The Physician as Patient. A Clinical Handbook for Mental Health ProfessionalsRichard Balon, MD
Wayne State University, Detroit, MI, USA
During this time of increased focus on professional behavior in medicine—professionalism is 1 of the core competencies—impaired physicians finally may be getting the attention they deserve. I am not referring to disciplinary measures or hyped media reporting; I mean attention from the house of medicine. This attention is in the form of more help available for impaired physicians and other health professionals, increased awareness, and writing about and researching this important issue. We know that impairment or unprofessional behavior in physicians often is caused by mental illness and/or substance abuse. However, for various reasons physicians frequently do not get proper treatment, if they get treated at all. Maybe, as Marzuk1 wrote more than 20 years ago, because physicians treat sick people, they are simply not allowed to get sick themselves. Maybe it is because physicians are difficult patients, although when treated appropriately physicians may fare better, as a group, than others. Maybe it is because physicians are not properly trained to treat other physicians. That is 1 of the premises—I believe a correct 1—of The Physician as Patient, a small book by 2 experienced clinicians who treat physicians, Michael F. Myers and Glen O. Gabbard. They wrote a volume that, in their words, “…is an amalgam of our combined perspectives and experiences in understanding and treating a cohort of human beings who are frequently misunderstood and inadequately treated” (p viii).
By Michael F. Myers and Glen O. Gabbard; The American Psychiatric Publishing Inc.; Arlington, Virginia; 2008; ISBN 978-1-58562-9; pp 242; $51.00 (paperback).
The book is divided into Introduction, 3 parts, and an Appendix listing resources and Web sites. Part I, “Physician characteristics and vulnerabilities,” contains 3 chapters focused on “The psychology of physicians and the culture of medicine”; “Minority physicians (racial, ethnic, sexual orientation) and International Medical Graduates”; and “Psychiatric evaluation of physicians.” In the discussion of physician psychology, the authors analyze what kind of person enters medicine. They focus on North American society’s sanctioned perfectionism and the compulsive triad of self-doubt, guilt, and an exaggerated sense of responsibility. They point out that perfectionism is not adaptive, but rather a vulnerability factor for depression, burnout, suicide, and anxiety. The authors also remind us that “…physicians are not entirely responsible for the outcomes of their patients. Most medicine is palliative, except for certain infectious diseases and surgical procedures. Some outcomes are not preventable. Psychiatrists in particular may have difficulties accepting the idea that some psychiatric disorders in some patients are terminal” (p 9). The discussion of physician psychology also includes female physicians. Interestingly, it seems that “women interact more effectively with their patients and foster relationships that are preventative against lawsuits” (p 13). On an alarming note, female physicians’ suicide rate is a disconcerting sign of their vulnerability, “whereas the male suicide rate is more than 4 times that of females in the general population, the suicide rate of female physicians is as high as the rate of male physicians” (p 14). The chapter on minority physicians reminds us that most minority physicians and international medical graduates will be treated by someone outside of their cultural group. Before getting into the specifics of physicians’ evaluation, the chapter on psychiatric evaluation discusses barriers to care (psychological resistances, systemic barriers, barriers deriving from the quality of treatment), the problem of reporting (here an important caution: “Mental illness in physicians is not synonymous with impairment…and…Similarly, addiction does not automatically imply impairment” [p 37]), and the fact that physicians’ treaters serve the patient and the public.
The second part, “Diagnostic and treatment issues in the distressed and distressing physician,” includes 4 chapters dealing with “Psychiatric and medical illness in physicians,” “Addictions: chemical and nonchemical,” “Personality disorders, personality traits, and disruptive physicians,” and “Professional boundary violations.” The chapter on psychiatric and medical illness points out that physicians as a group are healthier than the general population, yet have a higher risk of suicide (p 55). It further discusses medical illness in physicians, unique physician related issues in various mental illnesses—such as mood disorders, anxiety disorders, dementia, and psychosis—determining impairment, biopsychosocial treatment principles, and advocacy strategies. The chapter on addictions notes that “Research suggests that physicians are no more likely to have a substance use disorder (especially alcohol abuse and dependence) than socioeconomically matched professionals serving as control subjects. …However some data indicate that physicians may be more likely to abuse prescription drugs because of their greater accessibility” (p 78). The authors also discuss various biopsychosocial determinants/risks of addiction in physicians, such as pharmacological optimism and knowledge, reliance on intellectual abilities, strong will, love of challenge, instrumental use of drugs, denial, overwork, entitlement, ready access to medications, cultural sanction, stigma, and aging. This chapter also includes early, later, and end-stage signs of addiction, a review of issues in treatment (usually prognosis is very good), nonchemical addictions (pathological gambling, sexual addiction, Internet addiction, compulsive shopping, and exercise addiction). The chapter on personality disorders emphasizes that the “disruptive physician” label is “often a euphemism for describing personality disordered behavior in physicians” (p 95). The main focus is on 3 personality disorders—narcissistic, borderline, and obsessive-compulsive. The authors also discuss sharing the personality disorder diagnosis with the patient, because it rarely is welcomed by the physician-patient. They suggest that “a good strategy when sharing the diagnosis with the physician-patient is to approach the diagnostic understanding developmentally” (p 110).
The chapter on professional boundary violations is interesting. It delineates the boundary violations, boundary crossings, and boundary transgressions first, then delves into the main issue—sexual boundary violations (including evaluations, “etiologies,” etc.), touches on sexual relations with former patients (American Psychiatric Association: never, AMA: more ambiguous), and addresses the assessment of amenability to rehabilitation. The second part of this chapter reviews nonsexual boundary violations, such as dual relationships, time and duration of appointments, excessive self-disclosure, gifts and donations, language (“honey,” “sugar”), physical contacts other than physical examination (hugs and kisses), and physical examination itself (chaperone!).
The last part of this book, “Prevention, general treatment principles, and rehabilitation,” consists of 5 chapters addressing “Psychodynamic psychotherapy,” “Individual cognitive therapy and relapse prevention treatment,” “Couples in conflict and their treatment,” “The suicidal physician and the aftermath of physician suicide,” and “Prevention.” The chapter on psychodynamic psychotherapy introduces some basic principles—for example, much of mental life is unconscious, childhood experiences help shape the adult, transference is a primary source of understanding, countertransference provides valuable understanding about what the patient induces in others, resistance to the therapy process is a major focus of therapy, etc.—discussion of efficacy and indications of this form of therapy, and some thoughts about psychodynamic group therapy. The chapter on cognitive-behavioral therapy reviews its applicability to physician-patients. They may like its parameters, interactiveness, and straightforward, mutually engaging, and psychoeducational character. This chapter also discusses biofeedback, relaxation therapy, and relapse prevention treatment. The discussion about couples reviews common complaints, impact of addiction, love and the medical marriage, complexity of a presenting complaint in medical marriages, and basic principles and benefits of couples therapy with physicians. The authors point out that “when treating medical couples in which one is a physician and the other one is not, the therapist must be especially sensitive to this fact” (p 177) and not enable the physician and “gang up” on the non-physician spouse. The chapter on physician suicide focuses on issues such as epidemiology of physician suicide (physicians kill themselves more frequently than the rest of the general population, for males the ratio is 1.41:1, for females it is 2.27:1), why physicians kill themselves, what we can learn from physicians who have attempted suicide but did not die, a portrait of a suicidal physician, when a physician is at imminent risk of suicide, assessment and treatment of the suicidal physician, treating the suicidal physician on an ambulatory basis, and aftermath of physician suicide. I found interesting the observation that “It is estimated that 50% of psychiatrists will lose at least one patient to suicide over the course of their career, and this loss is deemed among the most difficult professional experiences encountered by a psychiatrist. In one study, approximately half of the psychiatrists who had lost a patient to suicide experienced stress levels comparable with those of people recovering from the death of a parent” (p 199). The final chapter on prevention discusses issues such as selection of medical students, emphasizing professionalism in medical school, promoting balance in residency training, self-monitoring, and preventive measures for partnerships and personal relationships.
This is a timely and highly useful volume. The chapters contain many clinical illustrations that are summarized in key points at the end of each one. The book is easy to read. It is written with passion and obvious great familiarity with the topic, both clinical and theoretical. Those interested in this topic will find it as hard to put it down as I did. I would recommend this book to all clinicians treating physicians and medical students, all medical school administrators, residency training directors, hospital and outpatient facilities directors, and members of state licensing boards.
- Marzuk PM. When the patient is a physician. N Engl J Med. 1987;317:1409–1411.
Annals of Clinical Psychiatry ©2009 American Academy of Clinical Psychiatrists