Addressing stigma and promoting physician mental health

Listen to this important conversation about the unique challenges physicians and clinicians face when seeking mental health support and real-life ways to foster a culture of wellness.

Willie Underwood III, MD, MSc, MPH, immediate past chair of the AMA board of trustees and advocate for physician wellness, joins Alex McDonald, MD, of the Southern California Permanente Medical Group, to discuss the traditional barriers to overcoming the stigma of mental health in the medical community, how things are changing for the better, and resources for medical professionals in need.

Guest

• Willie Underwood III, MD, MSc, MPH, American Medical Association.

Podcast transcript

Transcript is autogenerated. Although edited for clarity, it should not be considered an exact replication of the podcast and may also be updated as needed.

Alex McDonald, MD: Hello everyone, my name is Alex McDonald. Welcome to today’s PermanenteDocs Chat. I am very excited for this discussion today. We are going to be addressing the proverbial elephant in the room, if you will, which is physician mental health and really addressing that stigma. We are joined by Dr. [Willie] Underwood of the American Medical Association, who is a physician wellness advocate. Dr. Underwood, welcome and thanks for being here.

Willie Underwood III, MD: It is my pleasure. Thank you for inviting us and giving us an opportunity to have this dialogue. And I’m hopeful that the physicians listening to this later will be able to get something out of it and we can continue this discussion to improve our wellness.

AM: Absolutely. So again, these are pretty short, high-yield conversations, a place to start the conversation. So if you do have questions, make sure you get those into the Q&A box early and often. We’re going to jump right in here. Dr. Underwood, tell us a little bit about who you are and what you do and how you came to this area of physician wellness.

WU: [I’m] Willie Underwood, immediate past chair of the board of the American Medical Association. And how we got into this is that this was an unmet need at the time, and still continues to be an unmet need. And as the AMA board of trustees, we jump on opportunities where we can improve outcomes of physicians’ well-being, outcomes of physicians’ health, outcomes of physicians’ financial, spiritual, mental, [and] professional health.

Breaking the stigma associated with mental health

AM: I think we’re breaking a lot of the barriers in society when it comes to addressing mental health and the stigma with mental health. Some very high-profile athletes and actors and famous people have started breaking the silence about their own mental health issues. But in medicine, we still have this culture, I think, where there’s a lot of stigma associated with addressing our mental health and our own mental health needs. Why do we need to address this culture and this stigma, and why is it such an important issue?

WU: I think it’s two-sided, right? One is how we’ve been programmed and sought to see the world. We’re physicians, we’re giants, we help others and we put others ahead of us. And to say that I’m not really sure, to say I don’t feel well — and that’s physically well or mentally well or spiritually well — is a sign of weakness. If you are a physician, we don’t call in sick, we call in dead. We don’t call in sick because what do you mean you’re sick? What are you talking about? You got 40 people here in the clinic waiting on you. You got someone on the operating room table in 20 minutes, you better be here and ready to roll and you better bring your best game ever, each and every time.

So we have that issue. The same issue is that, well, if you have problems, then you have to explain that for the rest of your career on credentialing forms, state forms. Every time you turn around, someone’s asking you, so what happened in 1987? 1987? This is 2024. Well, in 87 you had this issue and so therefore you’re unemployable, therefore we have to monitor you, therefore we have to have concerns. So it’s twofold: what society expects from us and what we expect we believe that we should be able to do in society.

AM: One of the analogies, which I have heard some of my other colleagues talk about, is synonymous with the medical industry and the airline industry. Pilots have very specific rules regarding how much rest and recovery they need between flights. And when I’m on the plane, I want my pilot on their A game. I don’t want my pilot tired, I don’t want my pilot overworked. And there’s very strict guidelines and there is a culture that if a pilot doesn’t feel well and isn’t up to the challenge, there’s no negative repercussions for stepping back. Whereas in the health care industry, and I felt this even as a resident and a young physician, it’s a badge of honor to work really hard. And it’s this culture where obviously our work is critical, our patients need us, but there’s this unwritten rule where, like you said, you don’t call in sick, you call in dead, right? There has to be something absolutely major for you to cancel on patients who’ve been waiting sometimes weeks or months to see you. How do we address that? I think that’s the bigger issue.

WU: We have conversations like this and we begin to push back on administrators, on state-level administrators and credentialing agencies, and we begin to say, listen, there’s a better way to do this. And that we do need physicians to be able to have confidential wellness programs, that we need to be able to have a dialogue. We need to be able to tap out and that not be something that follow us forever or seen as a sign of weakness. We [need to] see it as a sign of courage, right? Listen, you know what? Today is really not a good day, or I haven’t had a good month, or I see that I’m frustrated, I see that I’m burning out, without it being a conversation where one doctor sits with another doctor and say, did you hear what Willie did? What is up with him? He had the nerve to say that he’s not up for it. Well, if he ain’t up for it today, then you can get to packing, you can figure out another career. Maybe we shouldn’t have ever let him in surgery in the first place, how there was a mistake made. Despite the fact that all the stuff you’ve done before that and all the things you do after that. So we have to have these kind of conversations and challenge these ideas.

Mental health support for physicians starts at the top

AM: There’s obviously colleagues who need to then see those patients or pick up that work for whatever reason. And we’re all working, it feels like we’re all working sometimes at 110%, which is just not sustainable in many ways. So, there are both intrinsic factors to the individual physician regarding coping mechanisms. And there’s also extrinsic factors, which, in the demands of a dysfunctional health care system for lack of a better term, are placed on that physician. So we can do something about some of those external factors, but it’s really those intrinsic factors. How do we help support our physicians? What tools or resources do you recommend for physicians who are struggling? Can we nip the problem in the bud before it gets to be very significant?

WU: First we have to change our total reporting structure. In April of this year, 27 state medical boards have audited or changed their licensure application. This benefits more than 700,000 physicians. And then 19 health systems have also audited and changed intrusive language from their credentialing process. That’s extremely important. So on the one hand we have to advocate for that within our health system, so that if you do come forward, you don’t have any issues. Secondly, you say, what does a confidential wellness program really look like? And I’m not talking about yoga or exercise. I’m saying how do we really increase our productivity by making a physician better through this process? And that’s what the pilots in the airline industry understand: safety first, over people and over profits.

Then we say, wait a minute, why am I in a structure where I’m seeing patients all day and I’m doing notes and documentation all night? And my family is suffering and I’m suffering? Those things don’t make any sense. So, how do we deliver care in a way that is sustainable? You said that 110% is not sustainable and you should not have to work 110%, that doesn’t make any sense. And there’s also best practices here. The AMA has a program that hospitals apply for and that’s the Joy in Medicine program. Just like the Olympics, you can get gold, silver, bronze. You submit the work that you’re doing and you get this award. I think last year they had 106 applications. And just because you get it one year doesn’t mean you’re going to get it the next year. And most people, if they get in at bronze, they want to go up a level. But, those kinds of programs and those kinds of things [make a difference], and it’s up to us to say something, too.

AM: I think that’s such a great point, you need to shed a light and promote these programs. And might I add that Permanente Medicine here in Southern California, I think we received a gold award last year for Joy in Medicine from the AMA. I’m really proud that the organization that I’m a part of makes sure we are promoting physician wellness because we know that a happy, healthy, sustainable physician is going to practice better medicine, they’re going to practice for a longer period of time. And having these systems in place where we can help support our colleagues who are struggling and provide them resources early and often as opposed to waiting before it’s too late is obviously correct. I’m a primary care doctor, I’m all about prevention. And if we can focus on a prevention that’s key.

WU: Correct. And we said this earlier in our conversation, the healthier you are, the healthier you are, the healthier you are. And the more productive you are. In business, we’ve figured that out. Let’s figure that out in medicine as well. I want my doctor bringing their A game. You mentioned something, that we expect our pilots to bring their A game. We want our physicians to bring their A game. So what does that mean? How do I create a system in such a way that when Dr. McDonald and Dr. Underwood shows up, they’re rested, they’re strong, they’re ready, and they’re prepared. And they have a stable home life and to the best of their ability they’re living their best self so they can provide the best opportunity for our patients to have the greatest outcomes.

AM: Absolutely agree. Now, you mentioned this a little bit before, this stigma of having to report any mental health challenges on your medical license and credentialing, which can then haunt you for decades afterwards. And then also some of those cultural barriers like, well, if I don’t show up to see my patients, then one of my colleagues is going to complain about me or vice versa. Are there other stigma? Are there other barriers specifically within the health care industry that are preventing physicians from seeking mental health or even being aware that they’re struggling?

WU: I think that’s the major one, right? Because we all train knowing that there’s a problem if we say that we’re having an issue. So, to me, that’s the major one. And secondly, as we talked about, some of it is just how we see the world. Because even now we know that after the AMA has partnered with state and medical societies and hospital associations in Massachusetts, Oregon, Virginia, to successfully advocate for statewide changing credentialing applications, I don’t think the doctors know that. So they’re still going under the previous premise that if I tell someone, then I will never be at a practice again. Or they will use that against me in some way, especially if they want me out, my partners want me out. I spoke up and raised my hand and said, I didn’t like the way we were doing the scheduling. Now I’ve got to worry that they’re going to use this against me. So I think that’s the major one, but I’m sure there’s other reasons that we are hesitant to seek help.

Meeting the mental health needs of the medical community

AM: I think you’re absolutely right. And probably for as many physicians out there struggling, there’s as many reasons for why they’re struggling. It’s not a one-size-fits-all approach. There are many aspects to medicine, it’s a demanding field, it’s a demanding practice. It’s very rewarding, but it’s going to be hard, it will always be hard no matter how many support systems we put in place. How do we make sure that we are meeting the needs of our community? We know there are not enough physicians, we know there’s going to be even more of a shortage of physicians. So how do we meet the health care needs of our communities while also not burning ourselves out and burning our workforce out? That’s maybe a bigger philosophical question, but do you have any thoughts? Do you have any insights on that challenge?

WU: We’re talking about a shortage of 86,000 physicians by 2036, right? 86,000. That’s a huge number to make up. We have to think about how do we provide care, as you said, and maybe we think outside of the box. How do we use augmented intelligence better? How do we create technologies that reduce or eliminate the idea that [when I’m at home], instead of being with my family or reading my daughter to sleep, I’m doing notes, right? Or I do the family thing and she falls asleep at nine o’clock and between nine and two in the morning, I’m doing notes. Those things are crazy. We have to create technology that actually helps us to do that.

And then we have to think about, just [like] in the automobile industry and other manufacturing businesses, workflow injuries and stuff like that. None of that we’ve done in medicine. We’re still doing things the same way we did in 1950. We’re just doing it in the hospital compared to private practice. That makes no sense. So there are companies out there, there’s things that we’re working with, we have to use our brains, think about this differently, and we have to put the systems in place that they’re open to create a more efficient system where physicians are working at their level [and] other people are working at their level. We have team care and all these things that actually work out. And we’re not fighting with each other. We shouldn’t be at war, the nurse practitioners and physician assistants. We should be partners in delivering care, put the patient first, but to put the patients first, we have to put ourselves first.

AM: You hit the nail on the head in terms of team-based care and making sure that everyone is practicing at the top of their license, whether it be the physician or the nurse practitioner or the PA or the LVN or the pharmacist or you name it. I try not to go too deep with the sports analogies, given the fact that I practice sports medicine, but medicine really is a team-based sport. And there’s no way that everyone can do everything. As physicians, we want to be all things to all people all the time. I remember this very moment very clearly, I was probably about four or five years into practice out of residency, and I was just killing myself, I would always add [patients] on or do something else and I was burning myself out. So I changed my motto to: I’m going to do what I can for who I can when I can. If I can make sure that I do that myself and keep my own practice sustainable, I’m going to be far more benefit to far more patients than if I burn myself out six years into practice and then quit medicine altogether. I think we need to help people and physicians, particularly early career physicians, understand that sustainability is so important.

WU: Alex, repeat that again for me. I want everyone to embrace that and internalize what you just said.

AM: I do what I can for who I can when I can.

WU: And there’s no guilt after that. You’ve done your best.

AM: Exactly.

WU: It’s that, oh no, I got 20 on the schedule. Oh, doctor, I just need to…okay, come on in, come on in, come on in. And then at midnight you’re trying to get the notes done because that person showed up saying they’re on the green pill, the blue pill, the red pill, and you spend a lot of time, energy, and effort trying to figure out what was wrong with them even before you help them. You said that we’re a team. The center doesn’t try to be the quarterback and the quarterback doesn’t try to be the center. The center does their job well so the team can march down the field and the receivers catch the balls and the quarterback throws it and hands it off. These are the kind of analogies and thought processes that we have to have in the delivery of health care as well. Right? You’re absolutely right.

But I love that. Say that again. I want us to really embrace that.

AM: Now you’re just putting me on the spot.

WU: But I’m loving it though.

AM: I do what I can for who I can when I can.

WU: That’s it.

AM: And I try to do it sustainably and one day at a time, one patient at a time. And if the patient’s there in front of me, I’m going to do the best I can for that patient and I’m not going to be able to do anything for the 400 other people who didn’t get an appointment that day, right?

WU: Correct.

AM: But it’s all about sustainability.

WU: Correct.

Promoting physician mental health programs and resources

AM: We have a question here in the chat I want to jump to. You mentioned the AMA Joy in Medicine program and that 106 applications came in. But compared to the number of medical groups in this nation, that’s probably just a tiny drop in the bucket. How do we promote this and how do we accelerate this program to get more people aware or interested?

WU: We have programs like this. The AMA also [has] a burnout meeting that is huge. It alternates between the US and outside of the US with our UK and Canadian partners every other year. And the programs are there, they’re being promoted. I think health system leaderships are becoming more and more aware of it. Also, the organizations that are receiving these awards are growing. Those who apply, even if they don’t get it, they learn how to be better. Plus, when physicians are seeking opportunities, they’re now gravitating to that because they have a culture and environment at that system that’s conducive to them delivering the best care in an environment where they can do what they can for who they can when they can.

AM: That sounds good, we should market it. What other resources are there out there? The AMA Joy in Medicine is a systems program; are there individual resources for individual physicians who are struggling and want some support regardless of where they are on that burnout-wellness spectrum?

WU: We have education and training modules available at the AMA ED Hub. We also have resources available to physicians on the STEPS Forward platform. Then we also have information and guidance for hospitals and health system to implement proven best practices.

AM: I just want to throw out there that we know that the rate of suicide amongst physicians and health care workers is far, far greater than almost any other industry. So if you’re struggling, please reach out. There are colleagues, there are friends, whether it’s your own individual family, your own colleagues at work or nationally, there are so many different support systems. Please reach out if you need help.

I’m going to take one more question. I have some colleagues who are, how shall I say this, a little old school in their training. They did residency before there was duty R restrictions, and they look at residents and medical students coming up now who are sometimes taking mental health days and they’re like, what is this? This is ridiculous, I suffered through this. This is medicine, this is a hard profession. If we don’t train them to work hard as residents and medical students, then they’re not going to be able to meet the needs. Again, I’m just playing devil’s advocate here. Some of my colleagues have complained about that. Do you feel that the pendulum has swung too far to medical student, physician resident wellness, and if it has, how do we course correct that?

WU: So, I’m not sure because we don’t know where the center is, where the right place is. So what has happened, it makes sense. Is that okay? I started my training doing every other and the other, when you got off call, it was at 9 p.m. at night. You came in at 5:30, you were there until the next day at 9, which was absurd, right? I turned the corner once and drove up on the curb. Physicians were getting in car accidents, driving the wrong way, all these sort of things. So then we said, okay, we got to work work hours first. And then out of that, wait a minute, something is wrong. I came here to help people and I can’t even help myself.

So since we haven’t been open to it, and since we haven’t really set out and said, what should top-level training look like? What should top-level practice look like? Well, we have people who are mentally, physically, emotionally ready to be able to provide top-notch care. What does that look like? It’s going to be a struggle, right? I remember my mother had come to town and I was working like crazy. She said, do they pay you overtime for that? I laughed. I was like, overtime? Mom, I’m glad they don’t fire me and they pay me. What are you talking about, overtime? She said, really? Are you crazy? Son, you’ve been working 36 hours. No, that’s not how that works, mom.

But we haven’t discussed it. We haven’t laid it out. So once we do, then we’ll know what the middle is and I think we can get to a sweet spot.

AM: I think it’s going to be different for every person, for every specialty, for every organization. I think what makes it so hard is there’s really not a one-size-fits-all. I remember someone telling me the analogy of wellness is like brushing your teeth. You have to brush your own teeth in your own way, in your own time. You can’t brush someone else’s teeth for them. It just feels weird. And that’s what makes this work so important, but so challenging also.

WU: Correct.

AM: This has been such a great conversation. We’re going to wrap up here with my favorite question. What makes you most proud to be a physician?

WU: Oh man. It’s a smile that I bring to someone’s face. That’s what I like the most is when I’m able to really help someone live a better life. As a urologist, guys who get diagnosed with an elevated PSA or diagnosed prostate cancer and they hear me say, okay, how do we turn this into an opportunity to make this better? That’s the best. The worst is when I can’t help people and I carry that home with me. And to understand that, like I said, I’ve done all that I can do and let’s try to figure out what we can do. Not worry about what we can’t do. Let’s do what we can do.

AM: Well said, Dr. Underwood, thank you so much for joining us. Thank you for all your work at the American Medical Association and really appreciate your insights today.

WU: This is a wonderful conversation. Thank you. Looking forward to viewing this and all those who are viewing this, please, let’s work together and let’s make our profession the best profession that it can be. Dr. McDonald, thank you.