“Doctors Don’t Go to Therapy”: Helping Providers Access Mental Healthcare

Physicians: A Surprisingly Vulnerable Population

In the last year, most of us have had an encounter with our medical doctor. In the patient role, many of us maintain the image of physicians as a robust group, untouched by basic life stressors. However, data suggest that this perception is inaccurate. According to a recent survey of 9175 physicians, 53% of them suffer from burnout, and 24% meet criteria for clinically significant depression. Even more alarming, 1 in 10 physicians have had thoughts of suicide or attempted suicide, and 300 – 400 physicians die by suicide annually. This is about twice the rate in the general population, and it has called attention to a mental health crisis among our doctors.

Despite these statistics, and the clear need for support, numerous physicians are reluctant to seek mental health treatment. Some of the reasons behind this reluctance are built into our healthcare system, such as lack of time given productivity pressures and increasing documentation demands, unpredictability with conducting procedures or being on call, and the expectation to sacrifice one’s own needs for patient care. Many malpractice insurance companies, hospital credentialing groups, and medical licensing boards ask invasive questions about mental health diagnosis and treatment on their applications. On these, doctors fear being seen as “impaired” and being subject to humiliating professional surveillance if they disclose their mental health history. Some hospital systems restrict insurance coverage to providers within their own organization, meaning that those doctors’ only option is to see a psychologist they might also work with. If that organization uses an electronic health record (EHR) or participates in a health information exchange, the physician runs the risk of their diagnosis or prescription medication being accessible to their leadership, colleagues, and support staff who have access to the EHR. To truly reduce barriers to treatment-seeking, these practical issues must be addressed.

Other barriers are more insidious. Medicine as a profession has a distinct set of cultural norms and values. The traits of stoicism, self-reliance, and self-sacrifice are perpetuated in training programs. Feelings of shame, stigma, and failure for having mental health symptoms are common. Like the military, there are distinct authoritative hierarchies in medicine. Those at the bottom strive to earn the approval of those above them by working hard to avoid being seen as “weak“. Physicians spend four years of medical school, three to five years of residency, and up to three additional years of fellowship learning how to put their emotions aside to deliver patient care under the most trying of circumstances. It should not come as a surprise that going to therapy and facing these suppressed emotions feels uncomfortable at best, and intolerable at worst.

A clinician well-suited to treating physicians is one who has intimate knowledge of the healthcare system and enough training to earn the respect of an exclusive group, but who can gently challenge the harmful norms of medical culture. It’s a great role for a clinical health psychologist, and one that I found myself in not long after receiving board certification in the specialty. Clinical health psychologists use psychological science to engage in the maintenance of population and individual health, the treatment of illness and disability, and the improvement of the healthcare system. In sharing my experience, I hope to encourage specialty psychologists to consider unique ways that our professional skills can be an asset to our physician colleagues.

Akron Physician Wellness Initiative

Akron, Ohio is not a glamorous place to practice medicine or clinical psychology. It’s located in the northeast part of the state, in the heart of America’s rust belt, where about 23% of residents live in poverty and the median annual per capita income is $37,729. Between 1910 and 1920, Akron boasted the fastest population growth in the nation, as factory workers flocked to the Goodyear, Firestone, and General Tire and Rubber companies.

Now the old factories have become office buildings and apartments, and the biggest employer is the healthcare industry. Two systems rank at the top of the list: Akron Children’s, a pediatric hospital, and Summa Health, an adult hospital. After completing a fellowship in clinical health psychology and bariatric medicine, I took a position at Summa Health’s Weight Management Institute. In this role, the other psychologists and I collaborated with bariatric surgeons, obesity medicine physicians, advanced practice providers, and registered dietitians. Though we loved the work, in a state with one of the highest obesity rates in the country, my colleagues and I often struggled to keep up with the demand for services.

Six years in, when the chair of Summa’s psychiatry department initiated a search for a psychologist to lead a new kind of clinic, I jumped at the chance. The clinic would exclusively provide behavioral health services to Summa Health and Akron Children’s Hospital staff physicians, residents, fellows, and advanced practice providers. At that time, facing the broken reality of healthcare in America, I was acutely aware of the limitations that pre-authorizations, insurance billing, productivity requirements, and performance metrics were placing on my ability to deliver the kind of patient care I learned about in training. Also feeling the demoralization of my physician colleagues, I was motivated to care for them in a different way.

The clinic, Akron Physician Wellness Initiative (APWI), was created as a collaborative effort between Robert McGregor, MD, the CMO of Akron Children’s Hospital, and Joseph Varley, MD, the Chair of the Psychiatry Department at Summa Health. APWI, a registered nonprofit organization, opened its doors to the first client in February 2021. With a team of three psychologists and one psychiatrist, APWI offers both psychotherapy and medication management. It is funded by donations from the two hospitals served, and in return their providers are eligible to receive 12 free behavioral health sessions per year. This helps the residents, fellows, and early career physicians (who on average carry at least $200,000 in student loan debt) afford services. It also eliminates the need for insurance billing and any associated electronic footprint, which reduces our clients’ concern about discoverability. It allows greater flexibility in diagnosis and treatment planning (for example, use of a DSM-V “V code” instead of a formal “disorder” which would be required to justify an insurance claim). Many doctors report feeling less risk when answering the medical licensure, malpractice insurance, and credentialing questions under this circumstance.

Instead of a shared EHR, APWI has paper charts and appointment calendars. This reduces a client’s concerns about colleagues and supervisors finding out about their treatment. The APWI clinic is located downtown, an equidistant five-minute drive from the main campuses of both hospitals, but discrete enough to be confidential. The clients have direct communication access to their provider via call, text, or email, without the intermediary of support staff. This level of connection and convenience improves barriers to access. If a client is running late due to patient care, they can simply send a text message to their provider and be notified whether or not they can still be seen. They can also engage directly with their provider to make appointments that work around their clinical schedules versus having to adhere to a rigid template.

By ensuring the utmost confidentiality while forming deeply personal relationships with our clients, we build trust and encourage them to view therapy with less shame and more empowerment. To combat stigma, we encourage our doctors to talk to their colleagues about going to therapy. Through the creation and dissemination of badge pins with our logo, the providers we serve can choose to self-identify as an “Ally in Wellness” – a supporter of our mission and of mental healthcare utilization. Client self-report data shows that these techniques are working: a full 72% of our clients hear about us through word-of-mouth (Varley et al., 2023). Forty-two percent say that without our clinic existing, they would not have sought mental health treatment of any kind (Varley et al., 2023).

While our utilization has increased by over 1,000 visits per each year of operation (Varley et al., 2023), we continue to engage in outreach efforts at both hospitals. These include presentations of our services as part of intern orientation and at organized meetings (Grand Rounds, APP Council, medical staff meetings, Graduate Medical Education Committee, and individual departments). We also make efforts to work with training programs to schedule each incoming intern and fellow an optional “mental health orientation visit” with one of our providers. These visits are informal opportunities for trainees to meet us, establish rapport, and learn what we offer, with the goal of increasing comfort seeking those services in the future. In addition, information about our services and the option to schedule an orientation visit is provided to each newly hired provider at both hospital systems.

For all its strengths, our program is not without limitations. The greatest of these is the required cap of 12 sessions per year. Providers work closely with their clients to determine a frequency of appointments that work best for them (once per month ongoing, biweekly for six months, etc.). Some have chosen to pursue a brief, solution-focused treatment modality, or to supplement their office visits with between-session interventions such as CBT worksheets, mindfulness applications, bibliotherapy, and journaling. Making time to attend appointments also remains somewhat of a barrier, especially for the residents and fellows, whose work weeks approximate 80 hours. We continue to advocate to program directors and others in leadership to allow their trainees protected time while on shift to attend appointments. We have also increasingly offered telehealth visits, especially during lunch breaks. Ongoing advocacy efforts to eliminate invasive questions on medical licensing and credentialing applications would be helpful, as well as efforts to better protect mental health information in the EHR.

The process of attaining board certification in clinical health psychology helped me develop a greater appreciation for the important role that a psychologist can play within the medical system. It has helped the physicians I see for treatment trust me. It is important that they view me as an ally, and someone who readily understands the realities they face. They can also save valuable time in therapy avoiding explanations of clinical terms, medical culture, and the expectations of their daily lives. In turn, I can better tailor my interventions to what is realistic and feasible given their work demands and norms.

In holding safe space for our clients, my colleagues and I are teaching them how to hold space for themselves and others. As aptly stated by Robert Wah, MD: “The most important patient we have to take care of is the one in the mirror.”

Author Note: The author expresses sincere appreciation to Angela Miller, PhD, MPH, MSCP, DBSM and Dimitrios Tsatiris, MD. Without you, this work would not be possible.