A career in medicine can be a long and lonely road. The 2024 MedScape annual Physician Burnout & Depression Report reported 49% of 9,226 U.S. physicians surveyed were burned out, and 20% were depressed. The suicide rate amongst doctors is 40% higher than the general population for men, and 130% higher for women (Kallie et al. Physician Suicide: A Call to Action. Mo Med 2019 116(3)(2019), pp.211-216). According to the ACGME, 28% of residents experience a major depressive episode during training, and 23% of interns have suicidal thoughts (acgme.org: 10 facts about physician suicide and mental health). These numbers are alarming and unacceptable. If we can start to understand the contributing factors, and intervene for ourselves and others at earlier points on the journey to overwhelm, we can start to make a difference.
One of the overwhelming aspects of the culture of medicine is that of competition. It starts early. Individuals start working on distinguishing themselves from their fellow students in high school or even earlier. College is consumed with getting the grades and building the CV required to be accepted into medical school. Medical school is enough to manage on its own, but in order to match in certain specialties or locations, one must be a standout again in terms of grades and CV. This is in a playing field of all smart, high-performing individuals. Residency continues with competitive angling for teaching awards, exam scores, preparation for boards, and applying for fellowships or desirable jobs. One might think that after training, the competition would abate, but it really doesn’t. Physicians must compete for excellent online reviews and ratings, for surgical numbers, and even compensation. Phew.
There are pros to being competitive, and let’s face it, if you are a physician, you are competitive. You likely are a high performing person in other areas of life as well. The acts of competing and winning release dopamine which gives one pleasure and satisfaction. This is a motivator for continued competition. Winning feels great. A sense of competition can give a quick surge in performance. The downsides of chronic competition outweigh its benefits, however. Chronic competition contributes to a hostile and stressful work environment. It decreases efficiency, and over time even decreases an individual’s intrinsic motivation. It chips away at trust and is a barrier to close working relationships. (Carr et al. Cues of working together fuel intrinsic motivation. Journal of Experimental Social Psychology 53 (2014), pp 169-184).
A second pervasive expectation in the culture of American medicine is that of rugged self-reliance. Inability to academically, physically, or emotionally handle the rigors of training completely independently has historically been seen as weakness. Vulnerability was weakness. Asking for help was not something that doctors did. Self-motivation, self-reliance, self-confidence, and self-sacrifice to any degree was rewarded.
Trainees and physicians early in their career often experience imposter syndrome. Wikipedia defines impostor syndrome as: “A psychological occurrence in which one may doubt their skills, talents, or accomplishments. He or she may have persistent fears of being exposed as a fraud. Despite external evidence of competence, those experiencing this phenomenon do not believe they deserve their success or luck. They may think that they are deceiving others because they feel as if they are not as intelligent as they outwardly portray themselves to be.”
A 2022 Mayo Clinic Proceedings study found that 36% of physicians studied had imposter phenomenon scores in the moderate range, 17% in the frequent range, and 6% in the intense range. “Although physicians are compassionate with others, they often hold themselves to unrealistic expectations and are perfectionistic and self-critical,” said Tait Shanafelt MD, the study’s first author. “A number of professional norms and aspects of the culture of medicine also suggest that physicians should be impervious to normal human limitations. This combination of these professional norms and a highly accomplished peer group can lead to feelings of inadequacy that also contribute to the imposter syndrome.” (AMA: Feel like an imposter physician? It won’t stop when residency’s over; Shanafelt et al. Imposter Phenomenon in US Physicians Relative to the US Working Population. Mayo Clinic Proceedings 97:11 (2022) pp. 1981-1993).
This combination of the culture of competition, expectations of self-reliance and self-sacrifice, and the experience of crippling imposter syndrome leads to intense insecurity, isolation, burnout, and depression. There are great benefits to being moderately competitive, self-reliant, and having the humility to recognize you always have more to learn and ways to improve. What we are talking about here, however, is the increasing loneliness of feeling unable to trust your colleagues, the pressure of feeling you must do everything alone, and the deep shame and fear associated with feeling like you don’t deserve to be in the position you’re in. It is a toxic and isolating mix.
So what can be done? First, talk about it. Many physicians are doing excellent work studying physician burnout and mental health. They are publishing papers, presenting at meetings, and initiating conversations. Many organizations are starting to recognize and validate the problem. By studying it, talking about it, educating our peers, our family members, and our trainees, we may be able to prevent the deep spiral that so many of our colleagues and predecessors experienced in isolation. We must value and reward collaboration, offer help, ask for help, accept help, and recognize our shared humanity. We must connect.
Think of every possible thing you could ask for help with. Lose any guilt, ego, or shame. Accept help when offered. Many times we turn down available help out of pride. Foster a sense of collaboration with your colleagues. Do not perpetuate the culture of fierce competition. Find a coach or therapist. The ACGME reports suicidal ideation among trainees was reduced by 50% after only four sessions of cognitive behavioral therapy. Make it fun. Find the humor. Make like Beyonce and Adele and develop an alter ego who is confident, resilient, and not afraid to ask questions or speak up. And if you suspect a colleague or loved one is struggling, reach out to him or her. Once someone starts to sink into isolation and depression, reaching out for help isn’t always possible. Provide only grace, patience, and support.
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