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Mental Health Conditions Among Cardiologists: Silent Suffering Free Access

Editorial Comment

J Am Coll Cardiol, 81 (6) 587–589
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Introduction

Pursuing a career in cardiology can be a master class in delayed gratification and quiet suppression of self-care. We commonly defer life timelines (debt reduction, investing, marriage, parenting, and so on), all in the spirit of commitment to patient-care excellence. And the intrinsic rewards of easing the suffering of our patients while experiencing the enrichment of the patient-doctor relationship cannot be understated. But medicine is increasingly isolating for many. Burnout (including the domains of emotional exhaustion, depersonalization, and professional apathy), psychological distress, overt mental illness, and suicidal ideation are legitimate threats to healthcare’s central aims.1 The question remains beseeching as it did in 1978 when Chuck—from Samuel Shem’s The House of God—confronts Leggo at the novel’s end; “How can we care for patients if nobody cares for us?”

The covert gaslighting and shaming of struggling subordinates by those who wield authority within our system ultimately compounds the weight of the problem. Cardiologists are trained to cope alone, silently, lest they risk being perceived as weak, mediocre, or uncommitted. The economics depend on exploiting “the professionalism of caregivers,” as Dr Ofri boldly detailed in her prescient opinion piece in the New York Times just before the pandemic began.2 Physicians carrying an exaggerated sense of responsibility are less likely to seek support for fear of barriers to licensure or career advancement.3 A recent analysis from the Centers for Disease Control and Prevention’s National Violent Death Reporting System estimated that we lose the equivalent of a medium-sized medical school class annually to physician suicide.4 More recently, the American College of Cardiology (ACC) has reinforced clinician well-being as critical to bringing the traditional “Triple Aim” of improved patient experience, better outcomes, and lower costs into the current health equity efforts (now called the “Quintuple Aim”).5 And we have learned that cardiologists reporting burnout are more likely to be mid-career, women, often struggling with family life, and experiencing workplace hostility.6 But what do we know about the burden of mental health conditions (MHCs) among the global field of cardiologists, and how are MHCs being addressed?

In this issue of the Journal of the American College of Cardiology, Sharma et al7 provide a sobering report on the global prevalence and potential contributors to MHCs among 5,931 cardiologists surveyed by the ACC in late 2019. The survey quantified the self-reported frequency of psychological distress (defined as anxiety, irritability, and anger), substance use disorder, suicidal ideation, and clinical psychiatric disorder (including post-traumatic stress, panic disorder, and major depressive disorder). Notably, trainees, noncardiologist team members, and administrators were excluded. Still, the study population was a diverse representation of cardiologists from many regions of the world (respondents from North America comprised 6.5% of the study population).

The key novel findings include a 28% overall prevalence of MHCs among cardiologists, with women more commonly reporting MHCs than men (34% vs 26%; P < 0.001). Men reported alcohol or drug use disorder more frequently, whereas women reported psychiatric disorders. An equal proportion of men and women (0.4%) reported attempting suicide, but women were more likely to report considering suicide in the past. Afflicted respondents were also more likely to be younger than 40 years of age, divorced, or in mid-career. A hostile work environment was acknowledged by an alarmingly high proportion (42%) of respondents experiencing MHCs. Emotional harassment, discrimination, divorce, and age younger than 55 years were the most notable clinically relevant predictors of a MHC. A staggering 84% of men and 78% of women among the 1,648 with MHCs responded that they had not reported their MHC, whereas 31% of men and 42% of women answered that they had not sought help for addressing their MHC. When asked about barriers to reporting, lack of privacy was the most highly cited, followed by a lack of time, embarrassment, and concern for detrimental impact on professional advancement.

Although the authors should be commended for presenting such impactful findings, some interpretation cautions are worth highlighting. These include potential confounding introduced by survey data relying on cardiologist self-reporting (with men commonly under-recognizing overt mental illness compared with women).8 Also, these data do not consider the vital cohort of trainees9 and critical cardiovascular team members such as nurses and advanced practitioners. Furthermore, this analysis precedes the global COVID-19 pandemic and, therefore, could underestimate the burden of MHCs among cardiologists who have been more recently traumatized by the moral injury associated with a feeling of disempowerment while bearing witness to a markedly increased burden of human suffering.10

So how can we take lessons learned and move boldly to action? One could justifiably argue that we have cause for implementing interventions at 3 general stages of the mental illness progression cycle (Figure 1). First, because multiple studies have confirmed the high prevalence of hostile work environments among cardiologists, stakeholders (partnering with the ACC) can selectively promote leaders who strive to mitigate implicit bias, discrimination, and harassment while advancing diversity, equity, and inclusion within the broad ranks of cardiologists.11 Because the association of hostility and workplace bullying are so tightly associated with MHCs, we can anticipate meaningful reductions in discrimination and harassment will allow for markedly improved mental health among cardiologists, particularly among women and early- to mid-career colleagues. Second, we must eliminate the stigmatization of mental illness among physicians. We need to handle MHCs with compassion and without blaming, like how we strive to treat our veterans who suffer from post-traumatic stress disorder. Organizations, state medical licensing boards, privileging committees, payers, and clinical practices should not be allowed to investigate questions related to mental health or a history of substance abuse without being scrutinized by an outside party monitoring for discrimination. Instead, identified MHCs should be treated by mental health professionals, and time should be guaranteed for the cardiologist to attend to the necessary therapy. Finally, mentorship programs should be formalized to assist the cardiologist in transition zones from early to mid-career, with particular attention to women and those experiencing a simultaneously increased load of family burdens that compound existing workplace contributors to burnout and psychological distress.

Figure 1
Figure 1

A Cycle of Covert Mental Health Deterioration Among Cardiologists

Trauma often precedes the deterioration of mental health. Cardiologists are prone to suppressing discussions about experienced trauma due to cultural contributors to feeling shame, fear, and isolation. Additionally, the lack of time and protection to come forward and identify struggles with mental health leads to unhealthy defense mechanisms and self-medication with alcohol or drugs, work compulsivity, and emotional outbursts, which can include rage, risk-taking, and grandiosity. These behaviors often contribute to further injury by disrupting relationships, with divorce being a severe consequence. Such additional injury perpetuates the cycle of further mental health deterioration. Breaking the cycle requires breaking the silence and destigmatizing MHCs among cardiologists while installing mitigators to reduce workplace hostility, such as formal career mentoring and promoting diversity, equity, and inclusion (DEI). MHC = mental health condition.

We can conclude by acknowledging that we have a cultural problem with appropriately addressing mental health in our ranks. We have fostered a culture of silent suffering. And although we know we need to better attend to our multiplicity of needs, we find ourselves immersed in dedication to our patients while subservient to a hierarchal system without compunction for exploiting our ethos while also conditioning us to retreat to our lonely workspace and think “I am crazy” rather than “This is crazy.” But there is cause for hope. Although isolation is deadly, connection heals. So reflected Samuel Shem, 25 years after penning The House of God. He expanded, “the only threat to a dominant group is the quality of connection among the members of the subordinate group.” And if shame is the language of isolation, embracing vulnerability and our collective need for belonging (all while ending our silence) will overcome shame along the path to improving connection and meaning in caring for patients with cardiovascular disease.12

Funding Support and Author Disclosures

The author has reported that he has no relationships relevant to the contents of this paper to disclose.

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Footnotes

Javed Butler, MD, MPH, MBA, served as Guest Editor-in-Chief for this paper.

The author attests they are in compliance with human studies committees and animal welfare regulations of the author’s institution and Food and Drug Administration guidelines, including patient consent where appropriate. For more information, visit the Author Center.