When doctors become patients: Med schools put new emphasis on mental health for residents

It's one of the first days of residency at the University of Minnesota and the new medical residents are sitting around tables in a big room in the university alumni center. Dr. Kaz Nelson, a professor of psychiatry, takes the stage. She's here to talk about mental health and suicide. But the patients she's talking about are the doctors themselves.

"I remember a time when I was worried about the health and safety of a colleague in medicine," she said, starting a prompt for the doctors to complete.

Nelson went on to talk about hearing that a recently graduated medical student had killed herself. Then she asked the new doctors to discuss their own examples of concern over the well-being of a colleague.

It's part of an effort by the university to bring mental health into the foreground. Every year, between 300 and 400 doctors kill themselves — about one a day. That's about twice the rate of the general population and the highest of any profession. Doctors also have high rates of burnout, depression and substance use.

Medicine is a demanding business. But the culture of medicine also contributes to the problem.

"We're really conditioned to appear competent and confident and professional," Nelson said. "And that's the face we want to represent to our public and the community we serve ... the people evaluating us. So we've essentially set up a system where perfectionism is rewarded and struggle can be punished at different times."

Patients wouldn't want to go to a doctor who doesn't seem to know what she's doing and doctors know that, so there's tremendous pressure not to acknowledge difficulties.

And "that's why it's imperative that we're proactive in saying, of course, people are going to struggle, of course this is tough work," Nelson said.

Mike Rose, a first-year resident in internal medicine and pediatrics at Johns Hopkins in Baltimore, knows just how important that message is.

He was in his second year of medical school when he developed depression. He had studied the symptoms of depression in medical school and would have recognized them easily in a patient. But he said a combination of factors — the culture of medical school, his upbringing in a farm town in North Dakota, his lifelong love of playing competitive sports — made it especially hard for him to acknowledge his condition.

Rose isn't shy about talking about his own mental health issues — he even wrote about them in the New England Journal of Medicine. And he was invited to address the new medical students last year. But even he feels ambivalent about getting help.

"I recently increased the dose of my medication with my doctor, and, you know, felt like that was like this failure, this set back, doing something wrong," he said. "But these are things we do in clinic every day."

Kaz Nelson's meeting for new residents is designed to reduce the stigma. It's also meant to let the new residents know about the help that is available to them. The residency program has contracted for confidential counseling services for residents. They've even talked to the local emergency room to ask that they treat residents with discretion if they come in.

These are an extension of services the university is now offering medical students. Those include a psychologist on site who is available to the students at no cost, with no questions asked. And they've changed the schedule for third- and fourth-year students so they have regular time off during the week, which gives them time to see a therapist, or just do laundry.

Rose said if this approach — and especially the openness with which mental health is being discussed — had been in place at the time, he might have been encouraged to seek treatment earlier.

A number of other schools and residency programs have been putting similar programs into place. The University of South Carolina has a Wellness Medical Director for residents and fellows. Northwestern University has a liaison who can give residents confidential guidance on mental health concerns. And Rose said Johns Hopkins emailed him weeks before he got there to connect him to somebody who can help with getting prescriptions, and another to talk about connecting with a therapist.

Carol Bernstein, a psychiatry professor and former president of the American Psychiatric Association, applauds such moves, but said more is needed to support doctors who encounter mental health problems. A lot of state licensing boards, for example, ask if a doctor has ever sought mental health care. "'Have you ever seen a psychiatrist? Have you ever been treated for major depression?'" she said, calling them intrusive questions that discourage doctors from seeking mental health care.

Licensing boards don't ask questions about physical health care, on the other hand, "They don't say 'have you ever seen an orthopedist? Have you ever seen a primary care physician?'"

Bernstein said the umbrella organization for state physician licensing boards is starting to push for change on that front, to prevent discrimination based on mental health status. And she's glad that medical schools and residency programs are making it a point to address these issues. But she's still worried about the profession as a whole.

"There's a lot of effort to protect and get access for medical students and residents," she said. "Unfortunately this doesn't extend to people practicing medicine."

This reporting is part of Call to Mind, our MPR initiative to foster new conversations about mental health.

If you are a medical student or doctor who has experienced mental health issues, we'd like to hear from you. Email Alisa Roth with your thoughts and stories.