Breaking the Stigma: Physician Mental Wellness and Burnout

Becca Battisfore:

Welcome to the latest edition of the College of American Pathologists' CAPcast. I'm Becca Battisfore content strategist with the CAP. In this episode, I'm joined by Dr. Alison Van Dyke and Dr. Darrell Kirch. We'll be discussing burnout and mental health challenges among physicians. Doctors Van Dyke and Kirch will also share their own stories to help break the stigma and highlight the importance of seeking help.

Before we begin, please note that today's episode covers topics that some listeners may find difficult, including brief mentions of abuse and suicide. If these topics are triggering for you, we encourage you to listen with care and prioritize your wellbeing. If you need support, please consider reaching out to someone you trust or a mental health professional. We'll also have resources in the show notes that may be of help. And now onto the episode.

Dr. Alison Van Dyke:

I'm Alison Van Dyke. I am a pathologist and cancer epidemiologist by training, so I wear two hats. I went to Wayne State University School of Medicine for my MD and PhD, PhD in cancer biology, and then went through AP training for pathology, did a fellowship and then immediately said, I really miss research in public health, so that's how I got to NCI, the National Cancer Institute at the NIH. So that's where I am now, and that's my professional journey.

Dr. Darrell Kirch:

Being a bit older, my professional journey is also a bit longer. I was an undergrad med student and resident all at the University of Colorado, and like the vast majority of medical students in that era in the seventies, I thought I would go into private practice. That was what the majority of us thought we'd do. We had no idea that within a few decades most physicians would be employed. That said, I was very fortunate in that while I was a resident, I had a mentor. I didn't even realize he was a mentor until after the fact, but he saw my potential, engaged me in some research projects and encouraged me to consider doing a fellowship At that time, and I think it's still available, there were two year fellowships you could do after residency training at the NIH. I had trained in psychiatry. I was very interested in the burgeoning area of neuroscience and started my fellowships studying schizophrenia.

Like many physicians, what I thought my career would be like was much different than it actually played out. I ended up spending a total of 13 years at NIH because, not because I was necessarily the best researcher, but because I was willing to take on the administrative tasks that help an organization run and get things done, and moved through a series of roles and eventually no one was more surprised than I was. When I was asked to serve as the acting scientific director of NIMH, the National Institute of Mental Health. It was a wonderful experience. I learned a great deal, but I really missed the academic environment. And I was out of the blue, asked if I might want to consider becoming the dean of the Medical College of Georgia, which is Georgia's only public medical school. Again, no one was more surprised than I was when I was offered the position.

And for the next seven years, had a wonderful experience at Georgia. I took on the responsibility of moving the health system out of state ownership into a new entity, and so became a health system leader. At the same time, I was then recruited to Penn State, the Hershey Medical Center for Penn State to be the dean of medicine, executive vice president for Health Dciences and CEO of the health system there. During that time, I became more involved in the AAMC, the Association of American Medical Colleges, which all physicians know because of its role in application and testing processes, but which is the main advocacy group for med schools and teaching hospitals. I was honored in 2006 to be selected as the new president and CEO of the AAMC, and I did that from 2006 to 2019. So over those four decades plus, I had arguably a great resume or CV as we say in medicine.

But I also had a personal story behind it and maybe we can talk about that a bit in a moment, but on paper, you would consider me if I was being introduced as a speaker for a group of physicians, you would consider me having had a very successful, arguably admirable career. But in those latter stages, starting around 2015, I became very interested in the topic of physician wellbeing. And we can go later more into how that came about for me, but I've been very privileged and very lucky. I had great mentors who saw things in me I didn't know there and who helped me move forward in a career that I never would've predicted.

Becca Battisfore:

Thank you so much for sharing. Dr. Van Dyke, do you want to share your personal journey and we can see then how it differs and how there were some similarities with Dr. Kirch?

Dr. Alison Van Dyke:

Yeah, absolutely. So ever since I was a very young child in the seventies when no one even talked about mental health, no one talked about psychology or seeing a therapist in my family, but as my earliest memories are either being very distraught or being full of energy full of life, just the ups and the downs. And fast forward many years until still was not diagnosed, until I was self-diagnosed when I was 21, I was taking an abnormal psychology class and reading the book chapter on mood disorders, and I was reading the signs and the symptoms and I was reading myself in my life experience with bipolar disorder. And I wasn't diagnosed until four years later at the age of 25 with bipolar type one. And I also have ultra rapid cycling bipolar disorder, which is one of the hardest to treat of bipolar disorder types.

And what that means is that I can go be high up and then in the depths of depression within a day or two. So very, very difficult to handle. And it wasn't until I was 25 that I started medication off and on. And when I started medical school, I, being a doctor and a scientist was so much more important to me than being off medications. I had a big stigma in my own perception and also people around me about having a mental illness. And it was really when I started medical school that a friend reached out to the student affairs at Wayne State and said, Hey, I think the student is struggling. She needs some help. Very quickly, I got into great psychiatric care there at Wayne State. They have at the Detroit Receiving Hospital, the former DRH or Detroit Medical Center, they have one of the best psychiatry programs in the country, as you can imagine, given the patient population and really got state-of-the-art care got on treatment.

And I've been in treatment for over two decades now since then and have really struggled through the years of medical training, especially I couldn't be on the level of medication, the dose that I needed because it was so sedating and to get through medical training and being on these sedating medications was very challenging. So I really started to thrive and flourish when I started doing my research postdoc at the National Cancer Institute. And from then on, because I've had consistent sleep, lower stress level, I actually have been able to really lead a successful, happy, healthy life from there. But I'm very interested in de-stigmatization of mental health and mental illnesses and really think it's critical that we speak about this openly because if it even helps just one person feel like they are empowered to go and get help or even help one person feel not so alone and isolated, I think it's worth talking openly about.

Becca Battisfore:

Absolutely. Thank you for sharing that. And I think as you stated, there was no one talked about it regardless of the industry or field you were in, it just was not talked about. So it does feel like there's been improvement in recent decades of at least it's talked about, but I imagine the stigma of having a mental health disorder while in the medical field is still persistent.

Dr. Alison Van Dyke:

Absolutely.

Becca Battisfore:

Yeah.

Dr. Alison Van Dyke:

Yeah. And I just want to add, I think there was a level of anxiety I experienced on top of just having a bipolar disorder, fear of having other med students, other trainees, attendings know that I actually had a mental health condition and we don't check our medical conditions or identities at the door when we walk into a hospital. And I think I was viewing it very negatively and just so fearful that colleagues would find out what those repercussions would be, that judgment that they may have towards me throughout medical training. I was very afraid for people to find out and the consequences in my career long-term. But now that I've made it to a certain level in my career, I feel comfortable speaking openly.

Becca Battisfore:

And Dr. Kirch, I'm curious to hear your personal story and how there might be some similarities with Dr. Van Dyke's.

Dr. Darrell Kirch:

There are incredible similarities. Dr. Van Dyke has a very impressive CV herself as a physician scientist, but she's described the yin and the yang of this very successful professional journey and some deep personal struggles in her case with her bipolar disorder. So the parallel for me is that I grew up being the first in my family to go to college. We lived a very modest life, and I don't think as a child I or people in my family even knew what a psychiatrist was, much less what a mental disorder was. That said things started off in a difficult manner for me. Shortly after I was born, my mother had a postpartum psychotic disorder, which often is a major adverse childhood experience that lays the seeds of other experiences. And then when I was a toddler and a bit older, I was abused by a trusted adult.

I had no idea what was going on, but I think it definitely left its emotional mark. From my earliest memories, I was an extraordinarily anxious, fearful child. I immersed myself in my schoolwork and even though I was anxious, unhappy, would've met criteria for being diagnosed as having an anxiety disorder. As a child, I pushed on through in high school and in college I was very uncertain about what I would do after college. I actually was a philosophy major and weighed the ideas of law school and medical school right up until my last few years of college ultimately decided I would give medicine a try, even though my anxiety and something that many, many physicians suffer from my imposter syndrome that how can I be here with all these high powered students in medical school? How do I deserve to be in this situation? I really struggled with those things and they all came home to roost during my first year of medical school.

At that time, my curriculum had a intense 12 weeks of gross anatomy in the middle of the winter in a dark basement room. I don't think I saw the light of day for three months, and I easily would've met criteria for burnout. During those three months becoming progressively more detached, more emotionally cynical, more questioning of the meaning of the work I was doing things really to a head for me. When something happened that I think often happens with clinicians and trainees experiencing burnout, there was a very short path for me from being burned out to having a full fledged mental disorder. In my case, I began to have severe panic attacks, overwhelming anxiety, really disabling anxiety. I approached the student affairs Dean's office not to get help but to withdraw from medical school, and in my case, a very sensitive, compassionate student affairs Dean said he wouldn't let me withdraw.

He wanted me to get into treatment, had a resource for me that I could see. I started medication and began to feel better, managed to stay in school, finish that first year of med school and go on to finish medical school. But not unlike Dr. Van Dyke, I didn't want to breathe a word of this to anybody. Culture is a very powerful thing. And what I had learned through the So-called informal curriculum is that when you get to medical school, and it was even more the case in my days, when you get to medical school, you're there to be a caregiver, you don't need care, you don't need sleep, you don't need a regular routine, you don't need breaks. You just are the caregiver for others. So I kept silent about my struggle, and fortunately with my treatment, functioned well enough to go on and do some of the things that we discussed, my research role at NIH, but it was when I was a dean at Georgia in my first deanship that my panic attacks returned as they often do out of the blue.

I once again returned to treatment, got on medications, and didn't breathe a word of this to anyone just pushed forward. Really since that time, I've remained on medication. It's been a bit of a struggle at times. I had recurrent flares of anxiety, but my job was to be the dean, to be the leader. I easily consulted with everyone from medical students to residents to faculty members who knew I was a psychiatrist and often sought my advice for themselves or a family member. And I've really talked about the need to be in treatment, that there was no stigma that should be associated with that. And yet, I had become a victim of one of the most powerful forms of stigma, which is self-stigma. I couldn't tolerate the image I wanted to have as a physician leader. I couldn't tolerate the dissonance of that in my own struggles, so I didn't speak about it.

The tipping point didn't come for me until 2015. In the summer of 2015, there were two residents, suicides, not from residents who knew one another, but in close proximity and time and location in New York City that were picked up by the New York Times. And it led to an editorial in the Times titled, why Do Doctors Commit Suicide? And when I saw that, I realized that there was this issue of stigma that was so profound that here you had clear cases of people who were struggling, who were in that very challenging period of early residency, had moved geographically, had all these issues loaded onto them, and rather than being able to get help, they took their lives. And that was when I decided that even though it was far too late, I would speak more publicly about my struggles.

At the same time, I had discussions with other leaders in academic medicine in particular, the head of the ACGME, the body that oversees residency training in the United States, head of the AMA, and most importantly, a good friend and colleague, Dr. Victor Dzau who heads the National Academy of Medicine. And in a series of discussions, it finally appeared to me that the issue of clinician wellbeing, both burnout, which is a workplace problem and the short path from burnout to our shared human vulnerabilities to depression, anxiety disorders, mood disorders, and the like, that the connection of those things needed to come out of the shadows. And I was very gratified when Dr. Dzau at the National Academies agreed that the National Academy starting in 2017 would create something called the Collaborative Initiative on Clinician Wellbeing. He said the academy would take it on if I would agree to co-chair it with him and Dr. Nasca from ACGME. And it has been a long overdue, but extremely important capstone for me in my career to at this point be to really push this issue out of the shadows into the national consciousness, not just in medicine, but in nursing, pharmacy, other health professions.

And it's an issue in workplaces far beyond healthcare, the twin problems of burnout and the struggles so many of us have with mental disorders. I've been very gratified at the response. I was very fearful when COVID descended on us in 2020 thinking that it would just push this issue out of the spotlight. But in fact, what we saw with the very highly publicized suicide of Dr. Lorna Breen and the establishment by her family of the Lorna Breen Foundation, she was someone who had struggled with depression, became very burned out during COVID, died from suicide, and led to congressional legislation about focusing on clinician wellbeing. So I so admire the fact that CAP together with other medical professional groups have really taken this on to bring the issue to the forefront of our consciousness. I think this is a battle that we're just beginning. This will be a long road. It never is easy to change cultural attitudes, but I think we have a good start.

Dr. Alison Van Dyke:

It's really interesting that you talk about a shift, a needed see change in the how we view mental illnesses and mental health and wellbeing. It's interesting because according to the Mental Health America, one of their surveys, they put out only 34% of employees surveyed said their leadership in their organization talk openly about mental health and the resources that are available. And I think that needs to change fundamentally. I think these conversations like we're having today really need to happen more openly. And it needs to be not just top down cultural change in that kind of hierarchical top-down structure, but I think having that grassroots among trainees, talking to each other, among physicians openly speaking to each other, it is so critical because even one person's suffering or one person's death is so tragic. And I echo Dr. Kirch's support of the CAP and Dr. Karcher, the CAP President, openly talking about the need for physician wellness and the importance of that and really focusing on that moving forward is so important.

Dr. Darrell Kirch:

I couldn't agree more. One of the things I did in 2020 was publish my story in a special issue of the journal Academic Medicine focused on physician mental health, physician wellbeing. And I was amazed at the responses I got. I received more feedback about that piece than anything I've ever said or written. And I think it's the power of personal narrative. And we've had this mythic belief in medicine that you are almost superhuman to become a doctor when in fact you don't leave any of your human vulnerabilities, your biological vulnerabilities, your family history vulnerabilities behind you carry those with you. And this is a battle though. The stigma, the structural stigma is very powerful, the social stigma as well as the self-stigma. In fact, one of the other initiatives I've chosen to work on at this point in my career career is a national campaign called Stop Stigma.

Together, it's brought together organizations ranging from the National Alliance on Mental Illness to the NFL. It's brought organizations together to just talk about how we need to break down the stigma that's out there. And one particular stigma for physicians that is not breaking down fast enough but is changing are the questions that are asked about mental health on medical licensure applications. Those questions historically have been very stigmatizing and inappropriate, such as asking, have you ever had a mental health diagnosis? The only appropriate question is do you have any kind of medical problem that might impair your ability to practice? That's it at the most. But we had all these stigmatizing questions in different forms. I can confess now that I personally just ignored those questions and did not answer them because I felt I would damage my career in some way potentially if I acknowledged my own struggles breaking down stigma, I be perhaps the biggest battle in this overall war.

Dr. Alison Van Dyke:

Absolutely. And I think there was a survey out there that was conducted in 2022. You can find it. It's on Medscape survey of over 9,100 physicians. And I cry, but no one cares. If you Google that, it will come up. And it's really, really interesting that some of the top reasons that physicians who report that they are suffering from depression, the reasons why they do not get help, fear of stigma of what their colleagues will think, fear of repercussions from the medical board instead of supporting people, which is what we really need to be doing, and pointing people in the direction of resources and care. I think in some respects, people feel like they're driven underground and that they can't seek care for the very medical conditions that they have, especially if it's a mental health condition. And this is really, yeah. Dr. Kirch, what do you think?

Dr. Darrell Kirch:

I was just going to say, so I was a dean for 13 years. During that period of time, two of my students died from suicide, and the third case was very likely a suicide, although not totally clear. And one of my regrets is that when I met each class on their first day of medical school, if I had just taken a few minutes to say, you're still a human being, I'm a human being. I've suffered from an anxiety disorder that has been disabling at times. Stigma initially kept me from seeking help or talking about it. Don't let that happen to you. We have resources for you. If you are struggling, we can get you confidential professional help because we want you to be a doctor. In many ways, your struggle with a mental disorder or even if it's workplace burnout, by talking about that more openly, you help yourself and you help others.

Dr. Alison Van Dyke:

I remember when I was in my pediatric rotation in my third year of medical school, I had done the first years of medical school, went and did three years of graduate school to get my PhD and then came back. And that first year back was the hardest I've ever experienced. And I remember on my pediatric rotation with the call schedule, the hours going up and down and all around I found myself so depressed that I almost committed suicide. And it was a classmates reaching out to me in the cafeteria. I was sitting way far away from everybody else. She came and sat with me. She knew the signs, she knew the signs of what to look out for someone who was in a mental health crisis, and she said, here's my number. I'm going to call you. You call me, and if you ever need me, I will be there. And so the time when I almost committed suicide, I walked out of the house and I sat down on the front stoop and I picked up the phone and called her and she got me to the emergency room. I have learned so much from that experience and that hospitalization because I never wanted to get that sick of her again.

And one of the biggest things is the importance of being able to spot a mental health emergency in another person because knowing how to respond, detect that and respond is just as important as knowing CPR to save lives. And I learned so much from that hospitalization of how to keep from getting that sick ever again. One of those is daily monitoring and just waking up and saying, on a scale of zero to 10, crying face to smiley face, where am I? And I shoot to be right in the middle so that I'm not too high, not too low. I'm just staying even Steven. And it's interesting because now the National Institute Mental Health has a page dedicated to apps. You can actually download and use websites you can go to where you can track your mental health conditions or your use of alcohol or drugs or cigarettes or whatever you're trying to improve in your life.

And I think that has been one of the most important parts of what I call the secret sauce to success with a mental health disorder. And that's one of the most important things. And the other thing is, one of the other things is having good social support, access to care. But the most important thing is good choices. I don't have the control over having whether I have this condition, but I do have control over the choices I make of how I get help, what I do when I'm not feeling well. And thankfully, even during the pandemic, I've been really stable and successful despite the isolation of the pandemic. But those are just some lessons learned that I had. And big takeaways. I think the most important thing though, aside from good choices, is getting help when it's a snowball and not an avalanche because it's so much easier to get better when you're at the snowball stage than when it's an avalanche and you're in crisis.

Dr. Darrell Kirch:

Taking that metaphor of snowballs and avalanches, one thing we all know is that COVID took a toll on us all as individuals and as a society. And we're still struggling with that. And that was especially true for physicians and other healthcare professionals. And burnout rates went up during covid. They may be coming down, but they're still far too unacceptably high. And burnout in the isolation that comes along with burnout, the feeling of losing your connection to others, your concern for the patient becoming cynical is an early stage of perhaps more severe things to come. And that's why the wellness projects like the CAP project, the establishment in health systems now of chief wellbeing officers really focus on that social connection, that ability to check in with the person, not just the job that can create a healthier workplace for people. And I think perhaps, I mean COVID was awful by any measure, but perhaps it's increased our awareness of just how vulnerable we are, especially as physicians and especially I believe as trainees in medicine, just how vulnerable we are and will be extra energy to this overall wellness wellbeing initiative.

Becca Battisfore:

Both of you shared. Someone noticed the signs, as you both said, someone reached out, someone gave you a different decision, an option to go to treatment rather than quit medical school. And those are those special individuals who knew something. And my hope is that more and more people through efforts like talking about it, will have more people out there to watch those signs. So thank you both for sharing your story on that. I appreciate that.

Dr. Alison Van Dyke:

Yeah, absolutely. I know suicide is something that no one wants to talk about, but it's the tragic endpoint that no one needs to go to and we really have to speak openly, have to support, especially our trainees. I think they're the most vulnerable in the whole system of medicine because they're not in a position of power or seniority to be able to really control much of their lives. And attendings their schools, their colleagues have so much influence over what happens next in their careers. So I don't know Dr. Kirch, what initiatives are now going on in the AAMC or ACGME.

Dr. Darrell Kirch:

Both the accreditation bodies for medical school and for residencies now have become much more explicit about the importance of having wellbeing and mental health resources, not just available, but buttressed in ways, isolation. Again, the surgeon general Vikek Murthy has talked very eloquently about how isolation is a social problem in general in our country and how it was exacerbated by COVID. And so this has to be both top down and bottom up. Everyone from the dean through the department chairs to the clerkship directors and residency program directors needs to have programs in place. But at the same time, you have to create mechanisms and a culture of support. One thing we've seen is medical schools, for example, and residency programs, really taking time periodically throughout the year to bring the trainees students together in smaller groups to just talk about how is the personal emotional experience of their training going For them, group support is one of the best antidotes to burn out and worse, so we're finally starting to institutionalize wellbeing and wellness within our medical training system and within health systems. So you need the right tone at the top, openness, acceptance, de-stigmatization at the top, as well as ground level mechanisms for people to stay connected and to be supportive of one another. 10 years ago, there were no chief wellness officers in health systems. It seems now every day or two, I learn about a new one being appointed. I think that's a very positive sign.

Dr. Alison Van Dyke:

There are lots of resources about workplace mental health and wellness. The Surgeon General has a website that addresses workplace mental health and wellness. Mental Health America has a workplace mental health and wellness toolkit with very practical tips on how do you speak to a colleague who has your suspecting has a mental health concern, even I think it's the American Society of Suicide Prevention. I'll have to look that up.

Dr. Darrell Kirch:

It's the American Foundation for Suicide Prevention.

Dr. Alison Van Dyke:

Prevention. Yes,

Dr. Darrell Kirch:

AFSP. Very good resources.

Dr. Alison Van Dyke:

That's what I was thinking about. And they have a toolkit just for and resources just for physicians. So there's so much out there, but really that personal connection to somebody that there's that saying, identify somebody who's struggling or needs help connect with them and understand what they're going through or the ICU abbreviation. I think that is really, really critically important. That social support network that people have can really make the difference between life and death.

Becca Battisfore:

Absolutely. Yes. We'll have links to all of those along with the episode so that people can find those. So thank you for sharing all of those. Are there any final thoughts as we wrap up that you want to share? I mean, you've already shared a tremendous amount, both personally and just as resources, but anything else that comes to mind that you want to share that we haven't gotten to yet?

Dr. Darrell Kirch:

I like to think of myself as very much a realist, and I know this is going to be a battle. There are lots of cultural factors we're trying to change, and culture change is not easy on any issue,

But we have such a well-established beachhead now, and I think that we need to seize this moment. We've come out of COVID, a time of global turmoil for healthcare. We survived that insult, and now's the time when we can really turn to building our collective wellbeing within the health professions. It was during COVID. We were just trying to do our best to take care of the patients. We now have a bit of breathing room, and we've learned a lot of lessons from COVID about burnout and the toll that mental disorders can take on clinicians. I think the time is now. And while I'm very realistic about the obstacles, I'm so optimistic when I see a generation of leaders like Dr. Van Dyke, when I see organizations like CAP taking this on. We just need to build the momentum. It started. We need to build on it.

Dr. Alison Van Dyke:

Just want to leave you with encouraging people to reach out to each other. That human connection piece can make all the difference in the world for somebody. So just open, encourage these open conversations. And one last thing is that while we focused on physicians here in the laboratory environment, there are also pathology assistance. There are, or pathologist assistants, there are lab techs, and they are just as vulnerable and susceptible to these conditions and the stress that we're all under. I think approaching it as not only talking about physicians, but the entire laboratory environment needs to be a healthy one and to have that psychological safety that Dr. Kirch talked about.

Becca Battisfore:

I want to thank Dr. Van Dyke and Dr. Kirch for joining the podcast to share their very personal stories. We are so grateful for their openness, which I know will help in the growing discussion on the importance of physician mental wellness. And I want to thank you all for listening to this CAPcast. You can find the resources that were mentioned during the episode along with other wellness read sources in the show notes. And for more information about the CAP visit cap.org.

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