Do fears of mental health-seeking among medical professionals begin when they are receiving their advanced degrees? What are the factors that promote these fears, and what can be done to remove or at least lessen them?
Until recently, self-care has not been taught as a core skill in medical and nursing rubrics. That, plus the fact that those who are drawn to medicine typically do not tend to put themselves first, has combined to perpetuate a culture where preserving one’s mental health is not emphasized in academic medicine, according to Chris Wojnar, MSN, RN.
“What’s missed in nursing schools is that they don’t teach how to cope with the stress and trauma that they’ll see,” says Wojnar. “But it’s a missed opportunity to offer coping skills and teach how to apply them in some of the more difficult situations that all frontline healthcare workers are bound to face.” Wojnar is currently transitioning from critical care into psychiatric nursing at Aurora Health system in Milwaukee, Wisconsin.
A study by Chen et al., (2023) in the Journal of Nursing Education, found that while resilience training improved mental health, self-confidence, awareness of personal resilience levels, and professional relationships in nurses, there remains no standard definition nor gold standard for resilience training in nursing schools.
Similarly, in medical school, the ethos of helping patients no matter the personal sacrifice is reinforced by the Hippocratic Oath’s mandate to “do no harm” that all medical students must pledge to uphold, but is not counterbalanced with an emphasis on one’s own mental health hygiene.
“We are far from where mental health and other kinds of self care are part of the standard curriculum,” says Lorenzo Norris, MD, Chief Wellness Officer at the George Washington University School of Medicine in Washington, DC, where he is also the associate dean of student affairs and administration. “Many schools have some programs, but there is not a uniform, rigorous approach.”
Values Gap
If self-care is not taught, there is the risk of a correlative understanding that it isn’t valued, according to Wojnar, who warns this values gap can lead to negative downstream effects such as the higher suicide rates among medical workers compared with most other professions, as we’ve explored in previous posts in this series.
“The silence about the bigger picture, the bad things that can happen such as workplace violence, or losing a patient, they add up,” Wojnar says. “But if nurses aren’t taught that it’s okay to voice their concerns about how these traumatic events impact us, we’re more likely to just suffer in silence.”
Culture of fear
This acculturation to suffering in silence is reinforced as new medical professionals move up the ladder. A survey by Smith and Jones (2023) in the Advances in Physiology Education found that many medical students and residents felt pressured to hide their mental health issues when applying for positions to avoid being perceived as weak or unprofessional. As we previously reported, there is also a danger that in coming forward with mental health concerns, a nurse or physician risks being penalized by licensing authorities.
“Medical boards are set up to protect patients, not doctors, and rightly so, but when you add the fear of losing a medical license, the culture of the medicine, and the education that is founded on the Hippocratic Oath, then removing the stigma around mental health becomes complicated,” Norris says.
It’s not that advocating for self care isn’t valued, says Norris, but it’s lower on the list of priorities than ensuring that the crushing debt and dedication that has gone into getting a medical degree results in employment and validating one’s identity.
“You feel trapped by up to $300,000 in debt, plus the fact that after the rigors of residency and maybe even a fellowship that comes at the end of at least eight years of training. It means that on average, you’re in your early thirties before you even get started in your career,” Norris says. “After all that, your identity is what you’ve spent all this time doing, and it’s fair to say that part of that identity is that you are a person who suffers in silence because you've been tough enough to make it through all that.”
Omission of important details
Why don’t nursing and medical schools prioritize self care and preparedness for the impact on their mental health that the profession will have?
Norris says full disclosure about the tricky road ahead before students enter the arduous trek toward becoming a physician would help prevent those who might be unduly stressed by the load, but who would feel too trapped by the debt to back out, from entering the field in the first place.
“I don’t think I would call it a culture of silence per se, but there are a lot of misconceptions about the lifestyle of being a physician,” Norris says, “Informing anyone going into any of the health professions about what they face can be eye-opening.”
For example, federal data show that healthcare workers are five times more likely to experience workplace violence than any other U.S. profession, and that from 2011 to 2018, the rate of injuries from violent attacks against medical professionals increased by 63%.
Among the many other risks is that for suicide, which also is among the highest per U.S. professions. In nurses, death by suicide occurs in 23.8 per 100,000 vs 20.1 per 100,000 in the general population (Davis, et al., JAMA Psychiatry, 2021), and for physicians, the rate is 40% higher than in the general population for male doctors, and 130% higher in female physicians than in the general public (Olfson et al., JAMA, 2023).
There is also risk from infection, and from musculoskeletal injuries from moving patients or heavy equipment.
For Wojnar, the reality is that it might come down simply to a matter of public relations: “I don’t know if there is a fear that if nursing students actually knew how bad it can get, they wouldn’t want to continue on. If they wanted you to know, I think they would teach you these things.”
Factors for change
Norris believes that culture change is already occurring as younger generations of physicians and other healthcare workers enter the profession. “Millennials and post-Millennials are looking at the data. And that data will take you aback. These generations have very different expectations than previous generations. The key is that the younger generations are more disruptive than older ones. Until recently, doctors were not willing to make waves.”
Such developments are making a review of what constitutes the elements of medical professionalism possible, according to Norris. “We should be clear with students about what they are getting into. We should be compassionate about mental health concerns being a medical condition that needs treatment. We should also help doctors learn to be a patient, not just be invulnerable. And, we should emphasize lifestyle as medicine, including self care.”
[[“You feel trapped by up to $300,000 in debt, plus the fact that after the rigors of residency and maybe even a fellowship that comes at the end of at least eight years of training. It means that on average, you’re in your early thirties before you even get started in your career,” Norris says. “After all that, your identity is what you’ve spent all this time doing, and it’s fair to say that part of that identity is that you are a person who suffers in silence because you've been tough enough to make it through all that.” (See Table.)]]
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How Much is Medical School? The Price of the White Coat | The Princeton Review