Thing were going well—on paper.
Scott H. Pasichow, MD, MPH, was advancing in his career. As a second-year emergency medicine resident at Brown Emergency Medicine in Providence, Rhode Island, he saw his responsibilities increase. And so did his leadership profile, in the form of a position as speaker for the Emergency Medicine Residents Association, which gave him a position within the AMA Resident & Fellow Section (AMA-RFS) .
Why, then, was he feeling no joy in the physician work he had aspired for so long to do? Why was he feeling as though every day was an uphill battle? And why, after a frustrating shift, was he letting loose his temper by victimizing a parking garage traffic cone?
“I went to work for my regular p.m. shift and just worked the night before and had a complicated patient that I got admitted. I didn’t really think much was wrong with them, and then I showed up for work and they had died” after being admitted, Dr. Pasichow said in an interview. “I just felt like I missed something. I don’t know if that’s true or not, but that’s how I felt at the time.
“I was stuck in a negative self-talk space of ‘I’m never going to be successful,’ and the anger built and I took that anger out on a traffic cone,” said Dr. Pasichow, who wrote about his experience for ACEP Now, which is published by the American College of Emergency Physicians. “Thankfully, the hospital and residency program said it was a sign that I needed to get help.”
Discover four ways that residency programs can help medical residents beat burnout.
That wasn’t the first time that Dr. Pasichow had experienced the death of a patient, but it was the first time he took it so personally and reacted with such anger. He said the incident was the culmination of months of signs that he had done his best to ignore.
“You could broadly categorize what I was feeling every day as signs of burnout, [things like] looking forward to going to work less,” he said. “Not feeling like I was having a meaningful impact in the lives of my patients. Feeling like I was fighting the system and struggling constantly, and not feeling like I was having the wins and the benefits for my patients.”
Eventually, those signs of burnout led to darker, more troubling thoughts.
“If I had paid attention to the burnout signs earlier, I could have prevented the suicidal thoughts before they showed up,” said Dr. Pasichow, an AMA member who is now assistant professor of emergency medicine at Southern Illinois University School of Medicine in Springfield.
Learn about congressional passage of a bipartisan, AMA-supported bill to promote physician mental health.
The traffic-cone incident led to Dr. Pasichow and his residency program agreeing that he would seek cognitive behavioral therapy. The therapy was difficult at first, he said, leaving him to unpack much of the anxiety and depression he had harbored in recent months during sessions. And it wasn’t until he paired therapy with medication that he began to feel better.
“The biggest barrier for me when I started [therapy] was what is my program going to think, which coming to them with a plan of what I want to do, they said: You are safe, and getting things safe and taken care of—those are the two things we care about,” said Dr. Pasichow, who tweets to #StopTheStigma about mental health @SPMD16 and is now the emergency medical services medical director at HSHS St. Mary’s in Decatur, Illinois, and HSHS St. John’s in Springfield.
“The barrier for medication was wondering ‘what am I going to have to report to a medical board and how is that going to affect my licensure’,” he added. “But if you are taking responsibility for and handling your mental health with a professional, even when taking medication, most states don’t ask about it. If it doesn't impact your ability to be a doctor, they won't ask.”
The AMA has been advocating for all state medical boards to review their initial and renewal licensing applications to support applicants’ mental health and wellness. The AMA supports questions that focus on whether an applicant has an untreated current impairment that could affect an applicant’s health or a patient’s safety.
On the other hand, AMA has been urging state medical boards and others to remove questions that ask about past diagnoses—questions that could cause individuals such as Dr. Pasichow to answer falsely out of fear of not getting licensed or being subject to stigma from his colleagues. Some states, including Minnesota and Ohio, have taken recent, positive steps to remove stigmatizing questions.
“Central to wellbeing is adequate access to mental health support. Any barriers to this directly impede the wellbeing of the physician workforce, and thereby the patients they serve. Requirements and questions for disclosure of mental health issues, create such barriers, and contribute to the stigmatization of mental illness,” said Sanjay Desai, MD, AMA Chief Academic Officer.
Find out more about why medical boards must avoid contributing to mental health stigma.
Dr. Pasichow said it wasn’t until months later that he got a social cue about how unhappy he was during those dark months, when a colleague came up to him and said, “It’s good to see you smiling again.”
“When you see the personality of your colleagues changing, after a shift ask them to grab a drink or a coffee, sit and talk with them, spend a little time with them,” Dr. Pasichow said. “Maybe it’s not their job, maybe it’s their home life, maybe they are just going through a stressful time. It’s so helpful to take a little extra time to connect with people and let them know you care about them.”
For residents who are going through hard times, your support system is there for you both inside and outside the hospital, Dr. Pasichow said. He continues to manage his depression with a regiment of medication and therapy. In looking at his experience he added that “I think it's important for people to see that this a process that ebbs and flows, but in some ways is always with you.
“Lean on your support structure and make sure you have somebody you can talk to about your struggles and success,” he said. “We’re all going to have bad days and bad weeks. And recognizing when the bad is going to outweigh the good—when you’re not finding you’re getting the satisfaction out of the job you are hoping for—reach out for help as early as possible, whether it’s through a therapist though the residency program or someone else.”
Learn about the signs to watch for in a physician colleague at risk for suicide.
In this Q&A, AMA Vice President of Professional Satisfaction Christine Sinsky, MD, clears up confusion on physician burnout and depression.