Monday, January 30, 2006

The signifying disconnect

So, as I was prepping class wandering through the internet between classes earlier today, desperately wishing I didn't have anything to do with Hegel on the theory calendar, I came across an interesting post: Doctor: Perhaps We can All Work Towards This on a blog called, simply enough, Doctor. Doctor's post begins as a response to a journal in the New England Journal of Medicine about physician's committing suicide. Bummer, I thought, and read on (because, really, I'm a cold so and so; did I mention how much I like Titus?).

Doctor then talked about an article from the Journal of the American Medical Association, and it was then that something stuck my Hegel-benumbed eyes. First, (and I'm copying from Doctor):

Thirty-five percent of physicians do not have a regular source of health care, which is associated with less use of preventive medical services supporting the observation that the medical profession does not encourage physicians to admit health vulnerabilities or seek help. [Emphasis mine]

Now, I'm going to lay out my assumption about physicians. Assumption: Most can afford health insurance or health care, or have health insurance/care through a job.

So, why do more than one third of physicians NOT have a regular source of health care? After all, these are the people who tell us to have this or that test taken at this or that age, have screening procedure X done every year, or every third year, blah blah.

But more than one third choose NOT to have a source of regular health care. Why is that? Okay, a FEW physicians are no doubt the only health care provider in a rural area, and there's just no one else. But if my assumption holds, then the choice IS a choice, and NOT about lacking money or health insurance.

What is it about? Do 35% of physicians not believe the stuff they insist on about tests and preventative medicine, wellness, and such?

Do they think that being asked if they wear a seatbelt is inane as I do? (Really, I've jumped out of an airplane in flight on purpose, and not because it was falling out of the sky. My seatbelt is the least of anyone's worries. And yes, thanks for asking, I do wear my seat belt. I'm nuts, not stupid.)

Or is the decision not to have a source of regular health care about other things? If so, what?

If so, here's one possibility from the first article Doctor quotes, "Taking their own lives--the High Rate of Physician Suicide" (NEJM), which says,
It has also been noted that physicians tend to neglect their own need for psychiatric, emotional, or medical help and are more critical than most people of both others and themselves. They are more likely to blame themselves for their own illnesses. And they are apparently more susceptible to depression caused by adverse life events, such as the death of a relative, divorce, or the loss of a job. [Emphasis mine]
Maybe it's because they think their peers will be critical and judgmental about their own foibles, perhaps because they themselves are critical? And just don't want to hear the criticism from someone else? They don't want to feel that they're to blame for their own illnesses?

Back to the JAMA article, "Confronting Depression and Suicide in Physicians" (the link is to the abstract), which argues that

It is reasonable to infer that physicians' concern about disclosure of mental health records is widespread, although studies are lacking. Breaches of confidentiality also are believed to harm openness between the physician (as patient) and the treating clinician and may result in needless disclosures to coworkers. Those concerns, coupled with professional attitudes that broadly discourage admission of health vulnerabilities, are likely the driving forces behind physicians' disinclination to seek mental health care.
So, physicians are worried about breaches in confidentiality. Do they know something about the effectiveness of HIPAA confidentiality rules that I don't? Like that they're not respected?

Doesn't this strike you as a bit of a disconnect? Physicians (who tend to tell the rest of us to get regular preventative health care) don't get it themselves, at least 35% of them don't.

Perhaps, they don't get it because they're already critical, and, perhaps, don't want to open themselves up to the criticism of others? And/or, they're worried about breaches of confidentiality. Or there's some other information they have that they're not sharing.

I'm trying to imagine a parallel in my own field: don't encourage your own kid to go to college because college is useless? Maybe a better parallel would be don't subject your work to the scrutiny of others who might be critical because you are?

I don't know. I do know that I see a disconnect between what people in the medical profession SAY and what they DO themselves, and the disconnect is statistically significant, and, according to these articles, significant enough to affect depression and suicide rates among physicians.

Now, I'm reading against the grain here, obviously; Doctor wants his readers to be concerned about physician suicide, and more specifically, wants to encourage his physician readers who are depressed to click on his link to the Physician Suicide Project.

In reading against the grain, to try to understand something else about the community textually represented in this study, I'm not dismissing the articles' or blog's concern about physicians committing suicide. But it does make me wonder why.

I know the stereotypical college professor gets up with caffeine and starts in on alcohol at 5pm, but I have to admit that I don't know any college instructors (at any level) who've committed suicide. (I know one grad student who committed suicide.) I know plenty of college instructors (and grad students) who seem depressed, though. Certainly, anyone without tenure might reasonably be concerned about breaches of confidentiality, especially about depression or suicide attempts.

We're a pretty self-critical bunch, and we, too, experience a serious level of disconnect between what we say and what we sometimes do: I teach Marx, but I have retirement "savings" in mutual funds which invest in the stock market. We're supposed to respect and care about our students, but every instructor in the world has complained about students at some point.

But the disconnect isn't quite the same as it seems in the article above; I think I have a strong sense that what I do is meaningful enough that I want to participate in it, teaching, learning, studying, contributing to understanding, knowledge. And I think most college instructors share that same basic sense that what we do really IS worthwhile and meaningful.

I guess that's where I see the significance of the disconnect I've been pointing to in those articles, and in the blog: if 35% of doctors don't see regular health care as worthwhile and significant, then at least some of them don't see what they do every day as worthwhile or significant.

I don't know if I could get up in the morning tomorrow, and face Hegel again if I didn't think doing so was worthwhile and meaningful, that it mattered. (And that's JUST Hegel! Imagine facing people who haven't been dead for 100+ years if you feel that what you do doesn't matter!)

It sure would be interesting if the researchers who wrote those articles, or if Doctor, himself, were to figure out if there's a correlation between the 35% of doctors who don't get regular health care and the doctors who experience depression or commit suicide.

(Okay, and because I can't resist the irony: Doctor says that physicians are more successful than most when they try to commit suicide.)


  1. I suspect that the 35% of doctors who don't get regular healthcare are acting as their own doctors. This is generally discouraged but quite common. Doctors aren't meant to prescribe medications for themselves, or their friends, but it does happen. Imagine I'm in the middle of a 50 hour stint in the hospital and I've got acute sinusitis. My face aches, I'm running a fever, there's mucky stuff coming out of my nose. What do I do? I certainly don't call in sick and go and see my own doctor. If I think antibiotics would help me I find a doctor in the hospital who is willing to write me a script and after a quick stop by the pharmacy department I get on with my shift. If I'm depressed, do I see my doctor? No, of course not. Because I should be able to pull myself together, right? Uh... yeah. I certainly won't commit suicide because who would turn up in the morning then?

    The medical training system is not healthy for its trainees. The younger generation are being trained to have their own primary care physician and to look after themselves, but the old expectations will take decades to shift (like, for example, the expectation that you should be able to work with 3 hours sleep in a job that has been recognised as being busy enough for two people, not just your poor self).

    Women doctors are likely better at seeking healthcare because (assuming we're sexually active) we know that we have to have Pap smears. Most of us aren't silly enough to try that ourselves. But we're still bad at seeking help for things we know we should.

    A colleague of mine committed suicide just over a month ago. It happens. It shouldn't.

  2. Thanks for your response, BB. I'm sorry to hear about your colleague. You're right; something's wrong when someone needs to turn to suicide, especially for work related problems and we socially need to do better for our fellow beings.

    I hope you understand that my post wasn't meant to disparage or dismiss the problem but was more thinking about a potential correlation that didn't seem to be recognized. When I look around through the blogosphere, though, physicians often stand out for seeming dissatisfied with their work, though maybe it's the work conditions rather than the work itself?

    I take your point about the self-treating, but I read the "regular source of health care" as having more to do with an ongoing relationship thing than as a self-treatment for feeling lousy on a given day. (And the idea of a self-inflicted Pap smear just seemed... well...)

    And I hadn't really thought about how the long hours might contribute to depression or overall health problems in general.

    Thanks again for your feedback.

  3. Don't worry, bardiac, I didn't think your post was disparaging or dismissive.

    I suspect that the greater push for an appropriate work-life balance will help address some of the issues with medicos and depression as I am certain that the long hours do not help. In fact, I sometimes develop a mild degree of mania when I get a few weeks of annual leave. With regular food and sleep I get so much energy I can hardly hold it all in. I feel human again. It's a wonderful thing.

    There are also a lot of programmes being developed to help unwell doctors (a term often used to refer to "doctors who have a mental illness or drug addiction).

    A lot of study in this area has also suggested that doctors are highly strung perfectionists which is thought to put them at greater risk of depression/suicide because they're not used to failing. So if they fail (either personally or professionally) it can send them into a tail-spin. I also suspect that doctors and other type-A personalities are less likely to seek help or admit that they need help when the chips are down, which compounds the problem.

    (Oh, and as for my suggestion of self-inflicted Pap smears, I only say that because I'm sure there's a physician out there who has tried it. Beggars belief, perhaps, but I'm sure it's true.)

    As for doctors often being dissatisfied with their work... I think that's true. A medical career is a large investment and there is a lot of pressure to continue following a path even if you realise that it's not for you. Also, long hours mean that work can become something that keeps you away from your family, your loved ones and all the non-work things that are important to you.

    I tell all my interns only to go into surgery if they love it. I've seen too many unhappy surgeons.

    Another problem that I see is that emotions are discouraged in medical training. I think most sane people realise that this is unhealthy.

    Oh well. It's an interesting journey. And luckily I can say that for the most part I love what I do.