The PAPERs Podcast

Episode host: Lara Varpio.

This episode, hosted by Lara Varpio, tackles the pressing issue of mental illness among physicians and trainees—a crisis that remains hidden due to fear and stigma. We examine a crucial study that uncovers the obstacles to self-disclosure in medical training and highlights the ways we can better support those who care for us. Listen in for a powerful discussion on breaking down the barriers to mental health in medicine. Note: This episode may be triggering for some listeners (listener discretion is advised)

Episode notes

Background 

What do we know about the struggles physicians and physicians-in-training face? A lot. We know the rates of depression among residents is high—around 29%–while the rate among non-physicians is much lower—closer to 8%. We know physicians die by suicide at twice the rate of the general population. And we know that, in October 2020, at the height of the COVID epidemic, 87% of emergency physicians reported feeling stressed, but 45% said they didn’t feel comfortable seeking treatment. So we know that a proportion of all physicians suffer from mental illness. 

We know that many physicians have real and justifiable worries about disclosing that they live with mnetal illness. Not living up to medicine’s expectation for perfection, what such a disclosure might mean for their license, being labeled “weak” or “problematic” by their peers: these are legitimate fears. 

Today, it isn’t safe for physicians to disclose that they live with mental illness. We know physicians are living with mental illness. And yet we make it very hard—if not impossible —for those individuals to disclose their experiences and seek help.  

The study I picked today addresses this very problem. It is by Kassam, Antepim, and Sukhera, published in Perspectives on Medical Education.  

Purpose 

It explores the barriers and enablers of self-disclosing mental illness by understanding the perceived outcomes (both positive and negative) of self-disclosure among medical learners. 

Methods 

The authors worked from a pragmatist orientation, and conducted a mixed methods study using a sequential qualitative research design. In this study, the survey acted as a selection tool and background framing for the qualitative portion of the study (quant->QUAL). 

The quantitative survey consisted of two parts. First, the survey asked several demographic questions that the research team used to provide insights into participants’ intersectional identities (eg. gender identity, ethno-racial identity, marital status). The second part consisted of three previously developed and psychometrically tested questionnaires: (1) Self-Stigma of mental illness scale (short form); (2) the Opening Minds Scale for Health Care Providers; and the WHO-5 Well-being Index. Continuous data were analyzed using independent sample t-tests comparing mean scores of the questionnaire sub scales and demographic data that were not dichotomized. They used Cohen’s d to determine the extent of relationships between the data 

The qualitative component of the study found the researchers conducting interviews with participants who had self-disclosed their mental illness to anyone in their sphere of training. They used hermeneutic phenomenology. They used 90min interviews to solicit narratives of experience. They also analyzed open comments from their surveys too. Analysis followed the hermeneutic approach—à la Ajjawi and Higgs—to move from first to second order constructs via immersion, understanding, abstraction, synthesis, illumination and integration.   

Results/Findings 

The quantitative results paint a grim picture. 36.3% of respondents reported having disclosed a mental illness. 24.7% have only considered disclosing. Medium effect sizes were found with:

• Radicalized learners having more stigmatizing attitudes overall, and more stigmatizing attitudes with respect to disclosure and
• Learners identifying as women having lower stigmatizing attitudes than those identifying as men.
• Poor well being was shown ACROSS all the participants.
• Residents had more negative attitudes towards people with mental illness and towards disclosing mental illness.
• People who identified as racially minoritized learners scored HIGHER in applying the stigma of mental illness TO THEMSELVES than white learners.

The qualitative results are not rosier. The authors first talk about enablers and barriers to disclosure. Nothing surprising when it comes to barriers; it is about fear and stigma. Fear of judgement from peers, fear of retribution or career outcomes from those with more structural power. Among medical students, they had fears of appearing as though they weren’t up to standards, not up to par. Residents described fear of a negative outcome for their career, fear of future licensure applications being problematized as a result.  In terms of enablers, the most prominent was supportive social relationships—e.g., preceptors who were genuine and empathetic and understanding. Supportive peers. Having reassurance of anonymity and transparent policies about what would happen if they disclosed. Participants talked about needing to give themselves permissions to self-disclose, to overcome their internalized fears of being weak, of being less-than, of not being worthy of their place in the profession. Participants also talked about their journey to disclosure—but those journeys were highly variable in terms of perceived identity and diagnosis. In terms of diagnosis—there seems to be a hierarchy. One participant described not being sensitive to their ADHD diagnosis but that they were very concerned about the stigma round their bipolar disorder. Another participant was less concerned about their bipolar diagnosis but they were very hesitant about their obsessive-compulsive disorder diagnosis. And their perceived identity also factored into their journey. If the individual feels “outside” the system because of part of their identity, it impacted their comfort with disclosure.  

“Participants described a sense of hypocrisy, double standards, or duplicity. Several noted that application processes seemed to seek students who were well rounded and that narratives of adversity were often anticipated, YET their experiences in medical training were discordant to their exceptions and their conceptualizations of what would make a good physician” 

The authors do leave us with one single thread of hope: participants described feeling positive about disclosure. They felt better and more confident about themselves after disclosure. 

Conclusions 

Mental illness stigma and the individual process of disclosure are complex issues that get more challenging over time. 

Comments 
We are perpetuating what is TRULY an unnecessary and yet persistent contradiction. We say we care about the health of our trainees and physicians in practice. The numbers tell us they are in crisis. BUT our traditions, our beliefs, our expectations of perfection, of grit, of Teflon-like resilience and invulnerability—we cling to these with such desperation that we willingly inflict harm upon ourselves.