On wellness in medicine: physician says times have changed, but stigma still exists

Years ago, when I was an associate dean at the University of Manitoba medical school, I organized a student panel on the emotional difficulties of clerkship. Several brave and superb learners spoke candidly and openly about the emotional challenges they had faced during training, and many others talked about seeking supports at pivotal times. It was an honest discussion, and when it ended, I felt we’d opened some doors.

So I was floored when, the next day, a student approached me to share that she had overheard several classmates in a back row making comments that those learners were weak, needed to “get a grip” and clearly weren’t capable of coping with the reality of medicine.

Our learners are often lauded for having different attitudes toward mental health in medicine than the generations before them. But, sadly, my experience has taught me that stigmatization of mental health and wellness is not a problem confined to the “old guard.” It is embedded in our culture.

I’m also sorry to say that occasionally, when I’ve shared my lived experience as a physician, I’ve also had ignorant and derogatory comments fed back to me from the equivalent of those “know-it-alls” in the back row.

I would like to say that it’s had no impact on the degree of vulnerability I am willing to bring to my teaching, but that wouldn’t be true and I think it’s important to be honest about the reasons why.

We do take a risk when we speak openly. If we want to change medical culture, we have to not only take that risk, but also ensure a culture of respect and support for people who are brave enough to speak up. Our entire profession — students, residents and practising physicians — must take that responsibility seriously. Change depends on it.

So what are the truly indisputable realities of medicine? This is a question that deserves our scrutiny. Medicine is a job we choose to be of service to patients — one with high cognitive, emotional and, often, technical requirements. But historical assumptions about how physicians work, about how they express sadness and grief, and about whether patients truly end up “coming first” in a system that profoundly effects physicians’ health are long overdue for serious scrutiny. Times have changed, and so has our understanding of the ways in which medical culture has often been counterproductive to helping physicians achieve their true potential.

Medicine is special — a thrilling and privileged journey. Like so many of you, I feel it was a calling. But it is also incredibly, relentlessly hard on the body and mind, and it would be difficult for anyone to credibly argue we have done all we can to protect what my colleague Mickey Trockler calls “the most important instrument of practice.”

Most of us have had the experience of watching a colleague suffer through a challenge related to their mental health; we recognize unequivocally that they need and deserve help. But based on my personal experience, it doesn’t always feel that we ourselves deserve help when we are in the thick of things, and this is one more example of the mental health messaging we need to tackle.

 The emphasis on coping through compartmentalization and the lack of training in sophisticated stress management and self-regulation skills is another historical failure on medicine’s part. Perhaps it’s why so many of us find these skills life-altering when we finally acquire them, such as through programs that teach cognitive behaviour therapy, mindfulness or other tools for emotional self-regulation. Sometimes, these programs can feel like a concession — we can be tempted instead to embrace the age-old accusation from the back row that we just need to “toughen up.” Ironically, learning and now teaching these types of skills has helped me to see even more clearly that many of the things I have struggled with in medicine have little to do with me personally, and these skills have afforded me new ways of working through the discomfort of advocating for system change, and practising and teaching in ways that sometimes go against the grain.

I don’t think it’s a disgrace to need help. I do think it’s a disgrace that we work in a culture that still has a tendency to frame situations that way. If we really, truly care about patients, somebody has to help the helpers. It’s time for us to confront our own professional prejudices when it comes to physician mental health.

The Wellness Support Line is here for you. How?

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This material is for informational purposes only. It is not intended to be a substitute for professional medical advice and should not be relied on as health or personal advice. The opinions stated by the authors are made in a personal capacity and do not necessarily reflect those of the Canadian Medical Association and its subsidiaries including Joule.  Feel passionate about this topic? Please connect with us at jouleinquiries@cma.ca.

About the author(s)

Dr. Jillian Horton

Dr. Jillian Horton is a general internist and is leading the development of new physician wellness courses for Joule. She’s completed chief wellness officer training at Stanford University and mindfulness training at the University of Rochester. She writes and podcasts regularly for CMAJ and Medscape and hosts a medical speakers series at the National Arts Centre. Her book on physician burnout, “We Are All Perfectly Fine”, will be released by HarperCollins Canada in February 2021.

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