Clinical Practice Guidelines for Assessment and Management of Psychiatric Morbidity in Medical Professionals

INTRODUCTION

The medical career and profession are considered to be one of the most stressful professions. Evidence suggests that stress in the life of medical professionals starts before joining the medical college, from the time of preparation for the entrance examination, and continues throughout life. To succeed during medical school and residency training and later in practice, they are expected to balance various demands, including pressures to constantly imbibe new knowledge and skills, meet the deadlines for various activities, and handle the workload. The association of stress with various mental illness is well known. Accordingly, medical students, residents, and practicing physicians have a higher prevalence of mental disorders. Data are mainly available for depression, burnout, substance use disorders, sleep disturbances, and suicide. Despite the high prevalence of mental disorders among medical students, residents, and practicing physicians, they are often reluctant to seek mental health services. They also have a lot of apprehensions about the use of psychotropics. Hence, mental health professionals need to understand these barriers, provide quality care to the medical professionals seeking help, and create a friendly environment to improve the rates of seeking help.

This group of clients are often ambivalent about seeking a psychiatric consultation and contact the psychiatry emergency services (such as crisis helpline) or services at the student welfare centers, and seek urgent help. They often contact the psychiatric services, when they are not able to manage their issues on their own and expect that the mental health professionals will be able to help them on an urgent and priority basis. This guideline provides a broad framework for the assessment, management, and prevention of mental health issues among medical professionals. The health care needs of the medical students, residents, physicians, and other medical professionals such as nurses and paramedical staff can vary. These guidelines are not framed keeping any specific setting or model of psychiatric care and will require modifications to suit the needs of patients, service model, and precise setting. Similarly, these guidelines do not provide recommendations for any specific psychiatric disorder in medical professionals. Instead, it gives a general outline of how to address issues specific to this group of patients. In this guideline, the term “doctor-patient client” refers to all groups of health professionals, such as medical students, resident doctors, and practicing doctors.

EPIDEMIOLOGY OF MENTAL HEALTH ISSUES AMONG THE PHYSICIANS

Data from all parts of the globe suggest a high prevalence of mental disorders among healthcare professionals compared to the general population.

Depression

A meta-analysis of the data on medical students suggests that the prevalence of depression or depressive symptoms is 27.2%. The longitudinal studies assessing depressive symptoms before joining the medical schools and during the medical course suggest an increase in the prevalence of depressive symptoms by 13.5% during undergraduate medical training.[1] A meta-analysis that included data on resident physicians estimated the pooled prevalence of depression or depressive symptoms to be 28.8% [95% confidence interval (CI): 25.3%-32.5%]. The meta-analysis also suggested that over the years, there has been an increase in the prevalence of depression with the increasing calendar year, and secondary analysis of the data indicated an increase in depressive symptoms by 15.8% after starting residency.[2] Another meta-analysis of data from Australia estimated the prevalence of depression to be 27% among medical students, 29% among registrars, and 60% among doctors in practice.[3] The data that have emerged from various countries during the COVID-19 pandemic has estimated the prevalence of depression among physicians to be 26%.[4] A meta-analysis of data on nursing students estimated the prevalence of depression to be 34%, with a higher prevalence among those of Asian origin.[5] The prevalence of depressive symptoms in nurses has been estimated to range from 12% to 43.3%.[6,7]

Available data suggest that depressive symptoms are associated with an increased relative risk of medical errors. Data also indicate that committing medical errors is also associated with an increased risk of depression.[8] Depressive symptoms and depression among physicians are associated with reduced work productivity, lower work satisfaction, higher rates of dysfunctional and worrisome approaches to seeking mental health services, and self-prescription of antidepressants.[9]

Meta-analysis of the data from India suggests that the prevalence of depression among medical students is 40% (CI: 32%–47%), with a significantly higher prevalence among girls.[10] A meta-analysis of studies conducted during the COVID-19 pandemic has estimated the prevalence of depression among physicians to be 41.9%,[4] and that in nurses has been estimated to range from 35.8%-70%[11,12] [Table 1].

Table 1.

Prevalence of mental health outcomes in healthcare professionals as reported in different meta-analysis

Psychiatric disorders	Medical students	Residents/Registrars	Physicians	Nursing students	Nurses
Worldwide Data
Depression or depressive symptoms	27.2%#	28.8%#	60%# 26%##	34%# 52%##	12-43.3%#
Suicidal ideations	11.1%#	-	17%#	-	-
Burnout	44.2%#	35.7%#	67%#	-	11.23%#
Anxiety disorders	33.8%# 28%##	-	25.8%##	32%##	37%##
Insomnia	55%#	-	41.6%##	27%##	34.8%##
Substance abuse	20-40%$	-	10-15%$	14-27.3%##	10%)#
Data from India
Depression or depressive symptoms	40%#	-	41.9%##	-	35.8%-70%$$
Suicidal ideations	53.6%$$	-	-	-	-
Burnout	16%- 80% $$	27.13%$$	24%-EE# 27%- DP# 23%-PA#		37.6% $$
Anxiety disorders	34.5%#	-	42.87##		40-74%$$
Insomnia	17.3% $$	-	31.9%##	-	43%- 83%$$
Substance abuse	40.3%#	-	10%#	-	-

^#Data from meta-analysis[1,10,13-19] ; ^## Data from meta-analysis done on data emerging during the COVID-19 pandemic[4,18,20]; ^$ data from review[17,21,22] ^$$ Prevalence studies.[12,23-25] EE-Emotional exhaustion; DP: Depersonalization; PA; Personal Accomplishment

Suicidal ideations and suicide

The prevalence of suicidal ideation is estimated to be 11.1% among medical students[1] and 17% among physicians.[26] Further, the data also suggest that suicide rates are higher among physicians and healthcare workers compared to the general population. A recent meta-analysis estimated that the standardized mortality rate for suicide among physicians to be 1.44 (95% confidence interval: 1.16, 1.72) when compared to general population, with a higher risk among females compared to males. In terms of specialty, anesthesiologists, psychiatrists, general practitioners, and general surgeons are at higher risk.[26] A study from India estimated the prevalence of suicidal ideations among medical students to be 53.6%.[27] A study assessed the prevalence of suicidal ideations to be 16.7% among resident doctors and faculty members in a tertiary care hospital.[21]

Burnout

The concept of physician burnout emerged during the 1960s. It is defined as “a persistent, negative, work-related state of mind in ‘normal’ individuals primarily characterized by exhaustion, which is accompanied by distress, a sense of reduced effectiveness, decreased motivation, and the development of dysfunctional attitudes and behaviors at work.”[28] It is considered to have three subcomponents, i.e., emotional exhaustion, depersonalization, and a sense of low accomplishment.[29] Different meta-analysis suggests that there is a high prevalence of burnout among medical students (44.2%),[30] residents (35.7%),[31] physician (67%),[32] and nurses (11.23%).[13] Emerging data from the USA also suggest that over the period (from 2011 to 2014), there has been an increase in the prevalence of symptoms of burnout among physicians, with a reduction in the satisfaction with work-life balance.[33] The risk factors for burnout among medical students include the curriculum, stress arising due to competition, examinations, finances involved in pursuing the studies, hospital conditions with the workload, exposure to patients’ suffering and death, management style, and young age.[30] Among the residents, high burnout rates are reported for residents pursuing general surgery, anesthesiology, obstetrics and gynecology, and orthopedics compared to other specialties.[31] Available data also suggest a high correlation between depression and burnout[14,34] and burnout and anxiety.[34] A meta-analysis of data suggests that burnout among professionals (not limited to medical professionals) is a significant predictor of hypercholesterolemia, type 2 diabetes, coronary heart disease, hospitalization due to cardiovascular disorder, musculoskeletal pain, changes in pain experiences, prolonged fatigue, headaches, gastrointestinal issues, respiratory problems, severe injuries, and mortality below the age of 45 years. Similarly, burnout is also significantly associated with adverse psychological consequences, including insomnia, depressive symptoms, use of psychotropic and antidepressant medications, hospitalization for mental disorders, and psychological ill-health symptoms. Burnout has also been associated with adverse professional outcomes such as job dissatisfaction, absenteeism, new disability pension, perception of high job demands, and presenteeism.[35]

Various studies have estimated the prevalence of burnout among medical students to range from 16% to 80%,[36,37] 27.13% to 90% among the residents/registrars and physicians,[38,39] and 37.6% among nurses.[40] A meta-analysis, which included data from 15 studies from India that included doctors, nurses, resident doctors, paramedics, and physiotherapists, estimated the prevalence of emotional exhaustion to be 24% (95% CI: 16 – 36%), and that of depersonalization to be 27% (95% CI: 15–44%), and 23% (95% CI: 11–42%) for burnout in the domain of personal accomplishment.[15] This review also showed that the prevalence of burnout was higher among females, those who were unmarried, and those who had long working hours. The prevalence was also higher in those with higher professional dissatisfaction, perceived stress, low remuneration, lack of time for leisure activities, disturbed sleep-wake cycle, and lack of respect at work.[15]

Anxiety

The prevalence rate among medical students has been reported to be 33.8% (95% CI: 29.2–38.7%), with a higher prevalence in students from the Middle East and Asia.[16] A large amount of data has emerged after the COVID-19 pandemic, and this suggests a high prevalence of anxiety among physicians (25.8%) and nurses (37%).[4] A meta-analysis of studies from India among medical students suggests that prevalence of anxiety is 34.5%.[17] Similarly, few cross-sectional studies have reported around 40 to 74% prevalence of anxiety in nurses.[11] During the COVID-19 pandemic, anxiety among physicians has been reported to be 42.8% as per a meta-analysis.[4]

Insomnia

The prevalence of insomnia in medical students has been reported to be around 32%, which is relatively high.[41] Systematic review and meta-analyses on the global prevalence of insomnia in physicians and nurses are lacking. However, the meta-analysis of studies that emerged during the COVID-19 pandemic evaluating insomnia in doctors and nurses reported the prevalence of insomnia to be 41.6%, 27%, and 34.8% among doctors, nursing students, and nurses, respectively.[18] The Indian studies evaluating insomnia in medical students and doctors report a prevalence of about 17.3%.[23] Meta-analysis of data emerging during the COVID-19 pandemic suggests that prevalence of insomnia is 31.9%.[18] Similarly, studies on nursing professionals from India report a high prevalence of shift work sleep disorders and poor sleep quality.[24,25]

Substance abuse

The worldwide prevalence of substance abuse in medical students has been estimated to range from 20 to 40%,[42] and the same in nursing students is 14 to 27.3%.[43,44] Among physicians and nurses, the prevalence of substance use is almost similar to the general population, i.e.,10-15% worldwide.[22,45]

A meta-analysis of studies from India suggests the prevalence of substance abuse in medical students to be 40.3%.[19] Limited data on the prevalence of substance abuse in physicians suggest that it may be about 10%.[46]

Epidemiological data for other psychiatric disorders are lacking for the healthcare professionals. However, it must be remembered that they can suffer from any mental disorder, as encountered in people from general population.

BARRIERS TO SEEKING MENTAL HEALTH CARE AMONG PHYSICIANS

Despite the high level of mental morbidity among medical professionals, they do not seek treatment. Data suggest that 50% of female doctors who meet the criteria for a mental disorder do not seek professional help.[47] Among the various barriers, stigma is one of the crucial barriers preventing doctor-patient client from seeking help, which is more among younger practitioners than older practitioners. The young practitioners also report a higher level of barriers in the form of confidentiality and impact on career progression and registration.[48] The reluctance to seek help has also been reported to be associated with stigma related to mental illnesses, fear related to licensing issues, wanting to solve the problem on their own, fear of colleagues coming to know about the same, lack of time, lack of convenient access, and issues related to confidentiality.[49–52] A review of 33 articles identified the following as the most common barriers to seeking mental health care among medical students: fear of the negative effect on residency/career opportunities, apprehension about the breach in confidentiality, stigma, and fear of shaming from peers, lack of perceived seriousness/normalization of symptoms, lack of time, and fear of documentation on academic record [Table 2]. Students also preferred to seek care outside of their institution for fear of the provider being an academic preceptor.[53] The experience of students who seek help for mental health issues also suggests that they are negatively judged by their supervisors and peers, revealing their emotional/mental health problems to others.[54]

Table 2.

Barriers to help-seeking among doctor-patient clients[Adapted from][21,53,55]

Individual level barriers	System level barriers
Medical Professionals & Interns
• Perceived structural stigma (fear that they may not be accepted onto a specific training program)	• Lack of access to care: access to services that are anonymous or not related to the individual’s immediate work or professional networks
• Perceived stigma (that others would think less of them)
• Self-stigma (that one should be able to cope without the help of others)	• Lack of convenient access
• Lack of time and prioritizations	• The professional culture of considering high levels of stress either a necessity of the occupation or indicative of effort or commitment
•Recognition and awareness of stress symptoms
• Treatment attitudes and expectations	• Concerns regarding confidentiality
• Preference for self-management	• Negative impact on career
• Concerns about the cost of treatment • The belief that treatment does not work
Medical Students
• Personal stigma against seeking care	• Affiliation of treating practitioner with university
• Apprehension about non-confidentiality	• Involvement of practitioner in medical training
• Fear of mental health care being noted on academic record	• Access issues
• Fears of decreased opportunities for residency and career	• Cost
• Fear of discrimination/judgment	• Limited number of sessions
• Lack of time to seek care	• Mandatory reporting laws
• Concerns about effectiveness/appropriateness of treatment	• Lack of education on resources
• A belief that the issue may self-resolve/is not severe enough to seek care	• Lack of available resources
• Normalization of symptoms	• Cultural stigma
• Previous experience with mental illness in close contacts
• Lack of experience with mental illness in close contacts
• Lack of knowledge of resources
• Preference for mental support from family, friends, peers
• Competition with peers
• Self-diagnosis
• Diagnosed mental illness or high severity of symptoms
• Fear of unwanted intervention
• Fear of treatment side effects
• Lack of positive mentorship

One of the studies from India evaluated the barriers in health care seeking among medical students and reported that about one-third of the participants indicated towards barriers to seeking mental health services. The commonly reported barriers included lack of confidentiality (61.2%), fear of unwanted interventions (56.4%), unsure about where to seek help (50.3%), stigma (45.8%), lack of time (40.1%), fear of the impact on the academic performance (38.8%), fear of side effects (30.2%), and cost of treatment (11.5%). When the barriers to help-seeking for mental and physical health were compared, a significantly higher proportion of students reported stigma, confidentiality issues, lack of awareness about where to seek help, and fear of unwanted intervention to be more common barriers to seeking mental healthcare services.[56] When the barriers to help-seeking were compared between those in the first year and final year, students of the first year more often reported lack of time, awareness about where to seek help, cost issues, and fear of future academic jeopardy as common barriers. In contrast, final-year students reported stigma as a barrier to seeking help for mental health issues.[57] Another study evaluated the barrier to seeking help among the medical residents and faculty reported that only 13% of the participants had sought help from mental health professionals for their work-related stress, and the commonly identified barriers to seeking help included fear of being stigmatized and labeled as “weak” and having a mental illness, fear of being accused of shrugging work, fear of the impact of seeking help on the attitude of faculty toward them, and time constraints to seek help.[38]

All these barriers must be considered while dealing with doctor-patient clients. The mental health professionals should remember that those consulting them may still be apprehensive about these issues. They should discuss the relevant issues with the help-seekers to relieve some of their anxiety.

BASICS OF ORGANIZING SERVICES

It is often said that doctors make the worst patients.[58] Taking care of doctors requires extra time and effort.[59] As pointed out, medical students and physicians have multiple barriers to seeking mental health care. Further, certain other behaviors make them complex patients [Table 3]. Some of these clients come with behavior akin to “VIP syndrome,” which is understood as a demanding patient resulting in an unsound clinical judgment on the part of the treating clinician to meet the unrealistic expectations of the demanding patients leading to deleterious outcomes.[60] These facts must be kept in mind while evaluating a medical student or a physician, and the clinician should try to be objective in the patient’s best interest.

Table 3.

Some of the issues to be kept in mind while detailing with doctor-patient clients as persons with mental health issues

• The stigma associated with mental illnesses

• Stigma leading to poor help-seeking-fear of being found by other colleagues/their patients in the clinic of the mental health professional, fear of loss of privacy, and confidentiality

• VIP Syndrome

• Self-diagnosis and reluctant about full-disclosure

• Unable to accept the patient role

• Under-estimation or over-estimation of the symptoms and severity of the illness

• Cutting corners when the history is being collected or attempts are made for detailed physical and mental status examination

• Poor medication adherence

• Reluctance to disclose the illness to close family members or other available support groups

• Poor follow-up rates

Some of the basic etiquettes should be kept in mind. The general principle includes attending to them on priority, whenever feasible. Physicians contacting mental health services should be treated as a priority and, if possible, at a mutually agreed convenient time. It is better to organize the services to cater to the need of this group of patients [Table 4]. One of the crucial issues is the ease of managing such patients on the part of the psychiatrist, as many of the physicians seeking help may be known to the psychiatrist or may be closely associated with them. If the psychiatrist feels uncomfortable managing a particular client, it is better to refer the physician-client to another psychiatrist after a discussion about the issue.

Table 4.

Organizing services and principles of dealing with doctor-patient clients as persons seeking help for mental health issues

• Decide whether you are comfortable seeing such a client

• Assess for yourself-whether you would be able to maintain a doctor-patient relationship with your colleague

• Try to schedule the appointment: mutually agreed time, be flexible in accommodating the colleague

• Discuss the issues of fee structure

• Have sufficient time in hand

• Allay the anxiety

• Request the colleague to come with a reliable informant, if feasible

• In case of a crisis call-try to accommodate and attend at the earliest

• Emphasize the need to maintain a doctor-patient relationship

• Don’t get swayed by the stature of the colleague in the city or the institute

• In case, a medical student or resident is to be assigned to a trainee psychiatrist-discuss the issue with the patient, take into account their wishes about whom to avoid

• Address the anxiety related to confidentiality, situations in which confidentiality would be broken (while working in an institutional setting-when and to whom)

• Clarify the treatment process-duration of treatment

• Clarify-which of their demands could be accommodated and which cannot be accommodated

• Telepsychiatry services and/or hybrid services: Keeping the time issue and confidentiality issues in mind, give the options of telepsychiatry and/or hybrid services to the medical students, residents, and physicians; work out the terms and conditions of such services

• Institutional Level Organization of Services

• Student welfare center/services: Designated team including faculty members, clinical psychologists, trainee residents, etc.

• Crisis-Helpline: 24-hour on-call services which could be contacted anytime for psychiatric help

Confidentiality is an issue for this group of clients. It is always better to be aware of the institutional policies regarding disclosure and non-disclosure about the students. In the institutional setting, the mental health professionals employed in the same institute may be required to inform the administration about the mental health issues the students/staff face. This kind of provision can have pros and cons, as some persons who are not suicidal/severely ill might find this to be unnecessary. An effort must be made to explain to the clients about the provisions, and who would be informed, as this often helps to alleviate the anxiety. The clinician can inform the doctor-patient client that in case as a treating psychiatrist they feel that the doctor-patient client can be a threat to their own life and to others (including the patients whom they are treating), the confidentiality would be broken in the larger interest of the doctor-patient client. However, if the medical student, resident or physician contacts a psychiatrist outside their institute, they are not required to inform the administration.

Concerning confidentiality, the treating psychiatrist should be clear upfront concerning what would be disclosed to whom and when (e.g., when the person seeking help is suicidal and there is a need to monitor the person with the help of family or other staff/colleagues). Whenever feasible and felt appropriate, the person seeking help should be encouraged to inform their family about the mental health status, who can get involved and provide the desired social support and supervision.

Many medical students, residents, and physicians self-medicate and often try to validate the prescription from the psychiatrist when they come across them in a social situation. Similarly, some people seek formal professional help once and then try to maintain informal contact. These behaviors should be discouraged, and regular formal consultations should be encouraged if the symptoms persist. At times, the doctor-patient clients, especially residents seek informal help from their fellow colleagues pursuing residency in psychiatry. In general, the residents pursuing psychiatry training should be discouraged to provide informal consultations, as these does not occur in a proper therapeutic situation and at times could land them in trouble, if the doctor-patient client exhibits a suicidal behavior.

In an institutional setting, services are often organized as a student welfare center/service and/or crisis helpline. The students can contact these services in their time of need and get help. In an institutional setting, when the medical students and residents seek help, they are sometimes assessed in detail and managed by the trainee residents. In such a situation, the consultant or the first point of contact should ask about the preference of the student/resident about the resident with whom they would be more comfortable, and this should take into account the—gender of the treating trainee, place of residence of the treating trainee, the language the trainee can speak, the seniority of the treating trainee, etc.

In institutional setting, at times a psychiatrist may be asked by the administration to evaluate a doctor-patient client due to the disciplinary issues. In such a situation, the doctor-patient client should be initially evaluated by a relatively senior psychiatrist (a faculty member and not a resident), who after initial evaluation can decide about the course of treatment. When a doctor-patient client is referred by administration, has a diagnosable mental illness, and is willing for treatment, the clinician can inform the administration (with due consent from the client) about the mental health issue and provide treatment as per the need. However, if the mental health professional feel that the disciplinary issue is related to personality traits, or are arising due to the inability of the client to fit into their role due to interpersonal clashes with colleagues, it is always better to request for formation of a medical board. If the administration is expecting the psychiatrist to make any recommendations beyond treatment, then it is always better to ask for constitution of a multidisciplinary medical board, rather than making recommendation on your own.

In case, a doctor patient client is referred by the administration for a mental health issue and the doctor-patient client or their family is unwilling for psychiatric consultation, the psychiatrist can inform the administration about the same and should not coerce them for treatment. However, depending on the doctor-patient client, the psychiatrist should make all efforts to counsel the doctor-patient client and their family members about their impression about the mental health issues, need for treatment and the possible consequences, if the treatment is not started. They should also inform the doctor-patient client and their family members that in case at any time they decide to seek treatment, they can contact them.

Assessment

A medical professional’s assessment of mental health issues should be like that of any other patient concerning evaluating the signs and symptoms of mental illnesses [Table 5]. However, some of the problems must be kept in mind while evaluating them. A doctor-patient client may be initially anxious and frightened like any other patient. Hence, the mental health professional should provide a friendly environment to open up and try to alleviate their anxiety. The treating psychiatrist should also inform about the professional doctor-patient relationship involved in the assessment and management so that the doctor-patient client realizes that it is not a casual conversation. It is also essential to reassure that they will be treated most appropriately, but as a patient and not as a doctor in this interaction. They should also be comforted that the confidentially will be maintained as for other patients, with certain exceptions (i.e., suicidality or if their behavior could risk the life of their patients). The clinician should also try to maintain professional boundaries by avoiding becoming overly close due to empathy or sympathy with their doctor-patient client.[58]

Table 5.

Assessment of mental health issues among the medical students, residents, and practicing physicians

History

• Current symptoms: onset, precipitating factors, course of illness, duration, severity, level of dysfunction/consequences of psychiatric symptoms on psychiatric symptoms on the personal, social, and personal life

• Suicidal behavior: ideations, attempts, planning, assess to means, suicidal gestures

• Past history of mental disorders

• Family history of mental illness

• Substance use: type of substance, the pattern of substance, any recent increase or decrease in the quantity of substance, last intake of the substance

• Chronic medical illnesses: diabetes mellitus, hypertension, coronary artery disease, cerebrovascular disease, Parkinson’s disease, Epilepsy, obesity, etc.

• Age and gender-specific issues: Premenstrual dysphoria, pregnancy, post-partum, sexual functioning/dysfunction, gender orientation, sexual harassment · Current and recent history of frequent infections (may be indicative of lower immunity)

• Medication history: review all the prescription drugs, over-the-counter medications, any recent changes in the medicines, any recent change in medication doses, medication adherence

• Self-medication: psychotropics, non-psychotropics; use of pattern—dependence/abuse

• Type of professional responsibilities: team leader, the junior member of the team

• Workplace stress: working hours, workload, interpersonal relationships with the seniors or other staff, academic pressure, sleep deprivation and disturbances, poor ability to cope with stress/dysfunctional coping (substance use), type and frequency of call duties (night call or weekend call), work environment, organization culture, level of documentation required at the workplace, financial remuneration and level of satisfaction with the same, risk of malpractice suits, kind of patients attended, control over the work environment, level of support from the superiors and the administration, type of leaders at the workplace, opportunities for career advancement, time pressure to complete the work, kind of hierarchy followed at the workplace, level of autonomy, amount of positive feedback received at the workplace, sexual harassment at the workplace

• Work-related behavior: level of dedication, conscientiousness, taking responsibility for the assigned work, level of commitment to work, workaholic, inability to delegate responsibility

• Studies-related stress (in the case of students and residents): exams, failures, academics, thesis, research-related issues, etc.

• Patient and caregiver-related behaviors: violence against the doctors, pending medicolegal issues, pending inquiries

• Level of social support outside the workplace or work environment: marital status, having a partner

• Personality: level of perfectionism, Idealism, ambitiousness, masochism, self-criticism, anxiety about competence, anger, and aggression

• Work-life balance: Problems of work-life balance

• Workplace abuse: emotional abuse, sexual abuse, etc.

• Personal stressors: loneliness, relationships issues in personal life (martial functioning, relationship with the partner (s) in case not married), work interrupted by personal concerns

• Coping mechanisms to deal with stress

• Ways of unwinding: hobbies, socialization

• Social support: number of friends, relationship with friends

• Consequences of the mental symptoms on work and personal life: Medical errors, level of productivity, absenteeism, interpersonal relationships, substance use

• Current status of work responsibility: Working independently or in a team, chances of risk to the life of the treated patients

• Other contextual factors: Place of residence (hostel, paying guest, rented accommodation), number of friends, problems related to adjustment to the new environment (food, housing, first time away from home, ragging or bullying faced, language barrier), access to medications (anesthetic agents, psychotropic medications) · Physical examination

• Detailed physical examination- looks for signs of anxiety (sweating, restlessness, tremors, etc.), substance withdrawal and substance use (marks of intravenous substance use), substance or medication intoxication (drowsy), and self-harm (cut-marks, scratches), etc.

• Mental Status Examination

• Besides the disorder-specific assessment, specifically focus on suicidal ideations, plan, attempt; relationship issues, and ongoing stress in the workplace

Investigations

• Routine investigations: hemogram, renal function tests, serum electrolytes, liver function test, serum glucose levels, electrocardiogram

• Other investigations: as per the psychiatric condition, physical comorbidity, and physical examination

• Rating of the severity of illness

Physicians and trainees may sometimes equate their symptoms/illness with weakness.[58] It is better to convey that their experience is part of an illness that anyone can experience.

Persons with a medical background often describe their problems using medical jargon rather than expressing their symptoms in detail, and try to cut corners when the history is being collected, or attempts are made for a detailed mental status examination. The psychiatrist should not take the labels of the symptoms described at face value and instead should ask them to explain what they mean when they use particular terminology. Further, many medical students and physicians will come up with self-diagnosis. The treating psychiatrist should not accept the self-diagnosis, and all attempts must be made to clarify the diagnosis. Another important aspect of this group of clients is that they may also tend to underestimate certain aspects of the problems such as substance use, marital problems, work-related stress, self-harming or suicidal behavior, dysfunction due to the symptoms, and impact of the illness on the professional life. Accordingly, the mental health professionals should go into the details about these aspects, spend enough time to evaluate the same, and seek collateral information from the informants, if they are available.

Another crucial point that must be considered while assessing doctor-patient clients includes focusing on profession-specific or work-related stressors to understand the association of psychiatric symptoms with work-related stress. An important aspect to consider is that some professionals may be workaholics and would not accept that the work stresses them and instead try to rationalize their behavior. Similarly, issues related to studies and careers should be evaluated while evaluating students and residents. Besides assessing the work-related matters, the treating psychiatrist should also not shy away from asking personal questions related to relationships, substance use, sexual history, sexual orientation, etc.

The prevalence of substance use disorders is common among doctor-patient clients. Hence, an attempt should be made to evaluate the same in detail concerning type of substance used, quantity, last use, impact on the same on the studies and profession, the impact of the same on work performance including patient-related activities, and any physical or psychological complications in the past. The mental health professional should not limit this inquiry into the self-reported substance and should extend the same to the evaluation of history for the use of all the possible substances. Further, information about excessive use of medications, such as benzodiazepines and other hypnotics and opioids, should be looked into.

The treatment history should also look into the past formal treatment received and for any kind of self-medication use. While evaluating the past treatment history, look for the duration of therapy, doses used, response to treatment, medication and treatment adherence, reasons for stopping medications, and the impact of medicines on professional functioning.

The assessment of suicidality is of paramount importance and should not be missed. All kinds of suicidal behaviors (past and current), including suicidal ideations, plans, attempts, and gestures, should be enquired. While evaluating the same, the doctor-patient can be reassured that it is common for people with certain mental illnesses to have such features that resolve with treatment. While assessing suicidality, it is also essential to focus on the means used in the past and the access to means, in case a doctor-patient client expresses suicidal ideations and plans.

Many doctor-patient clients suffer from symptoms for a reasonable time before they seek consultation. Hence, it is also crucial to focus on what led to the current consultation. This will help to decide whether the client requires a crisis intervention.

Another important aspect of assessment, especially among the medical students and residents, is understanding their living arrangements. Often, this group of clients lives in hostels or live in rented accommodations. This understanding can help determine the social support and supervision available. Other contextual issues which may be relevant to the assessment of medical students and residents include evaluation of problems related to adjustment to the new environment (food, accommodation, first time away from home, ragging or bullying faced, language barrier), and access to medications (anesthetic agents, psychotropic medications).

It is also vital for the psychiatrists to understand that some of the students, residents, and physicians may have problems related to their personal life rather than solely work-related stress. Hence, these should not be ignored while carrying out the detailed assessment.

While evaluating this group of clients, the psychiatrist should remember that depending on the institutional policies and environment, clients may not meet a mental disorder’s syndromal diagnosis and may present with, at best, an adjustment disorder or physician burnout. The psychiatrists should familiarize themselves with risk factors, causes, and clinical features of burnout [Tables 6 and 7]. In general, it is essential to remember that social conflicts, overwhelming demands, lack or loss of resources, insufficient rewards, and absence of fairness at the workplace contribute to burnout. While evaluating physician burnout, it is also essential to assess the organizational work culture, as this may help in understanding the context in which the person is working or studying. While evaluating doctor-patient clients, the psychiatrists should also remember that even if the person fulfills a syndromal diagnosis, they may be having symptoms of burnout or burnout that could be contributing to the manifestation of a psychiatric disorder under evaluation. If required, the clinicians can use structured instruments like Maslach Burnout Inventory (MBI),[29] Oldenburg Burnout Inventory,[61] Copenhagen Burnout Inventory,[62] Burnout Clinical Subtype Questionnaire,[63] Shirom Melamed Burnout Measure,[64] and Stanford Professional Fulfilment Index[65] to understand the level of physician burnout.

Table 6.

Risk factors and features of physician burnout[66,67]

Risk factors for physician burnout	Causes of Burnout
• Young age	• Workload: high face-to-face time, documentation time, administrative time
• Female gender	• Specialty: Neurosurgery
• Negative marital status	• Practice setting: rural/urban, academic/non-academic, inpatient/outpatient
• Long working hours	• Patient characteristics: demand, entitlement, adherence, compliance
• Low levels of job satisfaction	• Sleep deprivation: self-explanatory
• Sleep deprivation	• Personality type: workaholic, masochistic
• High level of work/life conflict	• Loss of meaning in medicine and patient care: decreased support, increased responsibility, without autonomy and flexibility
• Work interrupted by personal concerns	• Challenges in institutional cultures: perceived lack of peer support, lack of
• High level of anger, loneliness, or anxiety	• professionalism, disengaged leadership
• The stress of work relationships	• Problems with work-life balance
• Anxiety about competency	• Methods of dealing with death and suffering: oncology, critical care, palliative care
• Difficulty “unplugging” after work	• Methods of dealing with medical mistakes: internal defenses, external support
• Regular use of alcohol and other drugs	• Malpractice suits: internal defenses, external support, nature of the complaint
	• Lack of control over practice environment

Table 7.

Signs and symptoms of physician burnout[68]

• Loss of motivation

• Feeling helpless, trapped, or defeated · Anxiety, fear, tension, Hypersensitive, frequently losing temper

• Lack of empathy

• Increased cynicism and negative outlook about everything, pessimism

• Lowered satisfaction or sense of accomplishment

• Feeling tired and drained most of the time

• Frequent headaches and muscle aches

• Tiredness not relieved with adequate rest

• Lowered immunity: frequent infections

• Change in appetite or sleep habits

• Withdrawal from responsibilities

• Cognitive dulling: poor attention and concentration, subjective memory disturbances, executive dysfunction

• Procrastination

• Skipping work or coming in late and leaving early, not answering phone calls, isolating self

• Reduced work performance: Slower in performing work

• Lack of flexibility: Poor tolerance of ambiguity, inability to compromise

• Committing medical errors

Assessment should also consider the impact of the current symptoms on the person’s work-related functioning. This assessment should be individualized concerning the specialty, place of posting, type of responsibilities, amount of face-to-face time with patients, possible consequences of any medical error which can occur due to symptoms, and risk to the life of the patient managed by them in the current mental state and risk to the life and medicolegal issues of the doctor-patient if they continue to work. Similarly, while evaluating the students and residents, issues related to upcoming examinations (theory/practicals) and meeting the deadlines for the academic assignments, including the thesis, should be kept in mind. Focusing on coping abilities, including the ability to bounce back in an adverse situation can also provide helpful information.

Finally, the assessment should also include evaluating the need for inpatient care or recommending leave. This assessment should consider the severity of symptoms, risk of harm to self and others (i.e., their patients), contextual factors including the available social support, and the working environment. If the assessment suggests that it would be better for the doctor-patient client to be off from work for some time, then the psychiatrist should be prepared to recommend medical leave.

Management

It is essential to understand that many doctor-patient clients seek help only once and have poor follow-up rates. Hence, the assessment and management should go hand to hand. Further, the follow-up with the treatment advice (both pharmacological and non-pharmacological) would be influenced by their attitude toward mental illnesses and psychotropics and psychosocial interventions. Additional factors that play a role in accepting treatment include the family’s and accompanying co-workers’ perspective toward the mental health treatment. The presence of inadequate or wrong knowledge about psychiatric illnesses and treatments also influences the treatment behavior.

Accordingly, the psychiatrist should appropriately utilize the first opportunity of assessment and management to address these issues, as this can go a long way in influencing not only the medication and treatment adherence of the doctor-patient client, but also influence their future attitude toward psychiatry as a specialty but also toward patients with mental illnesses. Once the initial assessment is complete, it should not be presumed that the doctor-patient understands their diagnosis and the course of the treatment. Accordingly, proper psychoeducation about the illness and treatment should be an integral part of the assessment. Similarly, if a doctor-patient client has come with a crisis, the crisis intervention should start from the first encounter itself.

The treating psychiatrist should spend enough time discussing the diagnosis and/or treatment plan. Give the doctor-patient client enough time to discuss the diagnosis and treatment [Table 8]. Again, re-emphasize the issues related to privacy and confidentiality. The psychiatrist should remind the doctor-patient client that the National Medical Council code of ethics requires every physician to disclose the information in the court of law under the orders of the Presiding Judge; in circumstances where there is a serious and identified risk to a specific person and/or community; and notifiable diseases.[69] They should be informed about any institutional policies concerning the students, residents, and physicians. If any information is to be disclosed to the administration, they should be informed about who will be notified, how they will be told, and what will be revealed. Often the doctor-patient clients have low self-esteem due to mental illness when they are evaluated for the first time. Hence, the psychiatrist should make efforts to reassure them and improve their low self-esteem. If inpatient care is being considered, inform the doctor-patient client about the same, along with the details about the indications for inpatient care, and risks involved in avoiding inpatient care. Inpatient care should be considered as per the recommendations for various diagnoses. However, some of the issues (not necessarily a comprehensive list) which may be pertinent for consideration of inpatient care are listed in Table 9.

Table 8.

Issues and principles to be kept in mind while closing the first assessment session

• Have enough time in hand after the assessment is done to address the issues of the doctor-patient client

• Give the doctor-patient client enough time to discuss the diagnosis and treatment

• If inpatient care is being considered, inform the doctor-patient about the same, along with the details about the indications for inpatient care and the risks involved with not admitting

• Again, re-emphasize the issues related to privacy and confidentiality and the exceptions to the same

• Address the low self-esteem

• Carry out crisis intervention, if the first consultation was precipitated by a personal life crisis or work-related crisis

• Choose the pharmacotherapy with mutual agreement and informed decision-making

• Decide about the non-pharmacological treatments which are feasible, effective, and evidence-based.

• Emphasize the need for medication and treatment adherence

• Discuss the high-risk management, as per the requirement

• Discuss the pros and cons of involving a family member in the treatment

• Address the issues of risk involved in continuing to work in the current clinical state

• Discuss taking a break from work

• Discuss the need for inpatient care, and its benefits

• Decide about the follow-up plan

Table 9.

Some of the indications for inpatient care

• Presence of suicidal ideations and/or plans

• Recent suicide attempt

• The patient has threatened or physically hurt someone else

• Impairment of reality testing, poor insight, and poor judgment

Rapidly deteriorating course

• Failure to improve despite adequate treatment

• Severe illness

• Violent and aggressive patient

• Patients with psychosis and mania lack insight and require treatment initiation

Severe emotional breakdown

• Substance intoxication or severe withdrawal

• Requiring special therapy

Similarly, if the assessment suggests that it would be better for the doctor-patient client to be off work for some time, i.e., till they recover, than this issue should be discussed in detail, and they should be informed about the facts being taken into account to reach such a decision.

If any kind of pharmacological intervention is being offered, spend enough time in mutual discussion with the doctor-patient client to choose the most appropriate agent for them. Like any other patient, they should be given the opportunity to select the pharmacological agent. When choosing a pharmacological agent, the impact of the medication on functioning should be kept in mind. The doctor-patient clients often underestimate or overestimate the need for medication and treatment adherence. They should be provided enough information about the risks involved with poor medication adherence.

Sometimes, despite being indicated, doctor-patient clients may refuse to take medications. In such a scenario, efforts should be made to explain to them the pros and cons of not starting the medicines. Additionally, the mental capacity of the doctor-patient client should be taken into account before making a final decision.

On the other hand, if the assessment suggests that the doctor-patient client may not require any pharmacological treatment, the same must also be shared with them, as this may also help to relieve a lot of anxiety.

Similarly, while considering non-pharmacological treatments, they should be provided with the full menu, explained the feasibility (time required, frequency of sessions, expectations from them as a patient), and be given the option to choose by taking into consideration the available time with them. If the doctor-patient client requires high-risk management, this should be kept in place at the earliest. All efforts must be made to explain to them the need for the same. At times the doctor-patient clients are not comfortable involving anyone in their treatment. This may be alright if they are not suicidal, but if there is a risk of suicidality, then all efforts must be made to ensure the safety of the patient.

Before closing the initial session, it is important to discuss the follow-up plan. The doctor-patient clients should be informed about the need to keep the consultation as a formal interaction so that the objectivity of the doctor-patient relationship can be maintained from either side. If the doctor-client patient is prepared to follow-up but is reluctant due to confidentiality issues (being seen by other staff in the psychiatry services), they should be given the option of following up on teleservices. In such a situation, it is better to discuss beforehand when the teleconsultation will be converted to a face-to-face consultation.

Besides addressing the issues of the doctor-patient client, the psychiatrist should also address the issues raised by the caregivers without breaching confidentiality. The interaction with the caregivers should also be taken up as an opportunity to discuss the high-risk management if required, addressing the issue of the need for social support and addressing the interpersonal issues in the personal life, if these are contributing to the clinical picture in any way. The caregivers can also be involved in the supervision of treatment, accompanying the patient during the inpatient stay.

Management of specific psychiatric disorders should be done as per the clinical practice guidelines for the particular disorder. The treating psychiatrists should follow the recommendations and modify the same as per the requirement of the doctor-patient client.

In case, a doctor-patient client is recommended leave or receives inpatient care, then during the follow-up, they should be prepared to handle the stigma. The doctor-patient clients often face self-stigma and public stigma. Addressing public stigma may not be in the hand of treating psychiatrists, but the self-stigma should be addressed. Self-stigma is defined differently by different authors. According to one of the definitions, it is understood as “shame, evaluative thoughts and fear of enacted stigma as a result of individuals’ own identification with a stigmatized group that serves as a barrier to the pursuit of valued life goals”.[70] According to another definition it “involves negative beliefs about the self, strong negative feelings, for example of self-hate and shame, as well as putting oneself at a disadvantage, for example through social withdrawal.”[71] Some of the commonly recommended strategies for reducing self-stigma include improving self-esteem, self-efficacy, empowerment, and self-compassion[72] [Table 10].

Table 10.

How to address self-stigma: Improving self-esteem, empowerment, and self-compassion

• Strategies to improve self-esteem

• Be kind to yourself

Reduce negative self-talk

• Focus on your strengths

• Don’t equate yourself with your illness

• Avoid self-isolation

• Have positive relationships

• Be assertive

• Try to say NO, when required

• Speak against stigma

• Strategies to improve self-efficacy

• Celebrate your success

• Seek people who give you positive feedback and avoid people who give you negative feedback

• Pay attention to your negative thoughts and try to counter them with positive thoughts

• Strategies to improve empowerment

• Having a positive attitude toward life

• Take care of self

• Have reasonable goals

• Have the company of positive people, use positive self-talk, be assertive, and take action

• Strategies to improve self-compassion[73]

• Treat yourself as you would treat a friend in need- encourage yourself rather than being harsh and belittling yourself

• Understand common humanity (no one is perfect- it is not me only who has deficiencies or limitations-every human has some or other deficit; take a broader perspective of own life)

• Mindfulness (i.e., being aware of own negative thoughts, don’t try to overidentify self with the same)

In case a doctor-patient client is recommended leave, the psychiatrist should reassess the person and ensure that the person’s symptoms have improved to such an extent that he can function adequately. This assessment should take into consideration the job profile (e.g., night duties, specialty in which the colleague is working, expected work pressure), available social support at the work place and outside the work place, past history of relapse or lack of relapse of symptoms after joining back, and the client’s own preparedness to joining.

Occasionally, a medical student, resident or a medical professional end up taking extreme step and consequently loosing their life as a result of suicide. In such a situation, the fellow students and colleagues are often shocked, distressed or in anger. In such a situation, a psychiatrist may be asked to address the fellow students. Depending on the situation (individual or group), the psychiatrist should listen to the fellow students or the colleague of the person who has lost their life, should acknowledge the loss, try to understand what others feel about the possible contributory factors, try to reassure them, address their emotional turmoil and if required inform the administration about the needs for corrections at the institutional levels to prevent future events. However, they should refrain from making any false promises on behalf of the administration. The psychiatrist can also take this opportunity to educate the students about the mental illnesses among medical professionals, need for seeking help, available resources in the institute and how the students can act as gate-keepers for their colleagues and prevent such unfortunate events in future.

The management of physician burnout involves the use of individual-level strategies and organization-level strategies. While dealing with the individual doctor-patient client, the psychiatrist can use individual-level strategies to address the burnout. Depending on the institutional ethics and culture, the psychiatrists should also strive to make changes at the institutional level to improve the working environment of the organization.

In terms of individual-level strategies, it is essential to remember that there is a significant overlap between the preventive and treatment methods. Some of the strategies which have been suggested include mindfulness-based techniques, self-care, stress management techniques, cognitive behavioral techniques, improving communication skills, gratitude interventions, development of interpersonal skills, and development of knowledge and work-related skills to enhance job competence and improve communication skills and personal coping strategies.[21,74] Enhancing control over the work, improving flexibility and work-life integration by focusing on organizational skills, personal efficiency, and personal factors that affect the work-life can also help to reduce physician burnout.

In terms of organization-level interventions [Table 11], the psychiatrist should make an effort at their level with the administration to make it more physician-friendly.

Table 11.

Organizational level strategies to manage physician burnout[21,74]

• Workplace supportive measures (appointing medical scribes, establishing a crisis helpline, and easy access to mental health care)

• Reducing stigma towards mental illnesses

• Inclusion of stress management and burnout prevention modules as part of the medical education curriculum

• Improving physician autonomy (ability to influence work environment and schedule control)

• Modifying the work processes and flow

• Promoting a collegial work environment (promoting healthy relationships and common goals)

• Adequate support services (such as nursing, secretarial, administrative, social work, and ancillary services) and support in the form of Apps, software, etc.

• Formation and implementation of a culture/social connection calendar to improve interactions

• Work hour modifications: rationalize the working hours, flexible working hours, and Time-banking system

• Having explicit policies for cross coverage, vacation, sick leave, maternity, and paternity leave

• Access to self-care resources

• Restructuring of the task

• Making the environment more congenial for learning

• Organization of social events

• Increasing the level of participation in decision-making

• Opportunities for professional development · Screening employees at regular intervals and identifying the problem areas to bring about changes

The mental health professionals should also strive to reduce stigma at the institutional level, which will promote help seeking.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.