Dr. Greenberg:
Along with the general population, physicians are vulnerable to substance use disorder, or SUD, with rates as high as 10 to 14 percent. And with our demanding careers, mental health and burnout can often exacerbate these stressors and addiction. So what help is available for those experiencing SUD?
Welcome to Clinician’s Roundtable on ReachMD. I’m your host, Dr. Michael Greenberg, and today I’m speaking with Dr. Chris Bundy, who is the Executive Medical Director of the Washington Physicians Health Program, and also Clinical Assistant Professor of Psychiatry at the University of Washington School of Medicine.
Chris, thank you for joining us today.
Dr. Bundy:
Thank you, Michael. It’s great to be here.
Dr. Greenberg:
Yeah, I think this is a great, amazing topic, so let’s just dive right in because there’s so much to talk about here. Can you explain the prevalence of substance use disorder among physicians and use characteristics?
Dr. Bundy:
So as you stated in your intro, I mean, I think you hit it just about right. Generally, 10 to 15 percent of physicians will qualify for a substance use disorder diagnosis over the course of their career, which is similar to lifetime estimates in the general population. We don’t believe that doctors have any special protection. Their medical knowledge, their experience doesn’t actually protect them, and as you mentioned, there may be some unique vulnerabilities. Probably, 70 percent or more use alcohol—is their culprit substance—followed by opiates in probably 25 to 30 percent, a growing number of cannabis users as cannabis legalization, and use has increased in the general population, so too amongst physicians. And oftentimes the problems begin really in medical school. Thirty percent of medical students have alcohol-related issues that they didn’t have prior to coming to medical school, and there’s a relationship between burnout and alcohol use disorder that begins also in medical school where students who have higher rates of burnout also report higher use of alcohol and vice versa.
Dr. Greenberg:
And are we spread out across the board, or are certain specialties more vulnerable?
Dr. Bundy:
It’s hard to know. If you look at treatment populations and you look at the proportion of physicians who are in treatment versus their prevalence in the general population it seems that anesthesiologists, as one might expect, are overrepresented in treatment in PHP populations. Psychiatry, emergency medicine also overrepresented amongst the specialties. There’s probably a fair amount of unmet need amongst surgeons. In other words, we don’t have as many surgeons in the program or in treatment as probably are suffering based on some pretty good work that’s done by Mick Oreskovich and others looking at prevalence of alcohol-related problems in surgical populations versus what we see. And then there seemed to be some specialties that for whatever reason are protected. Pediatricians seem to be not as highly represented in treatment in PHP populations relative to their prevalence or to their numbers in the healthcare community.
Dr. Greenberg:
So how can the stress of our careers play really into SUD? And are there other risk factors unique to our population?
Dr. Bundy:
Yeah. So stress and burnout, which are ubiquitous in the population, especially in the wake of the pandemic, we had an epidemic a decade long or more epidemic of burnout in the profession, increasing rates of burnout by all measures, moral distress. The ethical quandaries increase our stress. We deal with life and death. We’re not given good tools for how to manage the stress associated with the profession. I consider it a trial by fire, battle hardening mentality of how we are trained as residents, sort of like if you get through residency you’re prepared to deal with a marathon of a career of stress and strain. Nobody really talks about these things in our training. I think that’s changing. I think that we don’t take a break oftentimes to look at how we are emotionally affected by the work that we do. We’re expected to suck it up or compartmentalize. And I think all of those factors coalesce together to make it, one, we become ill equipped to self-monitor. So not only are these illnesses, like depression and substance use disorder, characterized by denial, characterized by a brain that tells us that either nothing’s wrong or what’s wrong with us has to do with our character rather than a true bona fide medical illness, but the system in which we’re trained also tells us you don’t get to eat or excrete when you want to. You have to wait, you’re on rounds, you have patient care responsibilities, you’re attending a code as a new intern, and you’re trained to compartmentalize and shut off access to how you’re actually doing, and I think that that presents some unique challenges.
I think the stigma of mental illness and substance use disorders has actually increased in the profession. It’s underscored, it’s enhanced, it’s magnified by the fact that we are supposed to be better than average. We are supposed to be highly competent, highly professional, driven to perfection, and those things run counter to our ideas and stereotypes about mental health and addiction in a way that I think makes the stigma and shame of having one of these conditions so much worse that it impedes our ability to get help. So I think that there are some unique characteristics of our practice, in particular our culture in which we’re raised as physicians that make it difficult for us to recognize when we’re having difficulty, and then seek care appropriately.
Dr. Greenberg:
So look, you’re very open about sharing your journey of recovery. I too am a recovered alcoholic, so there’s two of us talking here. What do you feel about the fact that because of the stigma, we hide? Do you find the physicians are hiding? Do you think it might be better if we showed up?
Dr. Bundy:
I think it’s a very individualized decision. I do think that more physicians, depending on their circumstances, have been willing to come out and be open. I do think that stigma and shame is still real, and physicians have to be cognizant of that and the negative impacts that could occur to their profession. Not everybody is as sympathetic to individuals who have mental health and substance use problems. And if you’re a patient who’s thinking about using one doctor versus another or where you want to get your care, the doctor who is in recovery or maybe you worry not in such good recovery, may not be your first choice, and so I think that what we need to encourage is for physicians who are thinking about being open about their story and advocating on behalf of the profession as it struggles with these conditions like any other human being is to do that with help and support and to make sure that you’re talking with your adult supervisors and others in your recovery community. Think about the pros and cons of disclosure, understanding that there can definitely be some benefits to shedding light on the illness and to destigmatizing the condition, but also that again, we haven’t eradicated stigma, and so there could be consequences to the individual.
Dr. Greenberg:
Sure. So listen, if you’re comfortable, would you mind sharing a little bit about your experience, and what impediments exist for physicians seeking care?
Dr. Bundy:
Yeah. So I probably met criteria for an alcohol use disorder by the time I hit medical school. My biological father, it turns out, was a very bad alcoholic, and I grew up with this mythology around alcohol use and alcoholism that it was a very bad thing, and because I had that experience, I really felt like that negative perception that I had about alcohol use disorders would protect me from developing the phenotype myself. And the truth was actually the opposite. I had four to five times the risk probably by having a first-degree relative with a severe alcohol use disorder, particularly a parent, so I probably inherited some liability. So I was operating under a false assumption that I was protected when I was, in fact, vulnerable, and that led me to drink in high school and college with impunity. And I was always that work hard, play hard guy, and I see that mentality throughout our profession.
I see medical school events. I see residents’ events. I see the way that we socialized and partied coming up where we embraced the model of alcohol use in our country that supports excessive use, binge alcohol use, and so on.
And so going all the way through, as I got more advanced in my training, and I became a psychiatrist, I really felt like I understood addiction from a professional standpoint, but what I would say is true for me, and I’d say this is true for anybody, is that this is such a great example of how we don’t have insight into our own issues, and we cannot be our own doctors. I came to the point where I knew I had a problem, but I still believed that given my experience and expertise that I was in the best position to figure out how to solve my problem utilizing the broken brain that was affected by the illness to try to solve the illness, which just doesn’t work.
And so I tried different types of intensive outpatient treatment and other sorts of strategies, and I even went to the Physician Health Program in Washington, the program that I now run, and had a meeting with them and bought myself five more years of progression to disease, until finally I checked myself into treatment five years later at a facility that specializes in the treatment of healthcare professionals. I think another perception that people have is that, that the doctors who end up in these situations are bad doctors. By all measures I was a pretty good doctor. I’d never had a licensing problem. I never had a malpractice complaint. I had a thriving private practice at the time, but I was also an academic psychiatrist, and I think I was reasonably well respected amongst my peers. But I say all of that because eventually I returned to the PHP knowing that I wouldn’t do well on my own, and then I was really grateful to have the support of the Physician Health Program at that point because I knew that I would probably not stay sober on my own without it.
Dr. Greenberg:
Thank you. This has been a hugely important discussion regarding the well-being of all physicians and the opportunities for care. I’d like to thank my guest, Dr. Chris Bundy, for being open with his journey, bringing light and love to the situation, and providing his insights to help others who might be struggling. Chris, it has been a pleasure speaking with you.
Dr. Bundy:
Thank you for the honor and the privilege, Michael. It’s been great to be here.
Dr. Greenberg:
Please join me and Dr. Bundy for a continuation of this conversation, and listen to part two of this program now on Clinician’s Roundtable at ReachMD dot com. I’m Dr. Michael Greenberg. To access this and other episodes in our series, visit Clinician’s Roundtable on ReachMD.com, where you can Be Part of the Knowledge. Thank you for listening.
