It’s not easy for anyone dealing with mental health issues or substance use disorders to ask for help, said Dr. Renata Villela, chair of the Ontario Medical Association’s Section on Psychiatry. Maybe even more so when physicians are the ones in need of assistance.
“How can you be a healer if you’re perceived by others as broken?” she asked, calling that way of thinking a “toxic notion.”
Dr. Villela was speaking at a Doctors Treating Doctors presentation and Q-and-A, hosted by the OMA’s Physician Health Program. The Sept. 21 virtual event, which drew 77 attendees, was a partnership between the PHP, the OMA sections on Addiction Medicine, Primary Care Mental Health, and Psychiatry, and the Ontario Psychiatric Association.
The event was planned to provide continuing professional development to OMA and OPA members about best practices when caring for another physician and to further support physicians who are treating their peers.
Doctors routinely treat their patients for mental health and substance use problems. When physicians themselves are among those patients, it is important to remember that the core approaches remain the same, although issues unique to the physician-as-patient must also be addressed. The session focused on the special considerations when treating a fellow health professional, as well as reflections on seeking help as a physician.
Doctors – probably better than most people – hide their suffering, said Dr. Michael Paré, a primary care medical psychotherapist. He talked about one physician’s journey from severe mental illness to recovery – his own.
Dr. Paré has experienced two major episodes of depressive illness. The first and most serious came when he was a pre-med student. “The depression felt like a constant burning in my brain, a constant psychic torture. There was no relief.”
He attempted suicide and was rushed to hospital. Luckily, he received comprehensive treatment, and went on to complete his undergrad, did a master’s degree in neuroscience, and entered medical school. After another depressive episode in medical school, he reached out to the PHP. He was referred for a psychiatric assessment and saw a psychotherapist weekly. Dr. Paré said many physicians are taught to believe they’re superhuman when they’re all too human.
For doctors, signs that they are in difficulty often show up in the workplace last, said Dr. Lisa Lefebvre, an addiction medicine physician and a PHP associate medical director. Signs might include irritability, withdrawal from colleagues, changes in physical appearance, increased absenteeism (unless the workplace is the source of substance misuse), cancelled clinics, and medical errors or near-misses. Impairment in a physician can put others at risk, similar to other safety-sensitive workers such as pilots.
Dr. Lefebvre cautions that well-meaning colleagues sometimes fail to intervene and contribute to delays in physicians receiving proper care by inappropriately diagnosing or treating them in “hallway consults,” covering up errors or doing their work for them.
Despite this, evidence indicates that calls for help are rising, she noted. During the first 18 months of the COVID-19 pandemic, outpatient mental health and addiction visits increased by 23.2 per cent for Ontario physicians, compared to 9.8 per cent for the general public.
She pointed out that the incidence of substance use disorders among physicians is actually similar to that of the general population. With comprehensive treatment and case management, the outcomes for physicians are excellent and many return safely to practice. A study of the PHP model showed that 78 per cent of doctors who had five years of PHP monitoring didn’t relapse, compared to a 40 to 60 per cent for the general population.
Doctors who treat other doctors have “a distinct privilege” but should also be aware of some of the unique considerations and challenges involved, said Dr. Samantha Wallenius, a psychiatrist and an associate medical director at the PHP. One advantage is a shared understanding of medical language. That can make communication around diagnosis and treatment more precise, with no need for medical translations.
However, “some physicians want to shed the burden of being a medical professional at the moment and just be a patient,” she said. Dr. Wallenius said doctors treating doctors shouldn’t assume the physician-patient has a baseline level of medical knowledge about their own condition, or that the patient is in a state where they can apply it to themselves in an unbiased manner.
There’s a need for consistency no matter who you’re treating, she said. When the patient is a doctor, the treater needs to be especially aware of boundary issues, role ambiguity and emotional response.
Dr. Wallenius added that colleagues deserve full and formal assessments, so doctors need to avoid corridor consultations. She said some doctors who treat other doctors might shy away from highly sensitive questions, perhaps because they can feel intrusive or embarrassing.
“Our primary role is to advocate for the well-being of the individual sitting in front of us,” she said. “Some of the time that requires engaging in challenging conversations.”
Other speakers at the session included Dr. Nicola Yang, chair of the OMA’s Section on Primary Care Mental Health, and Dr. Angela Ho, president of the OPA.
A physician-psychotherapist herself, Dr. Yang spoke on the importance of having safe spaces where physicians could share and support each other through unique challenges they may face, emphasizing the need for physicians to care for themselves while caring for others.
Dr. Ho noted the importance of recognizing profession-related risk factors for physician suicide, such as loss of autonomy, medical licence complaints, lawsuits, access to lethal medications, and social isolation due to geographic moves.
The session was moderated by Dr. Jon Novick, the PHP’s medical director, and Ted Bober, the PHP’s director, clinical services, who led the Q-and-A discussion that followed.
Dr. Novick spoke about how the PHP provides confidential support for individuals who are struggling with substance use and mental health concerns, as well as other behaviours that have a personal and professional impact.
During the Q-and-A, Dr. Paré said stigma is still prevalent around these issues, in society and in medicine. Doctors dealing with these problems can feel shame, and other physicians sometimes stigmatize their patients and colleagues who have a mental illness. Knowing that Dr. Paré speaks openly about his experience with depression, another physician once suggested that he had “switched teams,” from being a doctor to a patient.
“Can’t we be both?” Dr. Paré asked. “We are both.”
Stuart Foxman is a Toronto-based writer.