Moral Injury VII

Self-harm

One of the biggest secrets of practicing medicine is that physicians and other providers often have poor mental health.

About 10-14% of physicians suffer from addiction to drugs or alcohol during their careers. However, as Peter Grinspoon remarks in an article for the Psychiatric times, the true rates may be much higher as physicians are incentivized to hide their addiction. Every year, 300-400 physicians die by suicide in the United States, and suicide rates among female physicians are 250-400% higher than their counterparts in other professions (Grinspoon, 2022. Matheson, n.d. ).

Why is this happening? I see three core contributors.

I. The culture of medicine is brutal

Traditionally, getting through medical school and residency is like running multiple ultramarathons back-to-back with no rest. For example, for me to become a board-certified psychiatrist, I had to complete:

-????????? 2 years of undergraduate “pre-med” coursework in sciences

-????????? 1 standardized 2-day MCAT exam

-????????? 4 years of medical school (we go straight through, no summers off)

-????????? 3 separate 2-day exams for the standard medical “board” exams

-????????? 1 year of internship

-????????? 3 years of psychiatry residency

-????????? 1 full-day board exam for psychiatry and neurology

-????????? 1 full-day oral board exam for psychiatry and neurology

Within each of these components, the competition was fierce. Before I started the medical path, I considered myself a big nerd. Once I got to medical school, I almost felt like a slacker. I got up every morning at 6AM and went to bed at 11PM. Every moment of my day was filled with classes or studying. This was nothing compared to some of my peers who seemed to exist on 2 hours of sleep a night.

Each day in medical school and residency was filled with challenges. In medical school, we would often be “pimped” by our attending physician meaning that they would rapid-fire questions at us and if we didn’t know the answer we were shamed in front of the group.

As we progressed through residency, the stakes got higher. We were expected to make life-or-death decisions every day. Mistakes happened, but they were shameful. We felt like we had to be perfect at all times.

II. Stigma about asking for help

I believe that medicine attracts stoic personalities and the discipline needed to survive training requires extreme self-management. Being independent has a cost; it is often difficult to ask for help.

As an example, in medical school I started having panic attacks. I really didn’t know they were panic attacks until I did my psychiatry rotation and we learned about different types of anxiety disorders. But despite knowing I was having panic attacks, I did not ask for help.

I assumed that the panic attacks were something I would cope with, the same way that I coped with everything else in medical school. I just powered through it and hoped things would be better on the other side of graduation. It never occurred to me to ask for help. It just wasn’t something I did. I never heard my peers talk about asking for help or coping with their mental health. We just did the work.

When I got to psychiatry residency, I decided to start my own psychotherapy. Why? Not because I was asking for help. Because my instructor recommended that we all do our own psychotherapy as part of our training. I asked for help because I was told to ask for help.

It was in my own psychotherapy that I learned about my anxiety and how to truly cope with my panic attacks. But I never would have gone to therapy in the first place without the explicit instruction of my supervisor. Of note, another reason I went to psychotherapy had to do with cost. As a psychiatry trainee, I had access to reduced-fee psychotherapy with very skilled therapists.

Physicians and other healthcare providers need to be explicitly told to care for their mental health. While times are changing and there is less stigma around psychotherapy, I believe it needs to be an explicit requirement or many (like me) will not ask for help.

III. Moral Injury

Finally, moral injury plays a role in worsening mental health. Experiencing something or acting in a way that goes against your values creates a deep psychic wound. This worsens any underlying mental health issues and can push some providers over the edge.

It can be instructive to look at military, where the concept of moral injury originated. When the vets return home from service, they are in theory “resting.” In the framework of burnout, you would assume they bounce back and re-enter civilian life. But this is not what happens.

Moral injury in the military also creates deep psychic wounds which require healing. This is different from PTSD, which can occur alongside moral injury, or separate from it.

Physicians and other healthcare providers suffering from moral injury may turn their emotional distress inward. Using alcohol and other drugs of abuse has always been a problem.

Did you know that there are specific organizations designed to quietly help physicians with substance use and mental health problems? Most people don’t talk about this because we don’t like the idea that our physicians are anything less than perfect. We don’t like to see them as human beings. We want them to be perfect because they are taking care of us, and we don’t want them to make any mistakes.

Unless we start talking about moral injury and how that compounds mental health and substance use problems in physicians and other healthcare providers, things will get worse. More providers will suffer, and more providers will die by suicide or substance use. This in turn harms patients because they are getting the worst version of their provider, and it impacts their care. Then the entire system suffers because clinical and financial outcomes are poor.