By Grant H Brenner

Medicine1 is a tough profession. Its both tremendously rewarding and terribly demanding.2 Along with a handful of other professions， doctors are privy to the most sacred and difficult aspects of human existence.3 We share in the joys and triumphs of illness. We witness the grief， horror， beauty， peace， and love that occur when people succumb to4 terrible diseases we have no way of effectively fighting or preventing. Physicians are at the front lines of humanity， along with other warriors like nurses， PAs， first responders， therapists， human rights workers， military personnel， clergy，5 and more.

But being at the front lines can take a toll6： In 2012， a study showed that physicians reported much higher work-life dissatisfaction compared to the general population. Within that study， 40.2% of physicians reported dissatisfaction versus 23.2% of non-physicians. The same study found that burnout rates were high across the board for physicians as well，7 with nearly 50% of doctors reporting that they were burned out. Emergency room doctors have it the worst， with nearly 70% reporting burnout， followed closely by physicians working in general internal medicine， neurology， family medicine， and a host of other demanding subspecialties.8

根據(jù)2018年美國精神病學(xué)會年會上公布的一項最新研究，醫(yī)生的自殺率是所有職業(yè)中最高的。在美國，每天至少有一名醫(yī)生自殺身亡，這一數(shù)字令人不寒而栗。權(quán)威醫(yī)學(xué)雜志《柳葉刀》近期報告指出，極大的工作量、超長且不規(guī)律的工作時間、患者需求導(dǎo)致的壓力、工作失誤可能造成的嚴(yán)重后果，以及在行醫(yī)過程中可能涉及的因違背自身價值觀而帶來的道德傷害等，都導(dǎo)致了醫(yī)生自殺率持續(xù)飆升。此外，對于背負(fù)精神疾病這一污名的擔(dān)憂，也使得很多醫(yī)生不敢尋求幫助。然而，在驚人的數(shù)字之下，這一嚴(yán)重問題長期以來卻并未得到應(yīng)有的重視和有效的解決。為何以治病救人為使命的這一人群卻無法獲得自救？警鐘是時候敲響了。

According to a 2015 Mayo Clinic9 survey， this situation is not improving any time soon. Of the nearly 36，000 physicians who were contacted， 6880 responded to an invitation to participate in a study of burnout. Results showed that these doctors became more burned out over time： 54.4 percent reported at least one symptom of burnout in 2014， up from 45.5 percent in 2011. Likewise， average work-life satisfaction ratings dropped from 48.5 percent to 40.9 percent in the same three-year time frame. Compared to the average U.S. citizen， physicians are much more likely to experience burnout and much less likely to enjoy work-life satisfaction.

Studies about physician burnout and stress are important but they typically dont reflect this groups high risk for even more dire10 mental health outcomes， like suicide. In a recent The Lancet Psychiatry review and meta-analysis，11 Katherine Petrie and her fellow authors reported that in addition to burnout，physicians also demonstrate a high risk for other depressive symptoms， like anxiety and suicidal thinking. Past research has also shown that physicians have a higher risk for suicide compared with other professions， ranking in the top ten of risky professions. And Petries study noted that while other occupational groups have high rates of difficult mental health symptoms， physicians are more likely to die by suicide. Chillingly， the study noted that one physician dies from suicide every day in the U.S.

The Lancet study authors also report that workplace factors contribute to physician suicide “including a large workload， long and irregular working hours， competitiveness of training programs， pressure of patient demands， the consequences of any errors， poor worklife balance， and the risk of moral injury if physicians are forced to work in ways that conflict with their ethics and values.”12 The authors note that the culture of medicine itself contributes to mental health problems， preventing physicians from seeking help because of factors like the stigma against mental health problems， burdensome regulatory practices， and concerns about being able to seek care for oneself due to confidentiality.13

From my personal experience both as a surgical resident and a psychiatrist， medical training is rough and at times， abusive.14 Despite positive changes in recent years， including some medical training programs that really do encourage openness and help-seeking， we are still haunted by stigmatizing labels. For this reason， revealing your need for help can be a risky business， as it can inspire comments about being weak， letting your team down， or not being able to“take it.”

According to The Lancet authors， despite growing research on burnout in medicine， there is little attention given to both the presence of diagnosable mental health issues or interventions that could prevent and treat mental health issues like suicidal ideation15. In my professional life， I have experienced this blockade16 first-hand： Early in my career， I was asked to participate in a physician wellness study. For the study， I was asked to stay on call， just in case they found any residents who needed psychiatric care immediately. I also recommended that they study depression and suicide risk as part of their survey. After I made that comment， I didnt get a call back and I was not invited to participate in the study； they just stopped responding to emails.

From my perspective， this new meta-analysis published in The Lancet is a major milestone for understanding and appropriately responding to the mental health crisis facing medicine today. Rather than dwelling on the past， the alarm has now been sounded17： Greater attention must be paid to physician well-being. We need better research that uses clear diagnostic measures and evidence-based interventions， on a large scale.

We need to look at interventions and preventive measures directed at individuals and groups， and we need to focus on systemic and organizational interventions that could change the very culture of medicine. We need to not only put new programs into place， but also take a deep dive into the culture of medicine itself to understand why a field devoted to caring for others is unable to properly care for itself. We want physicians to be safe and well， but we also need to help those we serve by modeling good health practices. When we fail to do this work， we let down not only ourselves， but also our patients and society.

1. medicine： 醫(yī)學(xué)。

2. 它報酬頗豐，而又要求極苛。tremendously： 非常地，極其。

3. 同其他一些行業(yè)一樣，醫(yī)生了解人們生而在世最為神圣且艱難的方面。privy to： 私下知情的；sacred： 神圣不可侵犯的。

4. succumb to： 死于。

5. PA： 即Physicians Assistant，醫(yī)生助理；first responder： 現(xiàn)場急救員；therapist： 治療專家；clergy： 神職人員。

6. take a toll：（尤指逐步）損害，破壞。

7. burnout：（工作勞累造成的）精疲力竭，倦??；across the board： 全面地，包括一切地。

8. internal medicine： 內(nèi)科醫(yī)學(xué)；neurology： 神經(jīng)（病）學(xué)；family medicine： 家庭醫(yī)學(xué)；subspecialty：分科。

9. Mayo Clinic： 梅奧醫(yī)療集團(tuán)，世界著名的私立非營利性醫(yī)療機構(gòu)，有醫(yī)學(xué)診斷的“最高法院”和醫(yī)務(wù)人員的“麥加圣地”之譽。

10. dire： 非常嚴(yán)重的。

11. The Lancet：《柳葉刀》，世界權(quán)威醫(yī)學(xué)雜志，如今已衍生出一些附屬性的專業(yè)期刊，刊名均以“柳葉刀”為開頭，如這里提到的《柳葉刀精神病學(xué)》（The Lancet Psychiatry）；meta-analysis： 元分析，一種定量分析方法，它不是對原始數(shù)據(jù)的統(tǒng)計，而是對已有研究文獻(xiàn)統(tǒng)計結(jié)果的再次統(tǒng)計。

12.《柳葉刀》這一研究的作者還指出，導(dǎo)致醫(yī)生自殺的工作場所因素“包括極大的工作量、超長且不規(guī)律的工作時間、培訓(xùn)項目的競爭性、患者需求導(dǎo)致的壓力、任何工作失誤導(dǎo)致的后果、工作與生活的不平衡，以及醫(yī)生如果在工作中被迫違背自身倫理和價值觀而造成的道德傷害”。

13. stigma： 恥辱，見不得人的感覺；regulatory：監(jiān)管的，管理的；confidentiality： 保密性。

14. surgical resident： 外科住院醫(yī)生；psychiatrist：精神病醫(yī)生；abusive： 虐待人的。

15. ideation： 思維過程。

16. blockade： 障礙，阻礙。

17. sound： 提出（警告），敲響（警鐘）。