In the days following the death of a recent graduate of the University of Minnesota Medical School in 2018, Brianna Engelson knew something had to change. This was the second University medical student who had died by suicide within the span of two months.

Reeling from shock, the first-year residency student received several texts from other students in the program. Some said they were not surprised to hear about what happened — they had thought about suicide too. Others told her they wanted to seek help but were afraid to.

Since summer 2019, Engelson has been working to understand what barriers prevent medical trainees from seeking help and what support they need to do so. Her research is currently underway, consisting of a small focus group of University medical students who are answering questions about the perception of therapy and mental illness in the field.

Looking to change the stigma around mental illness in the medical community, several other University Medical School graduates are advocating to modify phrasing in the medical licensing application and foster an environment that supports those seeking treatment.

“I think we as physicians are sometimes put on a pedestal,” said Kaz Nelson, an associate professor in the Department of Psychiatry and Behavioral Sciences at the University. “Physicians are human beings too. And even though we understand a lot about optimal health and disease, it doesn’t make us immune from a whole spectrum of health conditions.”

Nelson said the path to medical training is extremely rigorous and challenging. After completing undergrad, physicians enter four years of medical school then three to eight years of residency before entering the workforce.

Throughout training, many physicians are evaluated constantly, resulting in an immense pressure to perform well. Because physicians have invested so much time, energy and money into schooling, many life goals are put off as a result, and the choice of leaving the profession becomes unthinkable, Nelson said.

Studies have shown medical students are two to five times more likely to screen for depression than their nonmedical peers, and the risk of depression, substance abuse and suicide increases with every year of training.

“We have higher rates of suicide in the medical profession than in other professions. The stakes are high, the pressure is high, the impact on one’s personal health and well-being is high,” Nelson said.

A former medical student at the University who is now a hospitalist in the Twin Cities said she suffered from anxiety and depression while training, which compounded into a drinking and narcotics dependency problem later on in her residency program. A hospitalist is a physician who exclusively provides care for hospital patients.

The alumna, who wanted to remain anonymous due to privacy and work-related reasons, said medical programs often cultivate a “gunner culture” that requires physicians to be high-functioning and achievement-oriented at all times, even to the point of self-sacrifice.

Stress from work made it difficult to build healthy coping mechanisms and routines, so she would often cope with alcohol on her nights off. When the alumna finally entered the workforce and that schedule changed, the transition was especially hard. Because she could still work at a high-achieving level, however, the alumna said she did not want to stop and expose her unhealthy habits until she had a breakdown at work last fall and decided to seek help.

She has now completed intensive outpatient treatment, has a therapist and a sponsor and is following the guidelines of the Minnesota Health Professionals Services Program, a state service that monitors the mental health conditions of physicians. She said the guilt still follows her.

“It’s a lot of shame as a physician to have not been able to fix it myself,” she said. “I offer help to people, like, that’s what we do. But to do it yourself is really hard.”

Physicians can either reach out to their bosses, the medical board or HPSP, which would monitor their diagnosis anywhere from one to five years.HPSP usually requires physicians to share their medical records, and the organization may notify the medical licensing board if the physician does not comply with the agreed-upon terms.

The alumna said when she was struggling, it felt like there was no intermediate to talk to about what she was feeling or experiencing.

“There’s nothing in the middle, really. And there’s no one to explain to you what will happen,” she said. “So I think that the default reaction is fear and just continuing to try it on your own.”

Licensing board applications

Nelson said although it is important to ensure that medical professionals are safe to practice and able to deliver care to the best of their abilities, the way some states monitor and measure physicians’ states of mind can produce barriers to people getting the care they need to practice safely.

Physicians must fill out the Minnesota Board’s medical licensing application annually in order to keep their medical licenses. On the application, the Board asks, “Have you within the past five years been advised by your treating physician that you have a mental, physical, or emotional condition, which, if untreated, would be likely to impair your ability to practice medicine with reasonable skill and safety?”

Although the Board says its intention with the question is to protect patients and ensure physicians are physically and mentally able to treat patients, some physicians believe the wording is intrusive and counterintuitive.

Sameena Ahmed-Buehler, an interim in family medicine who graduated from the University Medical School in May, has been especially vocal about prioritizing the conversation around student mental health in the medical community.

Although Ahmed-Buehler agrees with the intent of the question, she said she does not think its wording accurately assesses a physician’s mental health. The time frame of five years does not address one’s current ability to practice, and the focus on a doctor’s diagnosis rather than the applicant’s current function also contributes to an assumption that a physician with a mental illness – treated or not – is unable to do their job, she said.

Anecdotally, the stigma around mental illness has profound effects on medical students and practitioners at the University, she said. Many do not know what will happen to their answers to this question after they submit the applications and worry about the effect on their medical licensures.

“I know a lot of situations and people personally where these questions have prevented individuals from seeking the treatment they need,” Ahmed-Buehler said.

One of the pre-med students she mentors told her she would benefit from therapy but did not want to risk getting a diagnosis that she would have to reveal on a licensing application later on. Another physician she knows said they were so excited to graduate residency because they could then go to therapy without worrying it would impact their future job prospects.

Though there is still room for improvements, advocates say that Minnesota’s licensing question is seen as more progressive than other states’ as it does not name specific diagnoses. Alaska’s questions, for instance, ask applicants to check off any boxes that apply to them: There is a list of 14 specific health conditions and condition categories, including depression, schizophrenia, seasonal affective disorder and “any condition requiring chronic medical or behavioral treatment.”

A 2016 study conducted by the Mayo Clinic found that nationally nearly 40% of physicians reported they would be reluctant to seek mental health treatment because they were concerned about repercussions to their medical licensure.

Ruth Martinez, executive director of the Minnesota Board of Medical Practice, said many physician concerns come from a lack of understanding about the application process.

She said that under the Minnesota Government Data Practices Act, only the applicant and the board that reviews the case have access to the application responses. The only time the diagnosis would be shared publicly would be in the case of formal disciplinary action.

Without asking this question on the application, Martinez said the Board would have no way of directing physicians to resources or help they may need.

Looking to the future

Cole Pueringer, a hospitalist who trained at the University from 2009 to 2015, is known as one of the few physicians openly talking about his experience in recovery.

Near the end of his first year in medical school, Pueringer took an unintended two-year medical leave of absence for treatment of a substance abuse disorder. Now nine years sober, he described how the intermittent social binge drinking of his youth transitioned to more dangerous habits. Over the course of a couple of months, he went from having three drinks a day to 30 and began self-medicating with prescribed Adderall to recover from the hangovers.

After Pueringer realized he had a problem, he knew he wanted to get help but did not know where to go. Worried about never becoming a doctor and being kicked out of the medical profession because of his mental illness, Pueringer said it was hard for him to find others to confide in.

“I never heard of any doctors that were in recovery and had made it through recovery or were sober and clean, and were successful,” he said. “I’d only heard some of the horror stories.”

Having completed substance abuse treatment, Pueringer attends weekly Alcoholics Anonymous meetings, works in an active 12-step recovery program and is a public speaker and volunteer at schools, universities and chemical dependency treatment programs.

Pueringer said he has been open about his past in order to keep recovery on the forefront of his mind and in part to show physicians that it is possible to be a practicing doctor in recovery. He also wants to push back against the stigma of addiction and mental illness as something of weakness or moral failure.

Pueringer said most people enter treatment not because they want to but because they are forced to or feel like they have nowhere else to go.

“I found that a lot of [the fears people have] are unfounded,” he said. “They presume a life of sobriety looks like something when it’s actually not. Or they fail to see that being monitored is not just a hindrance to them, but it actually helps prove that they’ve been sober and clean.”

He said being transparent about his mental health has opened many doors for him.

“I’ve never had anyone be openly critical to my face. And if anything, being open and transparent has done nothing but help me in ways that are really important to me, like personal relationships,” he said. “It helps me go somewhere or pick a program or be around people that want me.”

Kaz Nelson said she is moved by the openness and fearlessness of younger physicians and medical students talking about mental health, something historically her generation would not address.

“I think this next generation, they are seeing what’s right and what’s wrong, you know, what’s internally inconsistent or critical in our own day-to-day work,” she said. “I’m completely inspired by their advocacy and almost fearlessness in the face of long-standing traditions or practices. They look at it with fresh eyes and say, ‘Why is it done that way? And how can we do it better?’”