Few studies focus on the ways in which physician mental health and well-being closely relate to patient mental health and substance abuse disorders (MHSUD). In this perspective, we describe how the COVID-19 pandemic impacts the mental health of physicians and highlight the bidirectional effects of physician and patient well-being.
The Impact of the Pandemic on Physician Mental Health
Even prior to the pandemic, there were reports of physician burnout, depression, and death by suicide, spanning medical students to physician leaders in medicine. The COVID-19 pandemic further highlighted the need for an increased focus on physician mental health and well-being. In a survey of more than 12,300 physicians across 29+ specialties in the United States from August–November 2020, 42% reported burnout, 20% depressive symptoms, 60% colloquial depression, 13% suicidal ideation, and 1% attempted suicide.1 Many factors have been posited for worsening mental health outcomes among physicians.
First, many likened the COVID-19 pandemic to a medical “war.” Physicians did not receive training in trauma or preparation for war as many soldiers do. This was not residency or a typical workday. They were trained to gather histories, examine, heal, intubate, break bad news to families, and even pronounce deaths, but not at the extraordinary physical, emotional, and mental demands from the pandemic. Physicians encountered mass causalities, limited access to resources, fear of becoming sick or dying, fear of infecting their loved ones, moral injury due to resource allocation decisions, and emotional support needs of patients. They even lived in isolation from their families to avoid infecting them. Ongoing COVID-19 surges and related upheavals in physician roles and responsibilities further affected their sense of well-being.
Multi-level Factors Contributing to Physician Mental Health and Well-being
Besides the direct effects of the pandemic on mental health, many have remarked on the unique stressors attributed to training and working in the medical field. Physicians often sacrifice time away from family, including significant life events, to complete their training and care for patients. Despite higher rates of MHSUDs among physicians compared to the general population, marked stigma in the medical field hinders adoption of effective treatments. At the healthcare system level, physicians also face scheduling demands, the ongoing need to adapt to technological and medical innovations (e.g., telemedicine, medical devices), documentation pressures, uncertainty of new normal of medical care delivery and work-life balance, to name a few challenges. All these factors were magnified by the pandemic and resulted in a mass exodus of physicians who provide direct patient care, as evidenced by increased rates of office closures, early retirement, and/or transitions to non-medical careers.
Interaction between Physician and Patient Mental Health
Elucidating the determinants of physician mental health not only has the potential to impact physician quality of life but also to mitigate the negative effects of physician well-being on patient mental health. Multiple studies have demonstrated increased rates of MHSUD over the last year, including among patients receiving the diagnosis of COVID-19 and who required hospitalization, intensive care admission, or who suffered from encephalopathy.2 Few, if any, prior work has examined the ways in which physician and patient mental health may be related, however.
First, we are human! Physicians and patients faced and still are facing similar stressors and triggers (both due to the pandemic but also to changing industries/technology) contributing to parallel mental health pandemics. Increasing rates of MHSUD in the face of limited time and mental health training and the degree of emotional support required likely negatively impacted the mental health and well-being of physicians. While understudied, physician mental health also has the potential to impact patient mental health in several ways. These may include decreased empathy during clinical encounters, suboptimal patient-physician communication, and an inability to concentrate during visits. There is well-documented mental health stigma among physicians, and it is unknown whether physician stigma influences how comfortable patients feel in disclosing MHSUD symptoms. On the other hand, physicians may avoid discussing MHSUD symptoms that remind them of their own. In a 15-minute encounter that requires reviewing chronic medical conditions, preventative health maintenance, and quality measures, physicians often lack the time to assess for MHSUD.
Meanwhile, physicians are needed now more than ever to care for the MHSUD needs of our patients and communities. Even prior to the pandemic, physician shortages and lack of training contributed to limited mental healthcare access and suboptimal patient outcomes. Shortages spurred the proliferation of task-shifting and multidisciplinary team-based care to meet patient needs. If the physician exodus from direct patient care continues, there will be a lack of physicians from “soldiers to generals” to lead the interdisciplinary care teams in managing patients with chronic, complex mental and physical health needs and leading initiatives to quell this war. Thus, physician mental health and well-being must be at the forefront of local and national government, healthcare organization, and professional associations’ agendas and policies to prevent a parallel mental health pandemic. If they are not prioritized, we run the risk of clinics, emergency rooms and hospital halls overflowing with patients who are suffering and dying from MHSUD and other comorbidities, and fewer physicians to care for them through this pandemic and beyond.
Where Should We Start?
Impacting patient well-being will require that physicians be vigilant and inquire of MHSUD symptoms, work against the already existing stigma of MHSUD in our communities, find safe treatment interventions in an already scarce pool of MHSUD programs, and advocate for, participate in and innovate/adapt team-based care models shown to be effective in reducing mental health disparities. Answering these calls however requires physicians to prioritize their own mental health needs. First, medical school and residency training programs will need to integrate mental health treatments like mindfulness into the fabric of their programs. This has the potential to reduce stigma, improve the well-being of future physicians, and teach skills to physicians that they can impart during patient encounters. Second, healthcare systems will need to allocate time and funding to improve physician and patient mental health and well-being alike (e.g., allocating time during multidisciplinary rounds for mindfulness exercises, disseminating mental health toolkits to patients in the waiting rooms).
In addition, more data is needed on whether and the mechanisms by which physician burnout and well-being affects patient mental health and physical outcomes; the bidirectional effects of MHSUD on both physician and their patients may be a novel area for research. Medical educators and investigators should consider adapting the Stanford Model of Professional Fulfillment, which focuses on the triad of a culture of wellness, efficiency of practice, and personal resilience3 to address both patient and physician mental health and well-being.
Finally, at the national level, government agencies, like the National Institutes of Health, will need to fund centers, similar to the World Trade Center Health Program developed for 9/11 first responders.4 Programs like these can be essential in screening, monitoring, treating, and investigating long-term effects of the COVID-19 pandemic, particularly given the onslaught of COVID-19 variants despite vaccination efforts.
Advancing mental health and well-being are here to stay for our patients, our communities, and physicians! We need to acknowledge it, feel comfortable about it, discuss it, reduce stigma, and advocate for mental health and well-being for physicians and patients alike. COVID-19 variants have spurred ongoing surges despite vaccination initiatives, which has the potential to create a mental health domino effect. Making an impact on physician and patient mental health care is essential and will require further research on the bidirectional effects of patient and physician mental health and well-being as well as national and local policies and innovations at the government, healthcare system, and organizational levels.