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Royal College Outlook
Volume 3, Issue 2, Fall 2006
Nowhere is the stigma of illness greater than among medical professionals. The culture of medicine promotes setting very high expectations of oneself and others, and it rewards hard work, conscientiousness, perfectionism and thorough ness. The "ideal physician" is one who comes in early, leaves late, makes house calls and is always available. This responsible and reliable physician pays attention to every detail. He or she is tough, in control, can handle it all, takes care of others and helps whenever needed. This concept of the ideal physician is reinforced by our teachers, training, peers and our patients; a blemish on this image is considered unacceptable.
A stigma is a stain, a reproach, a characteristic mark of disgrace or defect. Given the expectations of an "ideal physician," when doctors are diagnosed with an illness they often feel stained, weaker or "less than," Such marks of disgrace lead to shame and fear of judgment by others, and foster several assumptions within the field of medicine that lead doctors to conceal ill health.
Stigma begets assumptions
It is wrong for you to become ill and need help.
Stories of doctors refusing to acknowledge illness-either their own or that of family members or colleagues-abound, For instance, one doctor waited until his child's eardrum perforated before acknowledging that the baby was really not well. An ER doctor worked a whole shift and admitted patients who were miscarrying, all while experiencing a miscarriage herself, A surgeon became so ill in the operating room that he started his own IV. A doctor who was diagnosed with cancer waited until it was staged before telling his colleagues so they would understand his need for time off.
Doctors often down play signs and symptoms of illness, deny a problem or wait until the illness is very severe or clearly evident before reaching for help.
Taking time off is a sign of weakness.
Doctors find it hard to take time off, go away on holidays, leave work early after call or stay home when they are sick.
Taking care of yourself is selfish.
Doctors become adept at delaying their own gratification and often put off taking care of themselves. Their needs are last on the priority list and are often lost.
It is wrong to admit you may need help.
Doctors do not want others to know if they require assistance. Many avoid calling provincial help lines for fear of exposure, and they do not attend workshops on physician health issues because they equate participation with admitting they need help. Doctors find it hard to see a colleague within the hospital for medical help and do not want to be seen leaving the office of another doctor-especially that of a psychiatrist.
Taking mdication indicates that you are really sick.
While some doctors may seek advice from a colleague, accepting that they may need medica tion-especially psychotropic medication-is seen as much worse because it is tantamount to being "a real patient." Prescriptions are often met with denial and resistance, and doctors often drive miles to a pharmacy in another neighbourhood to fill their prescriptions to avoid being "found out."
Diagnosing a mental illness is a negative judgement.
While a sense of shame exists for physical prob lems, mental illness remains an even bigger disgrace in the eyes of many physicians. For example, one physician tells of having a heart attack and being admitted to hospital. His colleagues sent flowers and gifts, and visited him daily. Yet, a colleague in the same department was hospitalized with depression in the same hospital, but received no gifts or visitors.
Just as some doctors feel that diagnosing a patient with mental illness can have negative repercussions and avoid such diagnoses in their charting, doctors feel a similar sense of being judged when they are on the receiving end of such a diagnosis. They worry that colleagues will think less of them and their abilities and competency.
Intellectual defences
Stigma in medicine reinforces our use of intellec tual defences to help us protect against others becoming aware of our illnesses. We deny, mini mize or rationalize our difficulties in an attempt to avoid dealing with them, which can result in a serious delay in seeking treatment. Most doctors only come for help when the illness cannot be ignored anymore and has reached a crisis point. Examples of extreme illness prompting doctors to seek out treatment include severe depression, contemplation of suicide and paralyzing anxiety. These illnesses may result from the threat of a lawsuit, or difficulty coping with a patient's death or a marital breakdown.
Why caregivers don't want care but should
It is hard for doctors to reach out for help. The culture of medicine promotes the use of the intellectual defences described previously. Our illnesses tap into our personal insecurities and we fear judgment and exposure if we seek out help. As patients, we can experience a sense of shame, guilt, failure and weakness, and we fear a loss of control. As professionals, we are concerned about confidentiality and fear negative impacts on our ability to obtain insurance. While no formal statistics support this concern, anecdotal evidence shows that doctors who declare that they have sought psychiatric help are provided insurance at higher rates or containing an exclusion clause preventing them from claiming disability for mental illness, or are denied insurance altogether. Furthermore, as professional caregivers, we are not familiar or comfortable with the role reversal placing us on the receiving end of care.
Difficult as it is for doctors to seek out help, it is also hard for doctors to offer help to colleagues. Even if we see signs that cause us concern, we are reluctant to intrude and worry that we may be wrong to assume our colleagues are having troubles. Some of us may even fear anger or retaliation from colleagues if we suggest they are unwell.
Physician health and well-being is gaining much more prominence as an issue of concern among doctors and health care organizations alike. This increased recognition of the importance of physician health will hopefully lead to efforts to reduce the stigma of illness in medicine, A medical workplace with a proactive focus on the promotion of physician wellness is encouraged.Prevention of illness by encouraging healthy lifestyles, advocating for healthier workplaces, devising systems for colleague appreciation and fostering a sense of community and connection between colleagues is essential. The University of Ottawa Medical School Faculty Wellness Program advocates the Neighborhood Watch Program, which is a prevention initiative to guide faculty members in identifying signs of stress within themselves and colleagues. The program encourages doctors to improve their confidence in stating their own concerns and reinforces the positive aspects of expressing care and concern for a colleague.
Education must be offered to help doctors realize that stress is normal and that getting help when help is needed is healthy, but this process takes time. This education can come from many sources at different stages of doctors' careers, for example, some medical schools are modifying their curricula to include topics of health and wellness. Workshops on managing stress can be organized for residents, while Hospital Grand Rounds are an appropriate way to address these issues for staff. Furthermore, provincial and national medical specialty meetings can include presentations and workshops on health and well being in their respective programs. In recent years, the Canadian Medical Association's Centre for Pysician Health and Well-being - a national clearinghouse of information on physician health - has created an innovative curriculum designed to educate medical leaders in specific areas of physician health and distress.
While doctors taking time to care for themselves were once seen as selfish and indulgent, colleagues can now benefit from the reassurance that investing time and energy into maintaining or improving their health and well-being allows them to be better physicians and have a more balanced life. Doctors need to appreciate the value of having hobbies, slowing down, pacing themselves, taking holidays and working fewer hours a week-all without feeling guilty.
Stigma can be lessened with open discussion. Positive and supportive media portrayal can help to diminish the stigma of illness. Doctors should write articles and share their stories, speak up and show that they are all in this together, dealing with the same struggles in similar ways.
Addressing and reducing the stigma of illness will help doctors realize that it is not wrong to seek out help. Physicians who are able to create a healthy work-life balance, identify signs of trouble early on and demonstrate a willingness to seek help will set an example that could erase the stigma of illness and change the culture of medicine to reduce vulnerability not only for themselves, but also for their colleagues.
Mamta Gautam is an Ottawa-based psychiatrist and expert in physician well-being, Her entire clinical practice is focused on the clinical treatment of physician colleagues. She is an internationally renowned speaker on topics related to physician health and well-being and she is on the faculty of several physician leadership courses in Canada and the United States. Dr. Gautam was the first director of the University of Ottawa Faculty Wellness Program. She serves as the chair of the Expert Advisory Group to the CMA Centre for Physician Health and Well-being and is the co-chair of the section of physician health at the Canadian Psychiatric Association.
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