Invoking Caste: Why Physicians With Psychiatric Illness Are Shunned

American medicine has a checkered history in its welcoming of physicians who are black, women, physically disabled, LGBT, to name a few. As a specialist in physician health and a 50-year career of treating physicians,¹ I would like to add another group that has struggled for acceptance—physicians who have suffered a psychiatric illness. I argue that caste may be the reason.

“Caste is the granting or withholding of respect, status, honor, attention, privileges, resources, benefit of the doubt, and human kindness, to someone on the basis of their perceived rank or standing in the hierarchy,” writes Pulitzer Prize-winning Isabel Wilkerson in her thought-provoking new book Caste: The Origin of Our Discontents.² Although the Golden Age of medicine,³ that started at the turn of the 20^th century, began to give way to a more humanistic modern era in the 1970s, vestiges of this storied time remain. It was an era when prestige, status, infallibility, competition, and perfectionism were the order of the day and any deviations from these lauded tenets were threatening and shut down immediately. I know this firsthand, as evidenced by the chilly and avoidant response to the suicide death of a medical school classmate in 1962.⁴ Let me examine portions of Wilkerson’s definition of caste, the granting or withholding parts, and their relevance to medical culture.

Years ago, as an early career psychiatrist advocating for my medical student patient, who was recovering from a major depressive illness after his single parent mother’s death, and was now fit to return to his studies, I appeared with him before a Dean’s Committee to plead his case. “We’re open to having him back if you can promise that he won’t give us anymore trouble” stated the chair. I responded with “Trouble….?” To which he replied “Like reporting to clinic, being on time, grooming himself properly, not hesitating and stumbling when asked questions by the attending physician, …..you know, just being a normal medical student.” When I attempted to explain that those were symptoms of his mood disorder and he was now well, another member of the committee shut me down, abruptly and sharply, and said “You don’t need to lecture us Dr Myers. We just want to make sure that both you and your patient appreciate the basic expectations of clerkship.” I felt patronized and insulted, but somehow kept my cool. But I shudder to imagine my patient appearing before this committee on his own.

This occurred in the early 1980s. Anachronistic? Largely, but I offer that more subtle or muted situations remain with us today. Here are some examples:

1. Mahad Minhas, MD, was quoted recently about how it feels to not match into residency⁵ and the toll taken on one’s mental health. While being interviewed for a residency position he was asked to share a hardship he had experienced in the past. He disclosed that he experienced depression after not getting into medical school 2 years in a row. The tone of the interview changed immediately, turning hostile and interrogatory “Are you still depressed? Are you on medications?” Dr Minhas felt attacked, penalized for mentioning his mental health. Not only did he come away with a feeling that it is not okay to talk about mental health, he felt shamed and embarrassed.

2. Michelle Silver, MD, argued in her article⁶ that applicants’ personal statements, an essential part of applying to medical school, are not personal at all, that they are sanitized (my word) to appeal to what today’s medical school admission officials want to read. I captured this in a recent blog entry.⁷ She wanted to disclose her history of and successful recovery from an eating disorder but was strongly discouraged from doing so by medical teachers and others, who were concerned that she’d be deemed unfit to enter medicine. Her reaction? “I felt defeated.” 

3. Katherine Termini, MD, has been wrestling with disclosing her attempted suicide at age 16 for years.⁸ Like Dr Silver, she was “advised by mentors to avoid the subject of my mental health history” when applying to medical school. She writes eloquently about suppressing her thoughts and feelings as she painfully bears witness in medical school to clinicians making “disparaging or dubious comments on patients’ suicidal ideations or their resolves to end their lives.” Her piece challenges the outdated conformity of medicine to some idyllic standard, with no tolerance for mental illness. She is committed to changing this.

4. Dr Anonymous, whom I have written about in the past,⁴ a patient of mine describing his hospitalization for a severe mood disorder, penned this: “I have been surprised and disappointed by the lack of support from my physician colleagues. The number of visits I have received, both at home and in hospital, are in single figures. Not a single card has arrived. As someone once said, ‘No one brings you casseroles when you’re getting ECT.’ Physicians (and others) with depression fight an extremely lonely battle. Please support your fellow physicians with depression, rather than leaving them in isolation.”

5. Adam Hill, MD, pediatric palliative care physician and best-selling author⁹ describes himself thus, in an earlier article¹⁰: “I have a history of depression and suicidal ideation and am a recovering alcoholic.” In that same paper, he writes, “When recently, I moved to a new state and disclosed my history of mental health treatment, the licensing board asked me to write a public letter discussing my treatment – an archaic practice of public shaming.” Dr Hill’s admonition is “We are all responsible for this shaming, and it’s up to us to stop it.”

"All of these examples can be viewed through the lens of caste in the house of medicine. Borrowing a few of Ms Wilkerson’s defining words, is this the message we’re giving to folks aspiring to a career in medicine and to our colleagues suffering in silence?: “We will not grant you respect, status, or honor if you have a mental illness, or a history of one. You do not have the rank or standing that we require. And, we will not give you the benefit of the doubt, and human kindness.”

References

1. Myers MF. Becoming a Doctors’ Doctor: A Memoir. Scotts Valley, CA: Createspace; 2020.

2. Wilkerson I. Caste: The Origins of Our Discontents. New York, NY: Penguin Random House; 2020.

3. McKinlay JB, Marceau LD. The end of the golden age of doctoring. Int J Health Serv. 2002;32(2):379-416.

4. Myers MF. Why Physicians Die by Suicide: Lessons Learned From Their Families and Others Who Cared. Scotts Valley: Createspace; 2017.

5. Grant K. The mental health toll of not matching. Medpage Today. Published July 7, 2021. Accessed August 13, 2021.

6. Silver MH. The good fit – why medical applicants’ personal statements are anything but personal. N Engl J Med. 2021;384(12):1086-1087.

7. Myers MF. How well-intentioned advice is suppressing the doctors of tomorrow. Psych Congress Network. Published online April 15, 2021.

8. Termini KA. My lie by omission. JAMA. 2021;326(2):133-134.

9. Hill AB. Long Walk Out of the Woods: A Physician’s Story of Addiction, Depression, Hope and Recovery. Las Vegas, NV: Central Recovery Press; 2019.

10. Hill AB. Breaking the stigma – a physician’s perspective on self-care and recovery. N Engl J Med. 2017;376(12):1103-1105.

Dr. Myers is Professor of Clinical Psychiatry and recent past Vice-Chair of Education and Director of Training in the Department of Psychiatry & Behavioral Sciences at SUNY-Downstate Health Sciences University in Brooklyn, New York. He is the author of 9 books, the most recent of which are “Becoming a Doctors’ Doctor: A Memoir”, "Why Physicians Die by Suicide: Lessons Learned from Their Families and Others Who Cared" and “The Physician as Patient: A Clinical Handbook for Mental Health Professionals” (with Glen Gabbard, MD). He is a specialist in physician health and has written extensively on that subject. Currently, Dr. Myers serves on the Advisory Board to the Committee for Physician Health of the Medical Society of the State of New York. He is a recent past president (and emeritus board member) of the New York City Chapter of the American Foundation for Suicide Prevention.

The views expressed on this blog are solely those of the blog post author and do not necessarily reflect the views of the Psychiatry & Behavioral Health Learning Network or other Network authors. Blog entries are not medical advice.