Barriers to mental health care: The culture of medicine

Physicians have a tough job, and they learn to be tough workers. But even people with feelings of strength and resilient dispositions may deal with mental health struggles. How does the culture of medicine contribute to that? Daniel Saddawi-Konefka, MD, MBA, and Christine Yu Moutier, MD, are co-authors with Jesse M. Ehrenfeld, MD, MPH, of the special communication, “Reducing Barriers to Mental Health Care for Physicians: An Overview and Strategic Recommendations,” published in JAMA. Here they discuss the work culture of health care.

Medical Economics: How does the culture of medicine, including those long hours, perfectionism, and reluctance to show vulnerability, contribute to clinician mental health struggles?

Daniel Saddawi-Konefka, MD, MBA:So we have a culture in medicine that's long rewarded stoicism and stress endurance and really has discouraged any acknowledgement of personal vulnerabilities. In fact, it's not even just that inadequate care is normalized. It's almost historically been celebrated. It's a badge of honor to work through illness. I know a mantra that I heard and I think I was of a vintage, that it wasn't really like pushed, pushed on me, but I definitely heard the the saying, you know, if you cough up along, you shove it back in and you get back to work, and that being sort of the things that people would say with pride. So this culture creates this, this hero narrative, this invincibility complex, that unfortunately gets in the way of of physicians being able to show vulnerabilities and follow that up with seeking help for conditions that would benefit from help.

Christine Yu Moutier, MD: I'll just add that in the broader societal culture, we already are dealing with a bit of a challenge in terms of the stigma and misunderstanding of mental health and mental health conditions. When you look at just the staggering sort of statistics that one in four Americans will have a mental health condition. It's just these are matters of human health, whether it's genetics, early childhood, trauma, you know, any number of biological, psychological, social and environmental forces at play, just like for any health issue. So we as physicians are human beings, and then we come into an environment where that culture of toughness and stoicism had driven people with you, and while also we're going to medical school and training right during those years when the onset of mental health conditions — 75% of those with mental health conditions will have their onset by age their onset by age 24. And we're not recognizing the majority of them because we're writing them off to stress and other things. So you kind of have a convergence of just human factors, along with an environment in training and in practice that was really misconstruing, reality, I would say. And I'll just point to an interesting part of our history that had driven so much of mental health, suffering and conditions underground, that by the time they showed up and the field of medicine had developed more specific pathways for physicians who were dealing with substance abuse and addiction problems — but again, by the time they surfaced, they were like stage four and required, you know, intervention and there was impairment going on. And so I think there was actually kind of a learned experience in the environment that taught some very incorrect assumptions about mental health conditions, which is that the large majority of physicians don't have them if they're in our environment. I was even asked the question when I started the education program with that was part of the here program, a suicide prevention program at UCSD asked the question, well, if these distress indicators are true, then our admissions process must not be doing their job. So there was an assumption that we could sort of screen out these, these problems. So it was a really stigmatized view of of these human health matters, of mental health conditions, the truth is, in terms of impairment, the vast majority of people with mental health conditions do not have a form of work impairment, just like that would be true for people with diabetes or hypertension. And the earlier you address it, of course, the more likely it is not it will not interfere with work as far as big “I” impairment. Of course, it affects, you know, more subtle aspects of of performance.