TUCSON, ARIZ. – Medicine is a high-risk profession for psychiatric morbidities. But several strategies can help reduce the risk of hitting bottom, Dan Shapiro, Ph.D., said at a psychopharmacology conference sponsored by the University of Arizona.
“Physicians are like big ships,” said Dr. Shapiro, a psychologist at the university who specializes in treating physicians. “By the time you can see that they are sinking, it's too late.”
One of his more radical solutions is the creation of a no-fault malpractice system in which physicians would be granted no-fault judgments in exchange for disclosing mistakes. Physicians and patients would share the cost of reimbursing injured patients by contributing to a shared local fund. Serious mistakes would be voluntarily reported to a local commission, which would also have the duty of compensating injured patients according to preestablished guidelines. State boards would investigate physicians and nurses who failed to come forward.
The system would improve the dismal rate of medical error reporting and address one of the biggest stresses for physicians. “Many physicians who are defendants say that being sued was the worst experience of their life,” said Dr. Shapiro, who is also an author and cancer survivor. Being lied about in court or characterized as an uncaring, negligent physician is emotionally traumatic to physicians. For those who did cause harm, the scars can last for years. His efforts to treat one such physician are detailed in his book “Delivering Doctor Amelia.”
Medical errors are a common topic when Dr. Shapiro asks physicians to take 15 minutes to write openly and honestly to a patient about something left unresolved. The patient need not be living, and the letter is never sent. Most physicians start writing immediately, about 10% have trouble getting started, and 5% ultimately never write a letter. The letters are read aloud, which can be cathartic for a group of people who in large part have been competing rather than relating with peers since grade school.
When a few excerpts were shared at this conference, the audience went silent and tearful faces filled the room. The mood lifted only when a letter was read addressed to “Dear fibromyalgia patients” and when an audience member asked whether such a letter could be addressed to an administrator.
Other suggestions from Dr. Shapiro included improving the work environment and improving physician self-care, typically by reducing hours, increasing sleep and exercise, and improving diets. Hospitals often bring in experts to discuss the symptoms of depression and stress. But the key is to address the problem of self-care where it starts–in residency, he said. Administrators and staff should model and demand self-care among residents, and give up the “hazing” model of training. At Arizona, for example, residents in family practice are being asked to establish self-care goals that are followed for compliance.
Part of the problem is that physicians celebrate self-denial instead of self-care, said Dr. Shapiro, who recalled a physician patient who started their session by remarking that he had had to use the restroom for the past 6 hours, but hadn't. “I told him, 'Go pee. That will be more therapeutic than anything I'll do for you in my lifetime.'” Studies have shown that 80% of physicians worked when they were ill, that 52% prescribed for themselves, and that they visited their own doctors at a rate equal to one-fourth the national average.
The results of unchecked emotional exhaustion and depression on the medical profession can be devastating, as evidenced by the reported higher rate of suicide among physicians, compared with the general population. A metaanalysis reported an aggregated suicide rate ratio for male physicians, compared with the general population, of 1.41 and a ratio of 2.27 for female physicians (Am. J. Psychiatry 2004;161:2295–302). Single women physicians without social support seemed to be most at risk, he said.