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Should psychotherapy be mandatory for medical students/residents?
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Yes.
Yes, but not “psychotherapy” as classically defined, a process that only works if there is a good fit between the two parties and it is voluntary.
A meeting with a psychologist could be embedded into orientation. After that, periodic visits should be encouraged but not mandated. This should be seen as part of general wellness and health care and would offset a stigmatizing mindset that implies some residents will be fine, whereas others will need therapy. This process could continue through the trainee’s residency if he or she finds it helpful.
Rates of burnout, a systems problem, are very high among trainees today, leading some to wonder whether we need to go a step further than just advising folks to see a therapist if they’re having problems. Trainees must not blame themselves. They are doing their best to cope with a hugely challenging medical system of education and patient care.
Generally, I have found that medical students and residents will admit to burnout much more readily than they would admit to depression. When a doctor says they are burned out, they may say, “I’m working so hard, this has been an awful rotation,” or, “The place where I’m training doesn’t really care about us.” These situations would cause burnout in any hardworking physician who lacks personal agency, or a voice in their training.
It’s very rare to hear a doctor say, “Yes, I thought I had burnout, but I actually went to a psychiatrist and she diagnosed me with major depression. I’m now taking an antidepressant and getting some good psychotherapy.” Physicians are very reluctant to disclose that, unfortunately, because we haven’t fully eliminated judgment and discrimination in medical training.
As psychiatrists working in this area, we take this very seriously, because we don’t want someone with depression to slip through the cracks and not get the proper treatment.
I am part of the “Zero Suicide” movement, the goal of which is to eliminate suicide in health care settings. However, we understand that this is an aspirational goal and that suicide can stem from a lack of effective care. We support steps that health care organizations can take to prevent suicide among their patients. We could extend that to trainees. All incoming residents and fellows could have a sit-down with their health team, including a primary care physician, psychologist, nutritionist and perhaps someone trained in mindfulness meditation or yoga. It could include all kinds of approaches that are holistic in their orientation — why wait until something happens to provide these services?
Some centers now give standard short psychological tests, like the Patient Health Questionnaire, to residents at the beginning, which they repeat at 3 or 6 months. Hopefully, physicians feel good about this, like they’re working in a setting that is watching over them.
When you make a mental health visit mandatory at the beginning of residency, the message you give is, “Training in medical school and residency can be stressful. We care about you. You’re going to be with us for 2, 3 or 4 years, and we want you to thrive here.”
Michael F. Myers, MD, is professor of clinical psychiatry in the department of psychiatry and behavioral sciences at SUNY Downstate Medical Center. He can be reached at 450 Clarkson Ave., Box 1203, Brooklyn, NY 11203; email: michael.myers@downstate.edu. Disclosure: Myers reports no relevant financial disclosures.
No.
I am very much in favor of psychotherapy when it’s appropriate, but I’m not in favor of making it mandatory. Making it mandatory trivializes what psychotherapy is about. Psychotherapy is a specific form of treatment for specific conditions. “Mandatory” treatment implies that everyone is suffering.
There is a great deal of interest in offering medical students and residents a face-to-face meeting with a mental health professional with the hope that such experiences will encourage them to seek treatment when they might need it. In some institutions, trainees may choose to opt out if they do not wish to go, whereas others offer “opt-in” opportunities for students and residents when they begin training. There is no clear evidence yet that these approaches are more successful in encouraging trainees to seek treatment if needed.
This idea of mandatory psychotherapy is likely rooted in the increased awareness of how much strain, stress and burnout health care providers face — not just physicians and trainees, but everyone who is engaged in providing health care in our current dysfunctional system. Also, there is significant stigma about seeking treatment for mental health issues, especially for physicians.
Burnout, however, is not a mental health problem, it is a systems problem that may be associated with depression or anxiety. Conversely, a person suffering from depression and anxiety may be more susceptible to burnout.
Resources for handling burnout are needed, but that is very different from mandatory psychotherapy, which not everyone needs or will benefit from. It is similar to saying everyone should be on penicillin or antihypertensive medication — you should have the medication or treatment when you need it, not when you do not.
Physicians who are struggling must have the opportunity to get help for depression, anxiety or any other mental health condition. Many anxiety and depressive symptoms overlap. Psychiatrist Glen Gabbard has described the “compulsive triad” in the physician’s personality — we suffer from doubt, guilt and an exaggerated sense of responsibility. Adaptive aspects of this triad contribute to our commitment to patients, our diagnostic rigor, our thoroughness and our responsibility not to violate our patients’ trust. Maladaptive reactions make it difficult to differentiate healthy self-interest from selfishness, difficulty relaxing, and an overwhelming sense of responsibility for what we cannot control. We want to do the right thing. We overwork, sometimes to our own detriment.
Physicians are afraid to seek help because, in addition to the stigma that exists, they are worried about losing their licenses and are ashamed of their need to rely on others. Although the licensure environment is changing, licensing forms in some states still ask questions such as, “Have you ever seen a psychiatrist?” or, “Have you ever had depression or bipolar disorder?” They wouldn’t ask whether a physician has had hypertension or diabetes.
There are many downstream reasons why doctors do not get help. It’s important that clinicians be aware of mental health services and have access to them when needed. However, mandating them in a nonspecific way doesn’t make sense, and it undermines and devalues the importance of psychotherapy for those who really need it.
Reference:
Gabbard GO. JAMA. 1985;doi:10.1001/jama.1985.03360200078031.
Carol A. Bernstein, MD, is vice chair for faculty development and well-being in the departments of psychiatry and behavioral sciences and obstetrics and gynecology at Montefiore Medical Center/Albert Einstein College of Medicine. She can be reached at 403 E. 34th St. #3, New York, NY 10016; email: cabernstei@montefiore.org. Disclosure: Bernstein reports no relevant financial disclosures.