When the greatest-of-all-time gymnast Simone Biles withdrew from the Olympics to focus on her mental wellbeing, most observers applauded her decision, viewing it as an act of courage and bravery, an eye-opener for breaking the stigma around mental health. Many felt it was a positive step (no pun intended) because it reignited conversations about elite athletes and other high-stress professionals and their ability to perform under psychological adversity. However, does the enlightened understanding accorded athletes extend to doctors? If Simone Biles were a physician, would she be embraced or shunned by the medical community?
Make no doubt about it, the practice of medicine is one the most stressful jobs around. Approximately one doctor completes suicide each day in the United States – and this was before the pandemic. The stress of practicing medicine has also filtered down to trainees – medical students and physician residents. One study estimated the prevalence of depression or depressive symptoms among medical students was 27.2% and that of suicidal ideation was 11.1%. Among residents, the data were similar: the prevalence of depression or depressive symptoms was 28.8%. By comparison, the CDC reports an 8.1 percent prevalence of depression in adults over 20 years old.
Despite the intense pressure of medical practice, the culture of medicine does not appear to be as forgiving as the world of sports. If one goes straight to the source – first-hand accounts of physicians and trainees who have suffered mental illnesses – the reaction of the medical establishment has at times been downright cruel, beginning with the medical education of students who were never taught to choose themselves over their patients or classmates. Paraphrasing a tweet from Today! host Hoda Kotb, can you imagine a medical school dean or strong-willed department head tweeting: “Doctor, you’ve already won, because you were accepted into medical school. You are a class act. You withdrew from the operation because you didn’t trust yourself … stayed and cheered your fellow surgeons … made sure their instruments were sterilized … encouraged … hugged them.” Explain to me again how this would be considered an act of bravery?
Here is one explanation from a medical student with a history of chronic depression. She wrote, “The downside to living with depression for almost two decades is that I have learned to succeed in spite of it by putting my health last. But in medical school, we are rewarded for this behavior. We are expected to prioritize school to succeed, spending long hours in classes, anatomy lab, or the hospital — leaving minimal time to study, let alone rest, eat or seek joy.” The medical student went on to say: “I often wonder, how many students like me reach out just to be shut down? Just as [tennis star] Naomi Osaka experienced with her self-disclosure [of depression], medical students who seek help put themselves at risk of penalty and negative career effects. No one should be punished for protecting their health, particularly in health care.”
Given this perspective, it is reasonable to ask: riding the wave of the Naomi Osaka and Simone Biles effect—the phenomenon of athletes choosing their well-being over rules and schedules that may not serve them – will the onerous aspects of the practice of medicine change? Can self-preservation trump outdated traditions that medical students and residents should suffer in order to instill character in them? A good first start is to dispel such antiquated thinking and make the issue public. I’ve been encouraged by the many medical practitioners who have recently opened up about their struggles with mental illness and substance use and have documented their experience in medical journals and social media outlets.
For example, I read about a psychiatric resident who was hospitalized at age 16 after she made a suicide attempt by overdose. The resident remained silent about her history all through medical school and while interviewing for residency positions. Medical school did not provide a nurturing environment. In fact, she witnessed clinicians make disparaging or dubious comments about psychiatric patients and suicidal thinking. The resident became convinced that she must lead by example and overcome the fear of what a confession might do to her career, as well as the fear of being perceived as somehow incapable of providing quality care. “If physicians step forward to tell their personal experiences with mental illness to an audience of colleagues willing to listen empathetically,” the resident commented, “we can make progress on the arduous task of destigmatizing mental health.” Indeed, once treated, unwell physicians have the capacity to provide quality treatment.
I also read a story about a physician (a psychiatrist) who overcame crippling psychiatric demons but was plagued by the shame and discomfort of a psychiatric diagnosis. He feared being judged negatively by his patients, lest his psychiatric history became known. “Who wants a doctor with a history of cerebral hiccups,” the psychiatrist remarked, apparently yet to overcome the stigma of his own mental health diagnosis. It’s difficult to imagine a groundswell of support for physicians even if they have recovered from their illness unless and until they come to terms with it themselves.
Just as Simone Biles has her detractors, there will always be physicians unable to empathize with their mentally ill colleagues, believing psychological struggles are a constant state of being human. But if taking care of oneself means temporarily leaving the workforce to receive professional treatment, then so be it. Physicians are beginning to feel empowered to protect themselves. Their acts of self-care can be seen as the first step in protecting and preserving mental health. Being mentally tough for practicing medicine is no different than being mentally tough for competing for a gold medal. In either case, it does not mean sacrificing your sanity. It’s time medical schools and institutions were on board with this notion.
Arthur Lazarus is a psychiatrist.
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