Destigmatizing Physicians’ Mental Health: A Conversation with Dr. Carrie Cunningham on the Stigma Facing Physicians Struggling with their Mental Health

Interview by Gianna Tout-Puissant

HUHPR Associate Editor Gianna Tout-Puissant interviewed Dr. Carrie Cunningham MD, MPH, associate professor of surgery at Harvard Medical School, section head of the Massachusetts General Hospital Endocrine Surgery Unit, and a senior scientist at the Mass General Institute for Technology Assessment. Dr. Cunningham received her B.A from the University of Michigan , MD from University of Michigan Medical School, MPH from the T.H. Chan Harvard School of Public Health, completed her residency in general surgery at New York Presbyterian Hospital - Cornell and her fellowship at Massachusetts General Hospital. Dr. Cunningham’s goal is to improve the lives of patients with endocrine-related diseases with surgery and research. She has recently spoken about her struggle with anxiety, depression, and a substance use disorder during her presidential address at the Association for Academic Surgery conference in February, 2023. Dr. Cunningham works to fight the stigmatization of physician’s mental health and help physicians struggling with their mental health get the treatment they need. This interview has been edited for brevity and clarity.

Gianna Tout-Puissant (GT): Thank you very much for speaking with me, Dr. Cunningham. Today I am interviewing you to ask some questions about how physicians’ mental health can be destigmatized. To my understanding, there are numerous concerns that discourage physicians struggling from mental illness from getting help, including licensing concerns, fear of lost work opportunities, and a professional culture that suggests it is unacceptable to be weak. How did you first decide to speak out about decades of depression, anxiety, as well as a substance abuse disorder?

Dr. Carrie Cunningham (CC): I decided to talk about my challenges with mental health because I had the platform, and it was during the same year that I had a mental health crisis. I was the president of a large academic surgical society and during that same year, I needed to take some time off of my work to address worsening mental health issues. At the same time, I had hit a crisis level. I had this speech which all AAS presidents give at the end of their presidential term that had already been scheduled. I didn’t know if I was going to be able to be back in order to give the speech or even be well enough to do so, but it wasn’t even a question to me that I would talk about my experiences. It was the right thing to do. I had been in inpatient treatment and outpatient treatment for three months, which is basically eight hours a day of therapy. By then, I had gotten very used to talking about it, I think, and then continued recovery meetings and therapy afterwards. Throughout that period of time, I put my same drive into recovery that I did in becoming a surgeon, meaning I read everything that I could possibly get my hands on about psychology, philosophy, recovery, addiction, childhood trauma, and Buddhism. I reflected through that process, not only for my own therapeutic benefit, but also to realize the threads of my own life. Why this? Why did I choose to go into surgery? Why was I drawn to things where I had to work ridiculously hard to prove to somebody something? It became glaringly obvious to me that these were themes, not just for surgeons, but physicians and other people who are similarly driven, themes that anyone could learn from. In general I also think that there’s a false threshold or distinction for people who have substance use disorders. Any kind of addiction - be it a substance or process, including work - is all part of the same process. Many of us lack healthy coping mechanisms, and rarely ask for help.

GT: What were the main fears you had speaking out about your mental health? I know you have said that it was very crucial to you to speak out at that time, but I’m sure you were still questioning whether it was something you should really do.

CC: That’s the most common question I get, how did you do that? People don't do that, you know. There's no crying in baseball or surgery. People don’t talk about mental health issues in surgery. I also had a very impactful experience: a very close friend died by suicide. Having gone through what I went through, and then when I looked under the hood, I realized how bad the problem was, I understood that even people like me, who are sort of in the know don’t know all the mental health resources that are available, how bad the suicide rate in doctors is, among other things. I felt compelled to tell other people. During the COVID-19 pandemic, surgeons and other health care workers were working tirelessly throughout that whole period of time, isolated from their families. We were in the hospital taking care of these really sick patients, some of them colleagues, which exacerbated challenges and definitely unroofed a lot of mental health issues. Everyone was on the same playing field; doctors and patients for the first time with everyone being on Zoom. Everyone in their sweats/scrubs all the time. Everyone was isolated, not just patients, but the doctors were isolated. Everyone had those feelings. It was so traumatic and so intense that I think it allowed for that conversation to happen. It came to a head because there was no other distraction, no denying that this mental health crisis was happening. Depression impacts at least 25% of the population, and I am a true believer that mental health impacts our society multitudes worse than any physical disease. Yet for some reason, we have such astounding stigma against talking about it and little funding it for research.

GT: The stigma around mental health is very frustrating because it’s something that affects so many people in society in general, not only physicians. In my experience, everyone refuses to talk about it, yet suicide is on the list of the top 10 causes of death, and is the second leading cause of death between the ages of 18 and 25. But as a society, we don’t want to pay attention to the thing that’s literally killing us.

CC: This is not just a physician crisis. I didn’t even realize that in 2021, more people died by suicide than people who died from breast cancer or colon cancer. We spend so much money and effort on these ads and medications for breast cancer, especially. Yet, 900,000 kids attempted suicide in 2021. That’s almost one million kids. God, does that make my heart break!

GT: Did you feel like there were any unexpected outcomes of speaking out, in terms of how people perceived you? Did your speech affect your relationship with your colleagues?

CC: Because of all the internal work I’ve done over the past year, all of the concerns about voicing my challenges that I would have had previously don't matter to me anymore. Will I be able to become a full professor at Harvard? Will I become a Chair of Surgery? I’m actually not even sure if I want the same things. Those were achievements that I thought were going to make me happy. Brene Brown has a great quote that courage is facing fear in the midst of vulnerability. You don’t know what’s going to happen. Soldiers don't know when they head out, whether or not they're going to survive or not, but they still go out to battle. That is courage. I was terrified. Don't get me wrong. After hearing my speech, friends and colleagues were saying, “Why didn’t you tell me?” and apologizing to me. But that is the thing, doctors do not feel comfortable or safe talking about these things. I was worried about patients seeing my speech, especially with the Guardian article that came out highlighting my speech. I think that the patients who have a problem with it aren’t gonna come to see me. I was nervous when a patient asked me about it recently, but I just asked her if I could answer any concerns or questions. She had depression and a substance use disorder. She said, “It was more comforting to know that I can talk to you about those things and you understand where I’m coming from, and you aren’t going to judge me.” At least my first experience was very good. The bottom line is that I know I’m doing the right thing, so I don’t think about consequences. I will deal with them as they come. I’ve learned so much about mental health and experienced so much that I feel worthy of talking about it and few others do. Unchartered territory. I’m learning as much as I can about it. I'm trying to be an expert on it and do the best I can at it, just like everything else. The response I’ve gotten from people is incredible. I’ve gotten thousands of emails, calls, letters in the mail thanking me for doing it and sharing their own stories with me privately. This is what the recovery community is like. We support each other by sharing and connecting with compassion. People were so desperate for a safe space to talk about it. Your generation has the power to change that. The Dr. Lorna Breen Heroes Foundation is working to make that change, which is why I’m so heavily invested with that group. They are working to change licensure questions in each of the States, and they passed a federal law to support improving the mental health resources of all health care providers. You haven't done any licensure applications yet, but they historically asked very intrusive questions like: Have you ever taken an antidepressant, or have you ever had a mental health disorder? Some things that were frankly against privacy law to ask, such inappropriate questions about mental health as distinct physical health. You either have to lie, or purposely not take antidepressants, so that you don’t have to answer yes on those forms. It’s just so absurd and frankly harmful.

GT: Licensure applications are something I have previously looked into. Am I correct that the application questions vary by state?

CC: Yes. It didn’t even cross my mind that we don’t just have to keep doing whatever we are told to do. You can make things change and improve. You can say something is not right. The founders of the Dr. Lorna Breen Heroes Foundation happen to be lawyers. Their sister, who died of suicide, was a physician. They’re working to change legislation. They are taking a different view of how we can work to fix the mental health crisis physicians face.

GT: Do you feel that changing the legislature is the best way to fix the situation physicians face when they’re seeking treatment for mental health issues?

CC: There are both personal psychological barriers and then there are cultural barriers, which are systemic. Surgeons, physicians, and highly driven, perfectionistic striving people believe that sharing their mental health issues is going to make them appear weak and or not as good as other people. We take an oath that basically says to always put the patient’s health above your own. That it is your honor and your duty to put your patient above all else, including your own health. This is an ingrained part of our culture. We experience repetitive events, sometimes referred to as microtraumas, as a physician: when patients die, when we harm patients at your own hands, unintentionally, it creates moral injury. Handling that repetitively over years and decades without talking about it, without grieving the loss of your patients is a cumulative traumatic event for all of us. Moreover, people fear loss of reputation, loss of their career, financial consequences, but also for many people their identity. I didn’t appreciate how much of my being a surgeon, a mom, or a tennis player was wrapped up into my identity, which is a scary place to be when it gets taken away from you. When I was forced to leave work, I feared losing the part of myself that made me feel comfortable and gave me self-worth, my identity as a surgeon. It’s a conglomeration of just huge amounts of barriers to overcome.

GT: Do you think if you weren’t forced to take time off that you would have gotten to the place you are today?

CC: The answer is no. I would not have stepped away. Even the first month I was out, I was still snowballing people. I was still telling them what they wanted to hear. I didn’t actually think I needed to take time off. I was just checking off boxes to get back to doing what I was doing. I didn’t actually sit still and reflect on why I was where I was. It still took me six weeks away from work even to begin to change and evolve. It was rough and I was angry and resentful. There were no licensing issues with me, fortunately. I wondered “why me?,” but they were totally right. I was going to wind up harming myself at some point in some way, shape or form. I don’t know how to encourage other people to seek help, and I talk about my experiences the way I do to prevent others from having crises before seeking help. Ultimately, it has to be the person in crisis to make the commitment, though. The same brain that is in crisis, needs to make a rational and difficult decision. I think that by changing the culture to where people can develop skills that are preventative, and talking about addressing issues before they become a crisis, we can make a real impact. I think the reason the suicide rate is worse in physicians is because they let it get so bad before seeing help, too late. They don’t take the medication to stop it in its tracks. They don’t get the therapy, so that their mental health issues progress, becoming a more severe disease than it has to be. I don’t know the answer. I have had a couple of experiences, where I’ve been able to pay it forward and help other surgeons take time off before they had a crisis. They asked for FMLA and they went and got help. They got into therapy. They got sober and they are doing great six months down the road because they did the work, without having it turned into a whole ordeal. That is a great source of pride. GT: As an associate professor of surgery at Harvard Medical School, what are your thoughts on working opportunities for medical students to discuss mental health into medical school curricula? CC: Lots of people working on that. I know I was in a place of privilege and power. I had a job already. I had already established myself professionally, built my reputation in my hospital. I had a very supportive work environment to come back to. Medical students and trainees do not have that same security. They have not found jobs, or matched in their residency programs. They don’t have money and they don’t have control over their schedule. Forget weekly therapy. There’s so many things that stack up against them. In conversations with those involved in educating medical students, I know that both resources for the students and a more broad education on mental health in patients are improving. A lot has changed since I was in medical school. I learned about neurochemical stuff and how the brain works, but not anything about the impact of trauma or isolation. In our surgical residency at MGH, we have process groups now. As I have been speaking around the U.S. at different institutions I can feel the tide shifting. Just asking me to speak on the topic is growth. The culture is going to take a long time to change and that will come with current and future students being used to talking about these things and then showing up in medical school and saying we can’t let the mental health crisis continue, which will march us up the ladder. I go now to various institutions and I walk in and I light a fire. I talk about these things in front of a bunch of people that have never talked about it before. Then I leave, hopefully making a safe space for them to talk and change things at their institution. GT: How helpful was the physician health program for you in getting help and how helpful do you feel it is for other physicians seeking help? Do you feel there’s a lack of resources when physicians do decide to receive treatment? CC: I think physician health programs are an underutilized resource. There’s one in almost every state. They are anonymous and peer supported. They’re an intermediary between the board on one end and the institution on the other. For a long time, I didn’t even know that Physician Health Programs existed. They’re not perfect, but they are an established resource and they are there to protect both patients AND you. Consultations are anonymous. In your state ask: What are the available resources for you/for a colleague? What would it mean to take time off work? What does it mean to get a fitness evaluation? People aren't out to get you, they're really there to help you. The success rate of these programs is incredible. There’s somebody there to create a monitoring program to assure your institution that you are safe to practice. I’m under contract now for three years with regular testing and therapeutic reporting from my therapist and monitors. I mean, it's a lot, but it works. It's not a question for me. This is what I have to do. There's a plan, and I follow it. I think it's actually harder for people who don't have someone monitoring them. They're a great resource. They're led by social workers and psychiatrists, and they can refer you to groups to get long-term therapy, not only immediate help, which is really an untapped resource.

GT: Thank you very much for your answers to my questions. It has been a pleasure to hear from you, Dr. Cunningham.