This is the first in a three-part series.
In October 1995, Steven Miles, MD, a gerontologist and then professor of medicine and bioethics at the University of Minnesota in Minneapolis, was preparing to teach a class, when he learned that one of the school's medical students had committed suicide.
"I was the third lecture that day and nobody had talked about it," he said.
In the lecture hall that morning, Miles made a difficult decision. He chose to share his own mental health diagnosis with his students. About 2 months earlier, Miles had struggled with extreme depression, anxiety, even suicidal thoughts, although he never made any "suicidal gestures," he told 乌鸦传媒.
Instead, he sought help from a psychiatrist who diagnosed him with bipolar II disorder and helped him find effective treatment. Miles did not stop practicing medicine, but he did cut back his participation in various committees.
"I'm proof that you can have a successful career and family life, if you get treatment," he told the class.
Miles said, "I did not make myself the focus of the lecture, except to tell the students that the faculty and the school cared about what happened to them."
He kept his message simple: "If you see someone struggling with a mental illness, get them help."
There was no backlash or repercussions for his disclosure, Miles said. In fact, some time later, the student committee on academic standing began sending students who struggled with mental health problems to Miles for support. At that time, there were no crisis counselors or other formal support networks available at the university. Faculty members also sought his advice, he said.
Just a few months later, in January 1996, Miles was completing a medical licensure renewal application and came across a question asking if he'd ever been diagnosed with an affective disorder. He answered "yes."
Miles is matter-of-fact about his bipolar disorder. It's a "disability" for which one makes "accommodations," he said, meaning he complies with a certain treatment plan.
But Minnesota's medical board didn't see it that way.
Miles had never been sued, never had any practice complaints to the board, and won "a bunch" of awards -- including "best gerontologist in Minnesota." Nevertheless, he learned he was being investigated by the medical board.
Within weeks of completing the forms, the board requested his psychiatrist's complete medical records and notes on Miles. Both he and his psychiatrist refused.
The board then threatened to suspend his medical license.
But Miles, who has a background in community organizing, held firm. In April 1996, he filed his first complaint with the U.S. Department of Justice arguing that the board had violated the Americans with Disabilities Act (ADA).
"The goal of 'Americans with Disability' is to eliminate or eradicate any form of discrimination against people with disabilities," Charles Weiner, JD, an attorney in Bensalem, Pa., whose practice includes disability law, told 乌鸦传媒. (Weiner has no relationship with Miles nor with Minnesota's Board of Medical Practice.)
And asking about a diagnosis rather than an impairment, or asking about a mental health diagnosis or treatment in terms that are not time-specific, Weiner said, "without a question, contravenes the spirit of the Americans with Disabilities Act."
An excerpt from the American Psychiatric Association's confidentiality statement published in in January 1997 (alongside an editorial written by Miles) echoed that "[n]o convincing argument has been advanced to show that a patient should be deprived of the right to the privacy of his or her medical record simply because he or she has chosen to study or practice medicine."
The APA also sounded a warning: "Far from protecting the public, it is likely that the abolition of the confidentiality of the physician's personal health records would simply discourage troubled people, many with treatable disorders, from finding appropriate medical help and would hamper those trying to help them."
But the board continued to argue that the only way to resolve the matter was by reviewing Miles' medical records, Miles explained in a 1998 .
The stalemate between Miles and the board lasted for more than 2 years, during which time the board continued to renew Miles' license, because they feared a lawsuit, he said.
When Miles was finally allowed to argue his case before the board some 2-3 years later -- the precise timeline is hazy, with 20 years having passed since the incident -- he cautioned the board members that they or their children, many of whom were physicians or aspiring physicians, could themselves one day face an unexpected mental health problem, he told 乌鸦传媒.
He bluntly told them that they were in the wrong. The Justice Department, the National Alliance on Mental Illness, and the Minnesota Psychiatric Society (MPS) sided with him, Miles said.
He called attention to a report from the MPS, which highlighted the deaths of two Minnesota physicians, both of whom committed suicide without ever disclosing their mental health problems.
Miles never learned the margin of the vote that determined the future of his career in medicine, but "they caved. They immediately dropped the request for records," after that meeting, he said.
Within a few months of the board's decision, it revised its licensure applications so that questions related to mental health focused on impairment rather than disease.
"It was a big win," Miles said.
Yet more than 2 decades later, Miles said he still gets calls from "three, four, five" doctors a year, across the country, caught in similar situations.
A Culture of Stigma, Shame
Published estimates suggest about 300 physicians complete suicide each year, although researchers themselves say those numbers are likely dated.
Throughout medical school, residency, and their careers, doctors are taught that they are physically and emotionally unbreakable. They cannot be wrong, cannot make mistakes, and cannot get sick.
"The system is brutal ... in terms of sleep deprivation, in terms of unrealistic expectations, in terms of being able to be supportive of someone who says 'I don't know;' brutal in terms of pressure towards perfectionism, brutal in terms of competition," said anthropologist John-Henry Pfifferling, PhD, who spent 6 years studying medical residents in the 1970s, and later founded the Center for Professional Well Being in Durham, N.C.
He noticed what he called the "hidden curriculum" of medicine, where students are taught early on not to share anything that causes them to be perceived as "different" or "unfit."
Ryan Bayley, MD, is an EMT turned emergency department physician turned career coach. He said he pulled back from medicine around 2013. He still practices, but his primary focus is on coaching.
After 17 years of dealing with long hours, an erratic work schedule, and increasing amounts of administrative work, he said he felt exhausted and burnt out.
Bayley distinguishes "burnout" from depression, with the former being a distinctly work-related phenomenon.
It wasn't that he was having bad days, just fewer good ones, he said: "I just got to the point where I had to take a step back."
He draws on that experience to counsel others. "Physicians are very good about not letting anyone else know that they're burned out. So, when you are burned out, and you're struggling, it feels like you're the only one," Bayley said. "To know that everyone goes through it; to know that there's many people on the other side of it; to know that there's resources for it, all would have been helpful."
The stigma around burnout and mental illness more broadly may explain why physicians have higher rates of suicide than the general population, and why physicians who completed suicide were less likely to have received mental health services than nonphysicians who also took their own lives, according to the .
A indicated that the suicide rate among physicians, at 28-40 per 100,000, is more than twice that in the general population.
And while everyone decries the stigma associated with mental illness, it's formalized, institutionalized, and made permanent in the medical licensure process, with the potential for life-long burden.
When asked to connect 乌鸦传媒 with other physicians who had fought with their states medical board over their own mental health diagnoses or treatment, Miles declined.
He disclosed his bipolar diagnosis multiple times to various groups after he filed his federal complaint. "The fact that I was willing to go to the mat with them ... that I was willing to blow my own diagnosis" took away the medical board's only leverage, Miles explained.
But he wouldn't wish that experience on others, he said.
He said he is also concerned about what he sees as the overuse of the term "burnout," or its use as euphemism for a more serious underlying problem.
"Physician burnout is not a DSM [Diagnostic and Statistical Manual of Mental Disorders] diagnosis," he said. "I'm concerned that burnout is in some ways eclipsing a real [mental health] problem."
Up next: Does the licensure process protect the public, or just punish those with mental illness?