#StopTheStigmaEM: A Call To Action on How Leaders Provide Mental Health Support to Emergency Physicians

Richard Wolfe, MD

Chief, Beth Israel Deaconess Medical Center, Emergency Medicine
Past-Chair, SAEM Wellness Committee

After returning from vacation in March 2020 to find her department drastically changed and then overseeing the treatment of COVID patients early in the pandemic, Dr. Lorna Breen was afraid to seek care for severe depression. Fears of being scorned by her peers or the risk of losing her medical license made her reluctant to access the help she needed. Despite receiving inpatient mental health care, Dr. Breen ultimately died by suicide. After her death, the Department of Emergency Medicine at Columbia University implemented a well-promoted process allowing providers easy access to anonymous mental health care. In the first year, the majority of the Department used the service. It’s most likely that the tragedy of her death and the additional loss and grief witnessed from the pandemic may have been the catalyst for the exceptionally high use of the service. In subsequent years, the number using the service has dropped.  Now, as we’re shifting gears with the pandemic, we need to be more vigilant about emphasizing and normalizing receiving mental health support because even at its nascent stages, many have anticipated the pandemic's toll on the mental health of healthcare workers. 

I spoke with Dr. Angela Mills, the Chair of Columbia’s ED, who was unsure if the drop in use was in part because some of the providers seen the first year were already engaged in regular mental health care. But it is also possible that without constant vigilance, encouragement, and normalization, personal concerns about the professional consequences of seeking mental health will reestablish themselves. As Dr. Mills stressed, mental health care checks for providers should have no more stigma than a check-up with one’s primary care physician or getting a routine vaccination. 

At Beth Israel Deaconess Medical Center, when we set up and promoted free and anonymous mental health care for physicians, I followed up with Physician Health Services a month later to see what percentage of my staff had used the service. Not a single emergency provider had presented to them. Six months later, only a tiny percentage had signed up. Even when one overcomes the institutional and regulatory barriers and the service is highly promoted, self-bias remains the most pernicious impediment to access treatment for mental health issues.

For years, despite a high rate of depression and burnout, we’ve known that physicians are notoriously reluctant to self-report mental health issues. In a paper published in 2021, the Department of Emergency Medicine at UC Davis implemented an advanced program for attendings and residents to help with depression. It was only used by a small percentage of the staff, highlighting the challenges of engaging providers. This contrasted with the satisfaction of the minority of physicians who successfully engaged in a treatment referral program.

Self-bias is a significant barrier to accessing mental health care. Canadian centers have developed simple tools such as the Mental Health Continuum to allow clinicians to self-assess their mental health.  This has shown moderate reductions in stigma and increased self-reported resilience and coping abilities.  

The COVID pandemic has made it clear to everyone the dangers to frontline providers of fatigue, depression, burnout, and suicide. Three years into it, we still lack the knowledge of how best to destigmatize access to mental health as burnout continues to rise. The Lorna Breen Foundation was the first to raise money to create grants and start addressing some of these issues. Superb advocacy by the Lorna Breen Foundation and others has paved the way for bipartisan support to provide considerable funding to The Dr. Lorna Breen Health Care Provider Protection Act, signed by President Biden on March 18th, 2022. Specifically, it includes ambitious funding goals to improve the care and well-being of our physicians, nurses, and other healthcare workers: 

* Establish funding to train health profession students, residents, and health care professionals on evidence-informed strategies that reduce and prevent suicide, burnout, mental health conditions, and substance use disorders, as well as improve well-being and job satisfaction

* Establish grants intended for employee education, peer-support programming, and mental and behavioral health treatment, with health care providers in "current or former COVID-19 hotspots" receiving precedence

* Identify and distribute evidence-informed best practices for reducing and preventing suicide and burnout among health care professionals and promoting mental and behavioral health and job satisfaction

* Create a national evidence-based education and awareness campaign geared toward health care professionals that urges them to seek support and treatment for mental and behavioral health concerns

* Develop a comprehensive study of healthcare professionals’ mental and behavioral health and burnout, including the understanding of the impact of the COVID-19 pandemic 

This support is needed to expand our knowledge of how to best ensure the well-being of the clinicians and to implement the changes that will provide the effectiveness of the safety net of the US healthcare system. All the benefits will result in the retention of a highly qualified workforce and better care by keeping clinicians fully engaged in delivering the highest quality care to our patients.

Chairs and leadership in emergency medicine need to engage in methods to de-stigmatize mental health care actively, not just sporadically but as part of a continuous effort to ensure the well-being of our staff. As in other areas, we need to provide training in recognizing and overcoming biases that threaten physicians and nurses and impair our ability to deliver high-quality care.