This article originally appeared in the Journal of Louisiana State Medical Society Vol. 171 No.3.
Physician burnout, depression, and more specifically, physician suicide, is an alarming reality of ‘modern’ medicine. A high rate of physician suicides has been reported going back to 1858.1 In more recent years, statistics have remained grimly unchanged: approximately 400 physicians in the U.S., more than one per day, die by suicide each year.2 The disease of physician suicide starts early: after accidents, suicide is the most common cause of death of medical students.2 More than 27 percent of 100,000 medical students questioned in a 2016 study experienced symptoms consistent with diagnostic criteria for depression, and 11 percent had experienced suicidal thoughts, yet only 15 percent actively sought mental health treatment.3 Another survey of 2,100 female physicians revealed that, since starting med school, 33 percent had been diagnosed with mental health conditions, and most of those self-prescribed rather than sought formal treatment.4
Self-medicating with substances abounds; approximately 10 to 15 percent of physicians have substance use disorders, in contrast to roughly nine percent of the general public.3 Compounding the self-treatment issue is that one in three physicians do not have even a basic therapeutic relationship with a primary care provider,2 and self-treatment profoundly displaces referral to appropriate mental health care.2 Alarmingly, physicians who die by suicide are 20 to 40 times more likely to have ingested benzodiazepines, barbiturates and antipsychotics than non-physician individuals.4 It is not surprising, then, that doctors who attempt suicide have a significantly higher completion rate relative to the general population.2
Most of us will have a moment of cynical thinking occasionally, and in this context, cynicism is an adaptation to the day-to-day frustrations of practicing medicine. Cynicism becomes toxic, however, when generalized to most circumstances for an extended period of time. Approximately half of all physician providers experience cynicism (as well as exhaustion).5 Burnout may contribute to medical errors. Perhaps more significantly, physician burnout “ … appears to be equally, if not more, important than the [scores on workplace safety measurements] to the risk of medical errors occurring.”5 Additionally, both medical errors and burnout, independent of each other, increase the risk of provider suicidal ideation two-fold.6
Globally speaking, burnout and cynicism develop gradually, often insidiously changing how we react emotionally, professionally and personally; there is a cumulative trauma from the repetitive loss of patients, best expressed as ‘a piece of my soul just died.’1 Cynical attitudes aren’t just for seasoned providers, either. In addition to practicing physician providers, medical students and residents have demonstrated a progressive negativity over the course of their medical training.7, 8 As cynical thinking takes hold, providers become detached and harbor negative attitudes toward patients (and peers), lose investment in the healthcare profession, and subsequently, lose out on meaningful interactions and information critical to sound medical decision-making.9
With so many indications of cynicism in the medical environment, is there hope? Thankfully, the culture of change is reaching the once-neglected arena of provider wellness and satisfaction. Both professional medical organizations and individual medical systems are proactively addressing the issue, and with satisfying results. Additionally, there have been increased efforts between major medical associations and the Federation of State Physician Health Programs to address barriers to care for physicians, including steps to assure confidentiality as well as to clarify and delineate boundaries between medical licensing boards and the respective state-run physician health entities.2
At an individual level, we must also allow ourselves the benefit of being human, recognizing that cynicism can develop from a place of vulnerability10 made ever more acute by the exaggerated sense of responsibility integral to identity as physicians.4
What can the physician do to combat cynicism and burnout?
Put your well-being at the top of your to-do list. Establish a therapeutic relationship with a primary care provider. One in three physicians do not have this type of relationship.
If you see yourself in this article, acknowledge that the problem exists. Ask for help and follow through with it. This is a sign of strength, not weakness. Your well-being depends on it. Do it. NOW.
1. Wible, P. What I’ve learned from my tally of 757 doctor suicides. https://www.washingtonpost.com/national/health-science/what-ive-learned-from-my-tally-of-757-doctor-suicides/2018/01/12/b0ea9126-eb50-11e7-9f92-10a2203f6c8d_story.html?utm_term=.53d56fec9030. January 13, 2018.
2. Andrew, LB. Physician Suicide. https://emedicine.medscape.com/article/806779-overview. August 1, 2018.
3. Hoffman, M, Kunzmann, K. Suffering in silence: the scourge of physician suicide. https://www.mdmag.com/medical-news/suffering-in-silence-the-scourge-of-physician-suicide. February 5, 2018.
4. Collier, R. Physician suicide too often “brushed under the rug.” http://www.cmaj.ca/content/189/39/E1240. October 2, 2017. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5628041/
5. Meszaros, L. Physician burnout triples the incidence of medical errors. Featured Articles in Internal Medicine. www.mdlinx.com/internal medicine/featured articles/. September 06, 2018.
6. White, T. Medical errors may stem more from physician burnout than unsafe health care settings. https://med.stanford.edu/news/all-news/2018/07/medical-errors-may-stem-more-from-physician-burnout.html. July 8, 2018.
7. Batley NJ, Nasreddine Z, Chami A, Zebian D, Bachir R, Abbas HA. Cynicism and other attitudes towards patients in an emergency department in a middle eastern tertiary care center. https://bmcmededuc.biomedcentral.com/articles/10.1186/s12909-016-0539-y. January 29, 2016. https://www.ncbi.nlm.nih.gov/pubmed/26823070
8. Peng, J; Clarkin C; Doja, A. Uncovering cynicism in medical training: a qualitative analysis of medical online discussion forums. https://bmjopen.bmj.com/content/8/10/e022883. August 8, 2018. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6196850/.
9. Lyndon, A. Burnout among health professionals and its effect on patient safety. https://psnet.ahrq.gov/perspectives/perspective/190/burnout-among-health-professionals-and-its-effect-on-patient-safety. February 2016.
10. Firestone, L. Is cynicism ruining your life? The risks of indulging in cynical attitudes and the rewards of being positive. https://www.psychologytoday.com/us/blog/compassion-matters/201212/is-cynicism-ruining-your-life. December 3, 2012.