of the punch for [the JAMA Psychiatry] piece was that, even with all the concern about what’s causing burnout in doctors, there’s also a concern in psychiatry that it’s easier for physicians to talk about burnout than it is to talk about depression. For some it may be easier to focus on the burnout. Can you explain why this is? It’s because depression is so stigmatized. Stigma is huge. I think it’s worse in doctors who come in with what we call the compulsive triad. Obsessiveness, being highly perfectionistic, wanting to make sure they catch everything, etc. And when you fail to do that, you feel terrible. This may be related to depression. But you may feel that’s not something that’s appropriate for you to have to deal with. The other problem is people are very worried that, if they go for psychiatric treatment, there’ll be consequences for them with licensing and credentials. Your JAMA Psychiatry article states that, according to Sen et al, rates of presumptive depression among interns entering residency are approximately 4% at the start of training and increase to about 25% within three months. Can you comment further? Srijan Sen [MD, PhD, Professor of Depression and Neurosciences, Department of Psychiatry, Michigan Medicine, Ann Arbor, MI] has really done amazing work in this area. The challenge with some of the data is that he’s using a self-report instrument called the PHQ-9 that we often use in doctor’s offices as a screening test for depression. If you rate above a certain level, then you’re considered to be depressed. But it’s not necessarily the same as depression a psychiatrist might diagnosis in his or her office. It’s not that it’s not concerning. It is. It’s absolutely a red flag. The really fascinating piece is that the interns before have a very low rate of depression, or whatever the scale is measuring, but then at months 3, 6, 9 and 12, it goes up to 25%. And that’s been duplicated in many places. You have to think about the fact that you go from finishing medical school— you’ve completed this life-long goal, you’re a high achieving, highly successful young person who’s finally gotten their medical degree, you’re kind of on top of the world—and then you go into a setting where there’s tremendous stress, where there’s long hours, where you’re sleep deprived, where you’re terrified you’re not doing enough, where patients are very sick and now it’s your job to deal with all of this. It’s very challenging. There’s no question that we’re never going to be able to totally take the stress out of medicine. You can’t do that. It’s a stressful deal. If this is the reality, can something be integrated into the system to try to circumvent or quell the problem? I think physicians are experiencing unprecedented stress and distress now. So I want to speak to that because it relates to your question in terms of what we can put into the system as opposed to what’s inherent in it. There’s a lot of things that have changed in medicine. I was an intern in 1980 and we had terrible work hours. They were horrible. It was ridiculous: 120 hours a week; one out of three weeks I was on call four nights out of seven. That’s nuts. People accepted it but things were different. Number one, not every patient was so sick. So, for example, we had patients who would come in with pneumonia. They’d be treated with antibiotics in the hospital for two weeks and then they’d go home. The same patient today might not even get admitted to the hospital. So that’s a huge deal. People coming into the hospital now are much more seriously ill. A lot of them are very complicated cases. There’s more treatment, there’s much more to know. So that’s really stressful. The length of stay is really short. So it’s like get them in and get them out. So there’s tremendous pressure on physicians to perform. There’s another thing—electronic records, which has brought wonderful capacity to monitoring—to be able to read the patient’s history as the doctor’s handwriting was the standing joke in the old days. But there’s so much in there that it’s sometimes hard to determine what’s the most important thing. And there’s so many different specialists that care can get very fragmented. There a lot of trees but nobody sees the forest. The status of doctors in the healthcare team has fallen a lot. Some of the value that physicians felt before for the work and the training isn’t as much as it was before. The regulatory environment and the insurance industry dictate what’s going to be acceptable. There’s a lack of autonomy and control physicians have over what they do. It’s a very slippery slope, no question. That’s why it’s so hard to figure out what the interventions are that have to be made. And last but not least the corporatization of American medicine is a big problem, with a focus on revenue. It’s has to be viable, you have to have a running operation, that’s all true. But the environment has become so corporate. And it’s taking away from what I like to call the mission of medicine. Are doctors then becoming disillusioned? There’s something in the literature now called moral injury. It’s a concept that’s been used for soldiers in war doing things antithetical to things we think we should be doing from an ethical standpoint. And so people get demoralized because there’s a conflict with their values. And when doctors come into healthcare settings where they no longer have control and can’t deliver the kind of care that they want to give to their patients, they get demoralized. And they can get burned out. What key steps can physicians take to reduce their risk of mental health issues? There are challenges with the individual piece. There are a lot of individual remedies. We all know that sleep, exercise, connection to others, being aware of what things are stress points and what things help fuel your energy level, mindfulness and meditation can be helpful to people. The problem is that this puts the burden back on the physician. We all know we’re supposed to do those things. Beyond the individual level, what needs to change in the system to better address physician burnout and depression? The environment, having leaders who understand the challenges is really important. If you have leaders who are inspirational and connect with people they’re working with, it can go a long way. If physicians feel valued and they sense that their values are being reflected in what’s going on, if the leadership in institutions cares about their well-being as well as the well-being of patients, it can go a long way. These are the kinds of interventions that can really help physician burnout. The depression story is different in that we have to reduce stigma and create access to mental health services for everyone. Everybody knows there’s a huge shortage of psychiatrists. There’s a problem with reimbursement; it’s kind of lop-sided. The value system monetarily is really placed on the interventional parts of medicine and less on the cognitive parts. One of the concerns that doctors have is that there’s questions in the licensing application that ask if you’ve ever seen a psychiatrist or if you’ve ever been treated for major depression. But they don’t ask if you’ve ever been treated for hypertension, for example. The Federation of State Medical Boards has come out, due to the efforts of one of its recent presidents, with a template of what a licensure application should look like that won’t discriminate. The same problem happens with credentialing for hospital privileges. So if the licensure community starts to become less discriminatory, that’ll eventually help in the credentialing world. Those are very concrete changes that’ll help reduce stigma. But there’s two big issues. There’s stigma and there’s access. We need to make sure there’s healthcare programs that provide appropriate access to mental health services. Many mental health practitioners deliver great services but you really need to get a comprehensive evaluation in the first place to see what’s necessary. Is there a final message that you’d like to convey? The point of [the JAMA Psychiatry] piece was to really make sure that depression didn’t get lost in the burnout discussion. And I’m a psychiatrist so I really care about that. The solutions aren’t going to be easy. The default seems to be to go to the individual but we’ve got to look at the system. And I think the question—How do we take care of ourselves while we’re taking care of our patients?—is really important. With Gloria Arminio Berlinski, MS Source
