Physicians, Residents, Medical Students: Burnout Syndrome, Depression and Suicide Rakesh Patel, MD, MBA, FACPAssistant ProfessorEast Tennessee State University

Goals and Objectives

• Learn to recognize burnout syndrome, depression, and suicidality in yourselves and educate medical students and residents to do so as well.

• Better identify those physicians at high risk of suicide.

• Conclude the need to establish regular source of health care and seek help for mood disorders, substance abuse, and/or suicidality.

Lets First Talk About…

BURNOUT SYNDROME

Burnout Syndrome: What is it?Maslach Burnout Inventory measures 3 main areas:

• Emotional Exhaustion** measures feelings of being emotionally overextended and exhausted by one's work. Exhaustion is a depletion of emotional energy, distinct from physical exhaustion or mental fatigue. Emotional Exhaustion is a clear signal of distress in emotionally demanding work.

• Cynicism or Depersonalization measures an unfeeling and impersonal response toward recipients of one's service, care treatment, or instruction. The depersonalization measured by this scale is a problem in careers that value and mandate personal sensitivity to service recipients.

• Professional Efficacy/Accomplishment measures feelings of competence and successful achievement in one's work. This sense of personal accomplishment emphasizes effectiveness and success in having a beneficial impact on people.

Source: Maslach Burnout Inventory. The leading measure of burnout. Christina Maslach, Susan E. Jackson, Michael P. Leiter, Wilmar B. Schaufeli, & Richard L. Schwab

The Questions on the Inventory1) I feel emotionally drained from my work 2) I feel used up at the end of the day 3) I feel tired when I get up in the morning and have to face another day at work4) I can easily understand how clients feel about things 5) I feel I treat some clients as if they were impersonal objects. 6) Working with people all day is a real strain for me 7) I deal effectively with the problems of clients 8) I feel burned out from my work 9) I feel I am positively influencing other peoples' lives through my work 10) I have become more callous toward people since I took this job 11) I worry that this job is hardening me emotionally 12) I feel very energetic 13) I feel frustrated by my job 14) I feel I am working too hard on my job 15) I don't really care what happens to some clients 16) Working with people directly puts too much stress on me 17) I can easily create a relaxed atmosphere with clients 18) I feel exhilarated after working closely with clients 19) I have accomplished many worthwhile things in this job 20) I feel like I am at the end of my tether 21) In my work, I deal with emotional problems very calmly 22) I feel clients blame me for some of their problems

Study done in June 2011 by Mayo Clinic and American

Medical Association reported that nearly 1 in 2 U.S. physicians report at least one symptom of

burnout.

Source: “Burnout and Satisfaction With Work-Life Balance Among U.S. Physicians Relative to the General U.S. Population,” Archives of Internal Medicine, Aug. 20, 2012

Burnouts among doctors

•HIGH Job Stress and LOW Personal Autonomy leads to higher chances of BURNOUT!

• Increase prevalence among medical students, residents, and physicians.

Burnout Rates by Specialties

Source: “Burnout and Satisfaction With Work-Life Balance Among U.S. Physicians Relative to the General U.S. Population,” Archives of Internal Medicine, Aug. 20, 2012

Please Answer This!

“My Work Schedule Leaves Me Enough Time For My Personal/Family Life”

A. Strongly AgreeB. AgreeC. NeutralD. DisagreeE. Strongly Disagree

Satisfaction with Work-Life Balance by Specialty

Source: “Burnout and Satisfaction With Work-Life Balance Among U.S. Physicians Relative to the General U.S. Population,” Archives of Internal Medicine, Aug. 20, 2012

Does Physician Compensation Make a Difference on Satisfaction?

Medscape Physician Compensation Report: 2012 Results

Burnout: Residents• In residents studies showed an average rates of burnout as high as 41-90%• The burnout levels increase quickly within the first few months of residency• Interestingly, ACGME changes to work hour duties for residents have

showed decreased burnout rates moderately but…• In a study in published in 2005* noted:

• 13% fewer residents experienced high emotional exhaustion• There was a trend toward fewer residents with high depersonalization (61% vs

55%; P = .13)• Fewer residents with a positive depression screen (51% vs 41%; P = .11).• Personal accomplishment did not change.• The assessment of self-reported quality of care did not significantly change from

2003 to 2004. • Residents reported attending fewer educational conferences per month (18.99 vs

15.56; P = .01). • Overall residency satisfaction decreased 6 mm on a 100-mm visual analogue score

(P = .02).* Gopal R, Glasheen JJ, Miyoshi TJ, Prochazka AV. Burnout and internal medicine resident work-hour restrictions. Arch Intern Med. 2005 Dec 12-26;165(22):2595-600.

Before and After ACGME Work Hour Restrictions

Percentage of residents with high Maslach Burnout Inventory subscale scores by year. DP indicates depersonalization; EE, emotional exhaustion; and PA, personal accomplishment. Error bars indicate 95% confidence intervals

Studies examining burnout among residents

Source: JAMA. 2004;292(23):2880-2889. doi:10.1001/jama.292.23.2880

What is a balanced life? Is this you?

Imbalanced: Physicians and Residents Life

WorkHealthPersonalHouseholdRecreationSpiritualExerciseFriendsFamilyPartner

Does Burnout Lead to Depression or Is It The Other Way Around?• Actually it can go both ways.

• Lets look at in terms of the Conservation of Resources (COR) theory which is based on the presence of downward spirals.• Deficiency of resources in one area, which leads to the

exhaustion of resources in other areas. • Depression Lack of energy Accelerated job burnout

OR• Overburdened at work Physical and mental exhaustion

Accelerate symptoms of depression

Decreasing Burnout• Notice self burnout and realistic recognition• Exercise: A study* show that Physical Exercise DOES decrease

burnout and depression.• Supportive help and talking with others about issues and

stressors• Professional resources• Forming firm Boundaries so to avoid increased stress and

problems• Using Humor and Laughter• Finding Non-Medical Hobbies• Working in various clinical settings or changing up clinical

duties periodically

* Source: Toker, S., & Biron, M. (2012, January 9). Job Burnout and Depression: Unraveling Their Temporal Relationship and Considering the Role of Physical Activity. Journal of Applied Psychology.

Now Lets Talk About…

DEPRESSION AND SUICIDEIN

PHYSICIANSRESIDENTS

MEDICAL STUDENTS

Depression and Suicide Among Us

Some Questions you may be thinking of.1. What are the Overall professions with the highest to lowest

rate of depression.

2. Why do physicians have higher rates of depression than the general population?

3. Which physicians specialty has the highest suicide rate? Others?

4. How do most physicians commit suicide?

5. Which gender of physicians has the higher suicide rate?

Depression Among Professionals

1. Nursing Home Employees and Childcare Providers2. Food Service3. Social Worker4. Doctors and Nurses5. Artist6. Teachers7. Secretaries and Administrative Support8. Maintenance Workers9. Financial Advisors10. Lawyers

Source: Health Magazine. Information compiled from a October 2007 report by the Office of Applied Studies, Substance Abuse and Mental Health Services Administration (SAMHSA), an agency within the U.S. Department of Health and Human Services.

Video

http://www.doctorswithdepression.org/

American Foundation for Suicide Prevention Physician Depression and Suicide Prevention Project. American Foundation for Suicide Prevention.

What is Depression?• Common symptoms of depression:

• Lost of interest in the things that were previously pleasurable• Depressed and Sadness• Hopelessness

• Other may Include:• Anxiety• Increased feeling of guilt• Irritability• Impatience• Sleep disturbances• Tearfulness• Difficulty concentrating• Appetite changes (loss/gain)• Increased Isolation• Somatic Pain • Substance abuse

What is Major Depression?Per DSM-IV, at least 5 of the following symptoms and the symptoms cause distress or impairment in social, occupational, or other important functioning

1. * Depressed mood

2. * Decreased interest or pleasure in activities

3. Significant variations in weight or appetite.

4. Insomnia or Hypersomnia.

5. Psychomotor agitation or retardation.

6. Daily fatigue or energy loss.

7. Feelings of worthlessness or guilt.

8. Difficulties in concentration or decisiveness.

9. Recurrent thoughts of death or suicidal ideation, plan, or attempt.

* One of these symptoms must be present

Depression in General• Estimated 19 Million Americans Suffer from Depression

• Women suffer from depression twice as much as men. • Regardless of racial and ethnic background or economic status.

• Depression in people 65 and older increases the risk of stroke and other medical complications.

• The economic cost of depressive illnesses is $30 million to $44 billion a year.

Depression in General, cont• More Americans (24 million) suffer from depression than

coronary heart disease (17 million), cancer (12 million), and HIV/AIDS (1 million).

• Even though effective treatments are available, only one in three depressed people gets help.

• Although most depressed people are not suicidal, two-thirds of those who die by suicide suffer from a depressive illness.

• About 15 percent of the population will suffer from depression at some time during their life. Thirty percent of all depressed inpatients attempt suicide.

Depression in Our Profession• Depression is as common among the medical profession as the

general population• Males: 12%• Females: 18%

• However depression is more common in medical students and residents• Estimated at 15-30% (screen positive)

• Preliminary study found that residents who experienced depression may be as much as 6 times more likely than nonaffected controls to make medication errors. Other studies have confirmed the association of depression with self-perceived medication and other errors.

Shaw DL, Wedding D, Zeldow PB. Suicide among medical students and physicians, special problems of medical students. In: Wedding D, ed. Behavior and Medicine. 3rd ed. Hogrefe and Huber: 2001:78-9 (chap 6).Fahrenkopf AM, Sectish TC, Barger LK, et al. Rates of medication errors among depressed and burnt out residents: prospective cohort study. BMJ. Mar 1 2008;336(7642):488-91.West CP, Tan AD, Habermann TM, Sloan JA, Shanafelt TD. Association of resident fatigue and distress with perceived medical errors. JAMA. Sep 23 2009;302(12):1294-300.

Depression in Physicians• Again: Higher rates in medical students (15 – 30%) and Higher

rates in interns and residents (30%) Higher than the General Population.

• Lifetime rates of depression in women physicians were 39% compared to 30% in age matched women with PhD’s Higher than the General Population.

• Lifetime rates of depression in male physicians (13%) may be similar to rates of depression in men in the general population, or they may be slightly elevated. Concerns of underestimating the prevalence secondary to limited self reporting

Welneret al., Arch Gen Psych, 1979; Clayton et al., J Ad Dis, 1980; Frank & Dingle, Am J Psych, 1999Wieclawet al., OccupEnviron Med, 2006; Center et al., JAMA, 2003; Valko& Clayton, Am J Psych, 1975 Kirsling& Kochar, PsycholRep, 1989

Let us now speak about…

SUICIDE

How about Suicide!!

It is estimated that on average 400 Physicians commit suicide a year in the United States!

Suicide In General• The latest data available from the

Centers for Disease Control and Prevention indicates that 38,364 suicide deaths were reported in the U.S. in 2010.

• This latest rise places suicide again as the 10th leading cause of death in the U.S.

• Nationally, the suicide rate increased 3.9 percent over 2009 to equal approximately 12.4 suicides per 100,000 people. The rate of suicide has been increasing since 2000. This is the highest rate of suicide in 15 years.

Suicide in General

Most recent figures from the Centers for Disease Control for the year 2010. All rates are per 100,000 population.

Suicide in General• Every 13.7 minutes someone in the United States dies by suicide.

• Nearly 1,000,000 people make a suicide attempt every year.

• 90% of people who die by suicide have a diagnosable and treatable psychiatric disorder at the time of their death.

• Most people with mental illness do not die by suicide.

Suicide in General, cont• Recent data puts yearly medical costs for suicide at nearly $100

million (2005).

• Men are nearly 4 times more likely to die by suicide than women. Women attempt suicide 3 times as often as men.

• Suicide rates are highest for people between the ages of 40 and 59.

• White individuals are most likely to die by suicide, followed by Native American peoples.

Physician Suicide• Positive:

• Physicians worldwide have a lower mortality risk from cancer and heart disease relative to the general population

• Physicians have decreased smoking and other common risk factors for early mortality

* Source: Gagné P, Moamai J, Bourget D. Psychopathology and suicide among Quebec physicians: a nested casecontrol study. Depress Res Treat. 2011;2011:936327.

Physician Suicide• Negative:

• Physicians are reluctant to address depression, a significant cause of morbidity and mortality that disproportionately affects them.

• Significantly higher risk of dying from suicide than the general population

• Among Medical Students: after accidents, suicide is the most common cause of death.

• To Note:• Suicide is usually a result of UNTREATED or INADEQUATELY

TREATED DEPRESSION, connected with knowledge of and access to lethal means*

* Source: Gagné P, Moamai J, Bourget D. Psychopathology and suicide among Quebec physicians: a nested casecontrol study. Depress Res Treat. 2011;2011:936327.

Physician Suicide• Physicians have a higher rate of completion than the general

population• 1.4 – 2.3 times higher

• Interestingly Female physicians attempt suicide less than Males BUT same completion rate as males• So they are more likely to complete a suicide making them 2.5 – 4

times more than the general population.*

* Sourcea: Frank E, Dingle AD. Self-reported depression and suicide attempts among U.S. women physicians. Am J Psychiatry. Dec 1999;156(12):1887-94.Schernhammer ES, Colditz GA. Suicide rates among physicians: a quantitative and gender assessment (meta-analysis). Am J Psychiatry. Dec 2004;161(12):2295-302

Physician Suicide, cont• Most common psychiatric diagnosis among those physicians that

complete suicide:• Depression and Bipolar Disorder• Alcoholism and other Substance Abuse

• Most common means of suicide by physicians• Medication Overdose and Firearms

* Sourcea: Frank E, Dingle AD. Self-reported depression and suicide attempts among U.S. women physicians. Am J Psychiatry. Dec 1999;156(12):1887-94.Schernhammer ES, Colditz GA. Suicide rates among physicians: a quantitative and gender assessment (meta-analysis). Am J Psychiatry. Dec 2004;161(12):2295-302

Per the American Foundation for Suicide Prevention: Depression and Suicide

• Each year in the U.S., roughly 300 to 400 physicians die by suicide.

• Physician deaths from smoking-related illnesses decreased 40 to 60 percent after targeted educational campaigns to reduce smoking among physicians. Suicide rates among physicians are not decreasing, presumably because little attention has been paid to this issue.

• Depression is a major risk factor in physician suicide. Other factors include bipolar disorder and alcohol and substance abuse.

Per the American Foundation for Suicide Prevention: Depression and Suicide, cont

• There is no evidence that work-related stressors are linked to elevated rates of suicide in physicians.

• Medical students have rates of depression 15 to 30 percent higher than the general population.

• Contributing to the higher suicide rate among physicians is their higher completion to attempt ratio, which may result from greater knowledge of lethality of drugs and easy access to means.

Per the American Foundation for Suicide Prevention: Gender Statistics

• In the U.S., suicide deaths are 250 to 400 percent higher among female physicians when compared to females in other professions.

• Among male physicians, death by suicide is 70 percent higher when compared to males in other professions.

• In the general population, males complete suicide four times more often then females.

• However, female physicians have a rate equal to male physicians.

• Women physicians have a higher rate of major depression than age-matched women with doctorate degrees.

Source: AFSP’s Physician Depression and Suicide Prevention Project was launched in 2002, with a conference in San Diego. A consensus statement was later drafted and published in the Journal of the American Medical Association in 2003.

Profile of Physicians at High Risk of Suicide

Silverman M (ed): Physicians and suicide, in The Handbook of Physician Health: Essential Guide to Understanding the Health Care Needs of Physicians. Edited by Goldman LS, Myers M, Dickstein LJ. Chicago, Il., American Medical Association, 2000

Center C, Davis M, Detre T, et al: Confronting depression and suicide in physicians: a consensus statement. JAMA 2003; 289:3161–3166

Why Us• Our own reluctance to recognize depression in our colleague

• Many stating, “I never had any idea that he or she was suffering from …”

• Our own reluctance to seek help (makes us look weak/unhealthy?)

• When depressed physicians do reach out they may find only limited sympathy from their own colleagues

Myers M, Gabbard G. The Physician as Patient: A Clinical Handbook for Mental Health Professionals. American Psychiatric Publishing; 2008.

Why Us, cont• Many clinicians are uncomfortable in treating fellow physicians in

general, especially for mental health issues. *

• Many times the first signs are physical /somatic complaints making depression harder to diagnosis.

• Marital problems, Litigation Issues are common precipitants of depression

Myers M, Gabbard G. The Physician as Patient: A Clinical Handbook for Mental Health Professionals. American Psychiatric Publishing; 2008.

Why Us, cont

Medical licensure applications and renewal applications:• frequently require answering questions regarding the

physician’s mental health history• may be out of compliance with the provisions of the

Americans with Disabilities Act (ADA).• Some states allow physicians enrolled in treatment to be

able to check “no” as long as compliant

Polfliet SR. A National Analysis of Medical Licensure Applications. J Am Acad Psychiatry Law. 2008;36:369- 74.Altchuler SI. Commentary: Granting medical licensure, honoring the Americans with disabilities act, and protecting the public: can we do all three?. Acad Med. Jun 2009;84(6):689-91.Schroeder R, Brazeau CM, Zackin F, Rovi S, Dickey J, Johnson MS, et al. Do state medical board applications violate the Americans With Disabilities Act?. Acad Med. Jun 2009;84(6):776-81.

How about Malpractice Insurers?

ANSWER THIS:Have you ever had an ILLNESS OR DISABILITY that impairs or could impair your ability to practice your profession. It is including but not limited to alcoholism, drug addiction, compulsive disorders, tremors, multiple sclerosis, or rheumatoid arthritis? If YES, the details required on a separate sheet must include the name and address of your treating physician.

How about Malpractice Insurers?

• Discrimination in obtaining insurance coverage is a common, but little publicized, problem for physicians with mental illness.

• Health, disability, and liability insurance may all be denied to a physician who admits to depression.

Louise B Andrew, MD, JD; Chief Editor: Barry E Brenner, MD, PhD, FACEP. Physician Suicide. Medscape. Updated: Mar 8, 2012

How about Malpractice Insurers?, cont

• Even if disability insurance has previously been procured, its use may subject physicians to repeated humiliating and invasive examinations by detached and dubious “independent medical examiners” for the insurer, whose motivation is to cut company losses.

• Many physicians affected by mental illness feel that insurers expect them to adhere to the standard prescription “physician, heal thyself.”

Louise B Andrew, MD, JD; Chief Editor: Barry E Brenner, MD, PhD, FACEP. Physician Suicide. Medscape. Updated: Mar 8, 2012

Where do Physicians go for help in Tennessee?Tennessee Medical Foundation's Physicians Health Program (PHP)• Professional assistance to physicians suffering chemical

dependence, mental or emotional illness, or both.

• The PHP’s purpose is to protect patients from identifiably impaired physicians and to afford impaired physicians every opportunity to be rehabilitated to productive medical practice.

Source: http://health.state.tn.us/boards/Me/complaints.htm

Where do Physicians go for help in Tennessee?, contTennessee Medical Foundation's Physicians Health Program (PHP)• Assist physicians and their families with a wider range of problems.

• rage issues, inability to get along with other group members, and various psychological issues that inhibit a physician’s ability to practice his or her healing arts.

• Success rate approaching 90 percent (ahead of the national par), the TMF-PHP intervenes with some 150-200 individual physicians, residents, and medical students across the state each year.

• The PHP has developed a highly successful, professionally managed program to help salvage the practices—and the lives—of impaired physicians.

Source: http://health.state.tn.us/boards/Me/complaints.htm

How Does the Physician’s Health Program Work?

• Identification• The Tennessee Medical Foundation (TMF) maintains a 24-hour phone line

for family members, patients, and co-workers to report, confidentially, their concerns about a physician.

• Verification• The TMF PHP medical director and / or case managers attempt to verify the

reported behavior. If the behavior is not verified, the process is halted or the information is held for further inquiry.

• Interview• If the need for help is substantiated, the physician is asked to make an

appointment for an interview with TMF PHP personnel. In exchange for support, the physician is invited to follow the recommendations of the PHP in seeking specified treatment at his or her own expense.

How Does the Physician’s Health Program Work?, cont

• Treatment• All treatment is carried out in approved hospitals and treatment facilities. The length of

treatment is based upon the physician's individual needs. Physicians affected by other emotional or behavioral conditions are treated with an initial evaluation and subsequently prescribed inpatient and / or intensive outpatient therapy.

• Re-Entry• Re-Entry into practice usually occurs within one or two weeks following treatment. During this

period, the PHP is often the physician’s strongest – and sometimes only- ally. The PHP medical director and case managers work in concert with the treatment center’s recommendations to establish contractual ground rules for re-entry into practice.

• Aftercare• Aftercare is a minimum five-year process. It is guided by an individualized contract, comprised of

recommendations of the PHP and the treatment facility.

• Family Support. Active and comprehensive program for family members, which at a minimum includes: • Families of newly identified physicians are provided opportunities to receive help through

support programs, sponsoring families, and professional therapist. • Caduceus Al-Anon groups are available. Meetings are held on a regular basis for the purpose of

self-help and group therapy.

Where do Medical Students go when they need help?

• ETSU’s Resident Assistance Program (RAP) is a confidential counseling and referral service for ETSU Medical School, Residents, and their Families.

• GOALS:• encourage self referral so that you can be helped with training issues,

personal and marital concerns before they lead to more serious difficulties.

• assist residents with substance abuse problems through evaluation and treatment so as to reduce risk to patients and restore residents to health and effective training and practice. Substance abuse services are coordinated with the State programs of the Physicians Health Program of the Tennessee Medical Foundation. A department chair or program director may recommend that a resident see RAP services, but residents are especially encouraged to request consultation on their own

Who do they contact?• Dr. McGowen (Associate Professor of Psychiatry at ETSU)• You may call 24 hours a day, seven days a week for support

and assistance when you need it.• Call: pager (423) 610-2048 - 24 Hours a Day.

• She may arrange an appointment with you in her office to discuss various options. These discussions are completely confidential.

• Your privacy is an important element of the RAP program. • The RAP program is completely independent of your

department.• All conversations, over the telephone or in person, are

confidential.

The services offered…• The majority of services are out-patient in nature. A range of

in-patient and out-patient psychiatric services can be accessed, however, and include intensive individual and group psychotherapy for individuals and couples, medication management, and drug and alcohol rehabilitation and after care

• The counseling sessions with Dr. McGowen are free to all residents and their immediate family members. If Dr. McGowen refers you to another physician, your health insurance through the University will cover the first six sessions at no cost for the resident and/or family member.

Educational Video

The American Foundation for Suicide Prevention has created a video on the topic for physicians and other medical trainees

http://www.afsp.org/index.cfm?fuseaction=home.viewPage&page_ID=9859BF59-CF1C-2465-128DAE02D3C9B309

American Foundation for Suicide Prevention Physician Depression and Suicide Prevention Project. American Foundation for Suicide Prevention.

For Further Information

Resources related to physician depression and suicide:• American Foundation for Suicide

Prevention at www.afsp.org• Black-Bile at www.black-bile.com