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What can we do to prevent devastating outcomes?
A few weeks ago, I received a message from someone in one of my physician social media groups that a member had taken his own life. Shocked, my instinct was to immediately pull open his Facebook page to try to make some sense of this tragedy. But there was no evidence of emotional distress to be found. Instead, this seemingly happy-go-lucky ER physician’s feed was filled with photos of his dog, cute videos, and positive messages, including an homage to his colleagues for Doctors’ Day just the week before. As I scrolled through the page, I was overwhelmed with sadness. I began to sob as I thought about the feelings of hopelessness and despair that this person may have felt, all while presenting a smiling face to outsiders.
The loss of someone we know—even if just a “Facebook friend”— by suicide is extremely distressing. Besides the pain of losing someone from our lives, we often ask ourselves if there was anything that we could have done to have helped, or if there was something that we missed, some sign or signal. But I’ve learned from my psychiatry colleagues that there are often no outward signs of an impending suicide. In fact, people who go on to demonstrate suicidal behavior often present themselves to the outside world with a mask that “everything is alright.” They tend to hide their negative thoughts and feelings from others, which is why suicide often comes as such a shock.
So, what can we do to prevent these devastating outcomes? While we know that systemic problems in our healthcare system are a major contributing factor to physician burnout and depression, a major overhaul is unlikely to come anytime soon. While we can and should work to make changes to our organizations and systems, the place where we can make the most immediate impact is on a personal level—by reaching out to our friends and colleagues to provide support.
According to physician wellness psychologist, Steven Cohen, PsyD, the key to preventing depression from progressing to suicidal thinking is to acknowledge and address negative feelings before they spiral into hopelessness and despair. By recognizing the signs of physician burnout and depression, we may be able to help our colleagues before they take drastic steps.
How to recognize a physician in need
Doctors dealing with depression may experience any of the typical anhedonia symptoms we observe with our patients – lack of interest in activities they used to enjoy. Take note if a colleague reports fatigue, somatic or physical complaints, appetite or weight changes or be short-tempered or irritable.
Another common sign of a physician in distress is a change in typical pattern of behavior. For example, a physician who is usually cheerful suddenly becomes irritable and cranky. Or a person who is always on time is now suddenly rushed and last minute, or an organized person is now constantly misplacing things.
Distressed physicians tend to isolate from others. While it may be more difficult during COVID19 as we are gathering less often, watch for signs of colleagues withdrawing from interactions with others. A doctor in distress may begin to come in late or exceptionally early to work to avoid small talk with colleagues or time with family. They may ignore or fail to respond to texts, phone calls, or emails.
If your gut says that something is wrong with a colleague, believe it. Don’t assume that someone else will step up, as often no one will – a phenomenon called “bystander effect” where everyone assumes that someone else will take charge, and no one actually does anything.
How to respond to a physician in distress
The best time to interact with a distressed colleague is when the physician is not rushed and when you have enough time to give your complete attention. Pick a private and quiet area, and start out in a general way: “How are you?” or “I notice that you seem to be stressed lately – is everything ok?”As they answer, watch them carefully for their facial expression and body language, and listen to their tone of voice.
Because opening up feels like a weakness to many physicians, they will often respond with a noncommittal response or a denial of any problem (“I’m fine”). Don’t accept this first answer—continue to probe a bit deeper. In fact, it can be difficult for a depressed physician to even believe that a colleague really cares because of the cognitive distortions associated with depression. This is where the use of empathy can be helpful to really show that we are concerned. For example, you can respond to the answer of the physician that “I’m fine” by saying: “You’re fine? OK, I just feel like something is off and I was worried about you.” This lets the physician know that we really do want the answer to how they are doing, and not just a token reply.
If the physician does start to open up or give hints as to their emotional distress, be prepared to listen and show empathy. No matter what, don’t start trying to problem solve.
Listening and emotional validation is the key
Often when a physician does start to open up about emotional stress, they do it in a more general and “safe” way. For example: “I’m just sick of this pandemic.”
Our natural inclination may be to try to start problem solving: “What about taking a vacation?” but this isn’t actually addressing the root of the problem. The physician needs to be able to start opening up and sharing emotions, and when you shift into “problem solving” mode, you actually shut down the flow of emotion. Instead, we need to use silence, listening, and emotional validation to allow the physician to continue to share feelings and emotions, without trying to “fix” them.
Use listening and validation of emotions repeating back “feeling” words or descriptors that the physician says. For example, if the physician says, “I’m just totally drained dealing with my patients,” you can respond: “I’m guessing you feel like this pandemic is never going to end.”
You will know if you are getting it right if the physician responds in an accepting way, in agreement, and continues talking and sharing.
Encourage professional help
Once a colleague has started to open up about concerns, this is a good opportunity to encourage them to talk to a professional. Consider sharing the Physician Support Line, where volunteer psychiatrists offer free and confidential support to physicians. Remember, it is our responsibility to reduce the stigma towards mental health care. It may help to say something like “Everyone is suffering due to this pandemic – take advantage of the resources out there.”We can also remind our colleagues that their patients need them, and it’s not a weakness to ask for help.Getting help makes you a better person and a better physician.
Even if the physician isn’t ready to accept a referral for further help right now, just starting the conversation may open the door for future consideration. It also lets the physician know that you care about them and are available if they ever need to talk.
Physicians are incredibly resilient, but we all have our limits. We need to support and encourage each other before we get to that point. After all, tomorrow can always be a better day.
Rebekah Bernard MD is a family physician in Fort Myers, FL, and the co-author of Physician Wellness: The Rock Star Doctor’s Guide.