Physicians offer prescriptions to boost low morale.

Just a couple of years ago, Charles L. Garrett, Jr., MD, was the picture of health--corpulent ill health, that is.

A forensic pathologist in Jacksonville, North Carolina, Garrett, now 66, had gorged himself to a belt-taxing 250 pounds.

He was also under tremendous stress. In addition to heavy involvement in directing the state's physician licensing board--he served as its president in 2004-2005--Garrett was carrying the load for a sick partner, single-handedly performing a demanding schedule of autopsies for hospitals and agencies like the Camp Lejeune Marine Corps base that contract with his Coastal Pathology Associates.

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"I think my overeating was due to the fact that I was working awfully hard," he says. "And it's really difficult to change those patterns."

In March 2004, at his wife's insistence, Garrett agreed to keep his appointment for a long delayed physical. As a consequence of his obesity, he learned, he had developed Type-2 diabetes. His fasting blood sugar level was a scary 212 milligrams per deciliter.

Garrett was all too familiar with his own syndrome.

"We are supposed to be role models for our patients!" he wrote in a front page "President's Message" in the North Carolina Medical Board's 2004 fourth-quarter report. "Most of us have quit smoking (except for occasional good cigars with single malt scotch). The majority of us wear our motor vehicle restraints at all times and some of us even exercise. But it amazes me ... how many of us are overweight, don't know our cholesterol profile numbers, get a colleague to sign off on our physical exams for renewal of our hospital privileges, or just put our heads in the sand when it comes to our own health....

"In these four years, I have seen the terrible toll that our inattention to our health care has taken on the licensees of this Board," he continued. "I am not talking about those that have had problems with substance abuse and mental illness, but those licensees that have suffered major catastrophic events due to heart disease, stroke, diabetes mellitus, and a variety of disorders that could have been significantly impacted by early detection and/or preventive measures."

Not like combat, but close

"One thing physicians traditionally do," observes Fred Jones, MD, CPE, FACPE, "is not take very good care of themselves. And with everything going on in health care--it's the perfect storm right now--things are pretty frustrating. It's not like being in combat, but it's not too far down."

Jones, a retired cardiologist who consults for The Greeley Company, also serves on the board of a small critical access hospital in Brevard, North Carolina. He speaks from broad personal experience. But his assertions are firmly evidence-based. Consider:

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* A survey of graduates of the Johns Hopkins School of Medicine, mean age 61, found that more than a third--35 percent--admitted to having no regular source of personal health care. (1) That's twice the percentage of the public at large. (Other studies have found that up to 56 percent of doctors don't have their own doctor.)

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* A 2003 statement by the American Medical Association on "Confronting Depression and Suicide in Physicians" noted that, although hard data are lacking, physicians' use of mental health services "also appears low." (2) Research among medical students in 2002 found that only about one in five who'd screened positive for depression sought help. (3)

* And yet, as the 2006 ACPE Physician Morale Survey found, doctors across the country feel they are close to the end of their ropes. Nine out of 10 physician leaders said they've witnessed severe morale problems among their colleagues: emotional burnout, fatigue, family disruption, depression, substance abuse, suicidal thoughts and more. Three-quarters reported they've experienced those symptoms themselves. And three in five survey respondents said they had considered chucking their medical career as a consequence.

"Most physicians," declares Jones, "are disappointed in the economic achievements they'd expected. Certainly that's true in primary care. So they're looking for ways to work harder. They characterize it as being on a treadmill. Boomers are probably the most frustrated group--the primary care doc age 55 is probably the one most at risk. I'm not in position to diagnose anyone as clinically depressed, but most of them are 'mad,' 'agitated' ... and 'upset with the administration' because they don't know who else to blame."

Meanwhile, he says, "the demands on physician executives time-wise are probably as great as they would be if they were in practice--but they're not in control. Some physicians want meetings at 7 a.m. and 8 p.m. Administrators want to meet all day. So as demands grow from both sides, the physician executive feels the pain of both parties. You've got to have some protective armament against that."

"The irony of working in an organization," agrees Barry Herman, MD, MMM, CPE, FACPE, senior regional medical director for Pfizer in Radnor, Pennsylvania, and a psychiatrist by training, "is that the higher up the ladder you go, the less ability you have to control the operating environment.

"As a leader, you're seen as a change agent--yet paradoxically, you don't have ultimate control. That creates a tremendous amount of stress. My guess is that physician executives experience a higher level of stress, although of a different kind, than physicians in clinical practice." (The "average life expectancy" for an HMO medical director, he notes is "about two years. I don't think anything can really prepare you for that.")

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No wonder

According to the researchers who studied the Johns Hopkins cohort, doctors who neglect their physical well-being tend to do so because of an innate conviction that health is more a matter of luck and fate than of medical intervention.

So, not only do those physicians (they are most likely to be internists, surgeons or pathologists) routinely blow off flu shots and screenings for breast, prostate and colon cancer for themselves, they're also less likely to preach such preventive care measures to their patients, the researchers found.

Doctors who spurn psychological help when things look bleak, on the other hand, have more pragmatic concerns.

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"If you knew your physician had been to a psychiatrist," challenges Josie Williams, MD, of Texas A & M University, "how confident would you be in him or her?"

In medical school, seeing a counselor has been known to torpedo one's residency prospects. (4) As a practicing physician, a history of psychiatric treatment can trigger "overt or covert discrimination in medical licensing, hospital privileges, health insurance, and/or malpractice insurance," the AMA statement acknowledges. And how would a doctor's patients react if confidential records of a mental disorder--even if successfully treated--were somehow to leak out?

Interweave all that with what the AMA calls "professional attitudes that broadly discourage admission of health vulnerabilities." No wonder, then, that the doctors Williams sees "in the trenches"--so many of whom, she says, are "suspicious, and they should be ... frustrated, and they should be ... barely coping"--no wonder they deal with their anguish by "occasionally talking to a buddy. Or they just suck it up."

Personal vigor

Surprisingly, perhaps, those are pretty much the coping basics recommended by ACPE-member psychiatrists Akintayo Akinlawon, MD, MPH, CPE, Jody Foster, MD, MBA, and Alan Sooho, MD, MBA.

"You can adapt," says Akinlawon. "Find things that make you happy and keep you going." For him--chief of service at the Veterans Administration Medical Center in Bath, New York--those include such simple pleasures as travel, exercise and reading. Oh, and riding a motorcycle.

When Foster began her residency at what was then the private Institute of Pennsylvania Hospital, in 1989, she says, it had a Freudian, analytic orientation. Average length of inpatient stay was 60 days, and some patients had languished in the hospital for years. Medication was introduced tentatively if at all. Drug effects were closely monitored for weeks or months.

Then along came managed care.

By the time she graduated in 1993, Foster recalls, "we were trying to get ALOS down to three or four days. Medications were started within 24 hours. The convalescent period occurs as an outpatient." Today, rather than teasing out the subtle causes of dysfunction on the couch, she says, "We intuit tips of icebergs and shoot at big targets."

Thoroughly demoralized, her older colleagues began pleading depression and wrangling for disability retirement. Or they quit to hang out shingles in the suburbs. "Managed-care changes destroyed the place," Foster says. "Eventually (the Institute) closed. But I took a more proactive course, and I survived."

Indeed, as the Institute dissolved around her and its staff of 250 dispersed, Foster seized the opportunity to "go back and get an MBA and expand my horizons."

Keeping one's mental balance when the earth is heaving beneath one's feet, she says, really comes down to "having the personal vigor to get on with it. When I found myself running an inpatient unit with nowhere to go in my career, I didn't start shooting heroin. I went to Wharton."

Foster's still at Pennsylvania Hospital, chairing its department of psychiatry. And she's executive medical director of the University of Pennsylvania's Penn Behavioral Health Corporate Services. Moreover, she's just had a baby, her first child, a daughter. "I'm in absolute heaven!" she exclaims.

To be sure, Foster finds current insurer-dictated protocols for the treatment of psychiatric illness less than ideal. "Inpatient care has become glorified crisis intervention," she says. "I've justified it to myself that instead of running a very deeply inadequate [inpatient facility], I run an exceedingly adequate ER. I've kind of refigured my goals."

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A matter of choice

That, too, is a fundamental strategy for countering the occupational blues, agrees Sooho.

"We all have choices in life," he says. "And one is attitude. None of us has to be unhappy. If at the very end we can't change our circumstances, then maybe we can change our attitude."

Sooho, who's been a Veterans Administration psychiatrist for 27 years--he practices at the Battle Creek, Michigan, VA center--says that's how he deals with discouragement.

"I feel like a baby when I'm stressed out," he declares. "I ask myself, 'Is anyone trying to shoot you? Is anyone trying to blow you up?' No, I'm having troubles with the union, or the air conditioner in the building is off, or the formulary has dropped the medication ... and I feel silly. Those are very insignificant when you think about young people 19-, 20-years-old, in life-and-death situations."

Those youthful troops in Iraq and Afghanistan made a pivotal choice, one they'll have to live with for the duration--even, perhaps, die with. Doctors commonly enjoy more flexibility.

Pediatrician Adam Mezoff, MD, CPE, for example, finally found the demands of a full clinical schedule, teaching at the Boonshoft School of Medicine at Wright State University in Dayton, Ohio, and running the Wright State University physicians group as its president/CEO just too much of a strain.

"One had to give," he concluded. So he recently resigned his administrative role. "I've refocused," he says. "I'm happy with my choice."

A decision to scale back sparked a renewal of satisfaction for three physician friends, adds Barry Silbaugh, MD, MS, FACPE. One is a solo practitioner who has reduced his office hours to write a novel ("he's not making as much money but he's enjoying life more," says Silbaugh); one is an emergency physician who's "branching out into working with animals and applying the body language of horses to the management of human beings;" one is a gastroenterologist who has carved out time to accompany his family on overseas trips.

Silbaugh, who lives near Albuquerque, has himself taken a purposive stride "outside my comfort zone" by accepting a half-time job as CMO of an Internet startup called Consumer Healthcare Advantage, based in Redondo Beach, California.

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"That's another key," he counsels, "live below your means--so you can take risks in your career to do things that are more interesting to you. If physicians aren't learning something new, their spirit tends to deteriorate."

But not every disheartened physician has the luxury of packing it in to follow his or her bliss, Sooho acknowledges.

"I once worked for a man who had five or six cars. The question is, does anyone need that many cars? Does anyone need the 4,000-square-foot house? If the answer is no, then downsize. If the answer is yes, then acknowledge 'that's what I'm working for. I'm doing this for my spouse, or my family, or the country ...' rather than just for a paycheck. If one can attach a mission to it, one has a sense of serving a greater good."

At the same time, points out Silbaugh, "we all deal with conflict--every single human being on the face of the earth. We all deal with frustration and low morale, usually from some kind of loss or perceived loss--of income, respect, prestige, routine, influence.... It would be nice if physicians recognized more often that they're just like everybody else."

Taking care

Psychiatrist Luis Sanchez, MD, directs Physician Health Services, Inc., a nonprofit corporation founded by the Massachusetts Medical Society to provide confidential consultation and support to doctors, residents and medical students facing health concerns related to alcoholism, substance abuse, behavioral or mental health issues or physical illness.

It's one of 46 such organizations around the country, nearly all united under the banner of the Federation of State Physician Health Programs, whose presidency Sanchez currently holds.

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Among Massachusetts' 25,000-plus doctors, reports Sanchez, about 160 are being monitored at any one time by his program for significant problems. And of those doctors, he estimates, at least 75 percent regain their footing.

But, of course, those are the very few whose desperation has driven them over a bright line--into heavy drinking, self-medication, intolerable belligerence, ineptitude or neglect in the care of their patients, attempted suicide. For every one of them, he notes, the Massachusetts program helps two others who have been referred or who have sought out confidential assistance for less severe distress. Each year Sanchez speaks at 40 or 50 of the state's 70 hospitals, he says, spreading the word about the resources his organization can deploy.

"Our goal," he declares, "is to have every physician in Massachusetts aware of what we do. But I don't say to doctors, 'Come to the Physician Health Service.' I say, 'Let's learn how to take care of ourselves.'"

Not that the profession and its organizations don't have a fundamental responsibility to protect the psychological and physical well-being of their own, Sanchez emphasizes--especially in a time of exceptional turmoil. It's a responsibility all too often ignored, he says.

For example, as the AMA statement notes disapprovingly, "many hospitals, clinics and malpractice insurance carriers continue to ask questions that inappropriately focus on psychiatric diagnoses and require review of medical records...."

Says Sanchez: "We think those questions should be thrown out. Eventually, the Americans with Disabilities Act is going to get them thrown out."

Sanchez hails as "terrific" a new requirement by the Joint Commission on the Accreditation of Healthcare Organizations that hospitals establish a physician health committee to identify doctors in trouble--and actually provide resources to assist them. But beyond that, he says, "it's time for CEOs to demonstrate what the values of our organizations are. That time off is okay. That sabbaticals are okay. That maybe every physician should be required to have a personal physician....

"Down the road," he continues, "there should be opportunities within institutions to have discussion groups where physicians can talk about what's going on in a safe, non-threatening environment. How they feel about the nurses, how they feel about their colleagues ... that kind of thing is very, very threatening right now."

Meanwhile, he advises, "it's vitally important that the people who're watching, when they see a colleague who's struggling, pull that person aside and in a private way--maybe over a cup of coffee--say, 'I'm worried.' There are always red flags."

"As a society, we need to de-stigmatize mental illness," urges Sooho. "We should make getting professional help from a psychiatrist as acceptable as saying, "I'm diabetic. I'm going to see my endocrinologist.' People would say, 'Mm, that's a good choice.'"

For his part, Sanchez doesn't question the accuracy of Williams' observation that doctors shun psychiatric counseling or treatment because they're afraid patients would flee if they knew. But, he counters, "the physicians who've been monitored by us--those are the ones I'd prefer to go to as a patient. Because they know their issues!"

He has himself, he reveals, recently experienced a spate of deaths in the family. "I'm 64," he continues. "Divorced. I have two kids. One with emotional problems. I've been in therapy. And I think I'm doing okay!"

Get moving

Alaska has oil. It has untracked wilderness. It has stirring vistas. It has snow. But it has essentially no homegrown health care personnel. So Douglas Eby, MD, MPH, vice president for medical services at the Southcentral Foundation in Anchorage, pays close attention to what will cement and what will dissolve the loyalty of the doctors he painstakingly recruits from the outside world.

Chief among the former, he says, is an organizational model that grants staff physicians "professional respect and influence over their work environment."

Southcentral is an Alaska Native-owned health care organization serving some 47,000 residents of the Cook Inlet region and its 60 scattered villages. It has worked closely with the Institute for Healthcare Improvement in Boston to develop an exemplary system of evidence-based, reliable, responsive, coordinated care.

"Every health indicator you want to measure is radically, dramatically improved," boasts Eby. Result: Physician satisfaction ratings routinely top the 90th percentile.

Not every doctor, he admits, flourishes in the system. Nor in the unique environment.

"To get to live in a kind of exotic place is an attractor and a mental health enhancement," Eby suggests. "And in this system, getting to work with a native population is culturally interesting. But ... most professional staff are away from their extended families. The number-one reason for our losing physicians is grandparents' pressure. And the winters are long. Snow is on the ground for five months of the year, essentially."

"Anchorage itself is in the 'banana belt, (1)" he notes. Further north, in Kotzebue, Nome and Barrow, for example, "there are no trees, just bare tundra, it's colder and darker."

Doctors who staff these isolated locales seldom stay more than five years, he says. "In the remote villages, those who move with their whole families tend to be healthier and stay longer than individual or single doctors," he adds.

But no matter whether it's the all-too-brief twilit days of midwinter or the chill or the loneliness, he has concluded, the antidote--the protectant against excessive melancholy--is vigorous action.

"If you do things outside," he declares, "Alaska is a fabulous place! If you sit inside and wait for the winter to pass, you have a hard time."

That echoes a recurrent theme among the physicians who commented for this article. The single best way to buoy one's spirits and maintain--or restore--a healthy mental and physical equilibrium, they all agree, is simply to exercise.

For Eby, that takes the form of kayaking, mountain biking, backpacking and "dip-net fishing in a raging river" with his three teen-age children.

Newly part-time Southern Californian Silbaugh "took a lesson in yoga out here," he chuckles "And I got a boogie board. I have a colleague who's gone into surfing. I may do that, too. It helps your balance and your self-awareness--how you're feeling from one day to the next."

Indeed it was exercise, albeit of a less flamboyant sort, that the once rotund Garrett--shaken by the results of his physical exam in 2004--seized on to reshape himself into the man he used to be. Which is to say a leaner, fitter, happier and more vigorous--even diabetes-free--two-thirds of the man he was when he weighed 250.

"I've lost 90 pounds," he says. "I now weigh 160. I walk or run two miles a day, either outside or on a treadmill depending on the weather. And I've cured the diabetes by losing the weight."

He does, to be sure, down a typical daily pharmaceutical cocktail for a man of his age and condition: metformin to lower his blood sugar, an ACE inhibitor to control his blood pressure and a cholesterol-reducing statin. And he pays rigorous heed to his dietary watchwords "plenty of fiber and EAT NO WHITE STUFF!" The payoff: His FBS today is in the 80s. His HgbA1c is within the normal range. His HDL is 90.

To his colleagues, Garrett urges, "Have a real physical exam. Get a personal physician and listen to him or her. Know your cholesterol profile numbers and, if necessary and if prescribed by your personal physician, take statin drugs. If you are over 50, have a colonoscopy and, most of all, develop a daily exercise program.

"We have a shortage of physicians ... in our state," Garrett reminded his readers in 2004. "Rather than increase the numbers we are training, help us keep the ones we have in good working order. If I can do it, so can you."

David Ollier Weber is a freelance health writer and frequent contributor to this jounal. He can be reached by e-mail in Mendocina, Calif., at [e-mail].

References:

1. Gross CP, Mead LA, Ford DE, Klag MJ. "Physician, heal thyself? Regular source of care and use of preventive health services among physicians." Archives of Internal Medicine. 2000, 160:3209-3214.

2. Center C, and others. "Confronting depression and suicide in physicians. A Consensus Statement." JAMA. 2003, 289:3161-3166.

3. Givens JL, Tjia J. "Depressed medical students' use of mental health services and barriers to use." Acad Med. 2002, 77:918-921.

4. Oppenheimer K, Miller M, Forney P. "Effect of history of psychological counseling on selection of applicants for residencies." J Med Educ. 1987, 62:504-508.

RELATED ARTICLE: Mental Health Problems Plague Health Care Workers

Health care organizations can expect at least one in four employees to endure an episode of significant psychological illness during their prime working years, based on National Institute of Mental Health estimates. And in any given year, more than one in 10 will experience clinical depression.

For some occupational categories the risks are even greater. Physicians, nurses, chiropractors, health technologists and dentists have higher-than-average suicide rates. Health technologists, licensed practical nurses, clinical laboratory technicians, nurses aides, registered nurses and dental assistants had among the highest rates of hospitalization for mental disorders in one study of 130 job classifications.

Recognizing the symptoms of depression in oneself or in one's coworkers is an essential first step. Those may include:

* Insomnia or compulsive sleeping

* A dramatic change in appetite accompanied by a notable change in weight

* Fatigue and lack of energy

* A sense of worthlessness, self-hate or inappropriate guilt

* Inability to concentrate without extreme effort

* Agitation, restlessness and irritability

* Lethargy and withdrawal from usual activities

* Feelings of hopelessness and helplessness

* Recurring thoughts of death or suicide

The number of symptoms experienced at once and their severity and persistence determine the degree of illness and the nature of therapy.

Getting help is the second step. Serious depression can be treated effectively by drugs and/or counseling. But according to the National Institutes of Health, one can also do many basic things to alleviate depressive symptoms:

* Get enough sleep

* Eat a nutritious diet

* Exercise regularly

* Avoid alcohol and drugs

* Get involved in activities that make you happy, even if you don't feel like it

* Spend time with family and friends

* Try talking to clergy or spiritual advisors who may help to give meaning to painful experiences

* Pray, meditate, practice tai chi or biofeedback 

* Eat fish like tuna, salmon or mackerel (for the omega-3 fatty acids)

* Take folate (vitamin B9) in a multivitamin pill (400-800 mg.)

* Try light therapy during the winter months to alleviate seasonal affective disorder 

In 2002, the U.S. Preventive Services Task Force recommended that all clinical practices screen adult patients for depression so long as they have "adequate systems in place to assure accurate diagnosis, effective treatment and followup."

Such screening in itself helps attune doctors, nurses and staff to their own symptoms when anxiety and burnout loom, the AMA suggests.

--David Ollier Weber