High self-demands, tremendous professional stress and a tendency to overwork: these are the conditions which many physicians cope with in their everyday working lives - and their maintenance can often lead to addiction. Addiction expert Michael Musalek tells medinlive why this is a big issue, at which point addiction starts and what structural models are required to deal with it.
medinlive: Is there any information on how many doctors in Austria are suffering from addiction?
Musalek: No, and it is also not practically surveyable, because an addictive disease is highly stigmatizing. This stigmatization is, of course, particularly high among physicians, because the disease often leads to professional consequences. And if you conduct a survey, the results are naturally much lower, because the majority of people hide their addiction. All available figures are based on estimates.
medinlive: The German Medical Association estimates that seven to eight percent* of physicians in Germany suffer from an addictive disorder at least once in their lives. How do you evaluate these figures?
Musalek: I think this figure is reasonable. We have to assume that if we calculate for Austria - and we are always just ahead of Germany in the top field - then five percent of our population is addicted. Now we can definitely assume that this percentage will be higher among physicians. Simply because they have access to addictive substances, such as drugs. We know that the availability controls the occurrence of addiction. The more available an addictive substance is, the more it is used and the stronger the dosage, and the more addicts there are. It' s an universal phenomenon that we see in virtually all addictions, whether substance-related or non-substance-related. If there is a professional group that has better access, it is to be expected that they will use more addictive substances. Nevertheless, this value does not seem very high to me, because if we are talking about other addictive substances (not just alcohol), this would be a lower value than in the general population, which cannot be assumed.
medinlive: You have lectured on the subject of addiction several times at medical events. Do you think this topic is covered sufficiently?
Musalek: It is certainly covered far too little. One reason for this is that it is an incredibly controversial topic. Without a doubt, it is a major problem and a very common phenomenon that is linked with extreme consequences: impairment in the professional sphere and - and I consider this to be the more dramatic aspect - it is the group that receives the worst treatment of all addicts, because the barrier to seeking treatment is exorbitantly high and, unfortunately, we do not have any facilities in Austria that specialize in this area. Attempts that I have started in this regard have failed. Meanwhile in Spain or Norway there are separate facilities for doctors and other undersupplied groups who work in the public sector or in neuralgic areas, such as politicians. These groups have fewer treatment options and also a much poorer prognosis.
medinlive: There is an addiction program offered by the Medical Association in Lower Austria. What is your opinion of this program?
Musalek: Yes, there is this program, but to be honest: This is only a drop in the ocean. What we need is an stationary facility where these people can receive intensive care and, above all, where anonymity is ensured.
medinlive: What might this model look like?
Musalek: I have identified two models that would be useful. One would be a clinic that is hermetically sealed off, where it is almost impossible that data leaks out. The other option is to offer combined treatment, for example, for workaholism and burnout. This is the approach taken in South Tyrol: there is an addiction and burnout clinic in Bad Bachgart. You can be treated there for burnout and addiction. Anyway, this is a common combination and would therefore be a practicable approach. Ideally, the treatment should be financed by the clinic itself.
I consider this to be the better model, as other substantial more recognized mental illnesses are also treated. The most widely recognized illness today is burnout. Depression, which often occurs in the context of burnout, is already much less recognized. The disorder that is the very least recognized is addiction. In fact some people think it is not a medical condition at all. Also, addiction is explicitly excluded in all private insurance policies - a remnant of a time when it was seen as self-induced. The argument to exclude addictive diseases because it is a chronic disease does not apply. After all, lung diseases, cancers or diabetes, which can also be chronic, are precisely not excluded. There is a widespread belief that addiction is not a disease. People should just have to 'get a grip'. Speaking about mental illness, Robert Musil said that people suffer not only from inferior health, but also from inferior illness. In the case of addictive disorders, there is also the fact that they are all too often denied being sick in the first place.
medinlive: How do you think an addiction program for physicians should be structured?
Musalek: Doctors do not have to undergo a more complex treatment program than other addicts. Of course, the content would have to match the specific problems that affect medical professionals. The length of hospitalization depends largely on the type of addiction. Patients with drug addiction and medication abuse usually need a longer stay than alcoholics. The majority of addictive disorders can be treated on an ambulatory basis, especially alcoholism (around 80 percent, note). However, the situation is different for drug addiction. Here, stationary treatment is always required because the withdrawal symptoms are difficult and more time-consuming to treat, and also because the comorbidities are more prominent. As a rule, these are self-treatment attempts, and the underlying diseases are correspondingly severe. Certain drug disorders also require hospitalization for longer periods of time. In any case, admission to an residential facility should be followed by appropriate long-term outpatient follow-up treatment.
medinlive: Why do you think a clinic in this field would be necessary?
Musalek: The need is obvious, considering that we have a professional group here that is medically underserved. Another thing that should not be ignored is that many addicts are excellent, high-performing people in their profession. As a rule, very good doctors become addicted because they place very high demands on themselves, easily overtax themselves and then need the appropriate doping substances to be able to withstand these demands. It is an extreme loss for the medical system if these people are not treated in a specific way.
medinlive: You mentioned programs for addiction in Spain and Norway. What marks out their effectiveness? Is there also the prospect of not losing appropriation despite receiving treatment?
Musalek: Absolutely. The idea behind it is that you can be admitted and receive treatment without informing the relevant authorities, chambers or institutions that might declare something negative. From the chamber's point of view, I assume that there will be a relatively high level of acceptance if someone seeks treatment. I see the problem rather in the fact that the reputation suffers in general, also among patients. In terms of effectiveness, we know that after treatment and controls, doctors are able to practice their profession again. However, one cannot expect that a doctor will be a patient at the Anton Proksch Institute and will meet all of his or her patients here.
medinlive: It is assumed that there is a kind of corps spirit among physicians, where doctors protect each other. What do you see as an obstacle and motivator for physicians to seek help?
Musalek: The problem is that wherever an illness leads to extreme consequences, there are no appropriate treatment options and it may not even be accepted to seek treatment, then people try to hide the illness, which also affects the patient. A step towards destigmatization could be a treatment facility with a focus on anonymity.
medinlive: One of the factors why doctors are more prone to addiction is availability. What other factors can you identify especially for the group of physicians?
Musalek: An addictive disease never occurs on its own. There is no addictive disease without other diseases, which are causing it, at least massive psycho-social problems. In this context, we know that professions that attract people who have a high value system and who place high demands on themselves are more predisposed to overstraining themselves. And then there are also occupational areas in which overstraining - both psychologically and physically - is immanent This is especially the case with medical professionals, who have to deal with the physical strain of night duty and the constant expectation of being available, and the psychological strain of having to deal with the massive pressure of possibly drastic consequences in the event of mistakes. Accordingly, these people are under enormous pressure.
Most physicians have not been trained in dealing with this kind of pressure. This is something that should be integrated into the curriculum. Specifically, that one learns better how to deal with this profession, which eventually endangers oneself. Like every craftsman learns how to deal with moments of danger. In the medical field, it is usually learning by doing. You think: You're psychologically so strong anyway that you can take it. But just being confronted with death or serious suffering on a daily basis in some professions, or having to constantly give people bad news, requires psychological stability and knowledge: How far can I push myself, when do I notice that I am overwhelmed and how can I counteract?
medinlive: The topic of addiction is indeed already present in university studies.
Musalek: Studying medicine presents a great challenge in terms of the amount of material, but also in terms of the subject matter itself. If you're constantly dealing with diseases, there's hardly anyone who doesn't suspect they have one, and you have to learn how to deal with that, too. If you are confronted with it every day in your professional life, you need mechanisms to deal with it. Because when we simply negate "I don't get sick, only the patient gets sick," we overlook the fact that we have the first symptoms of illness in the psychological area. If you don't do anything about this, it gets worse and worse. And then there are ways to quickly find a remedy. Because addictive substances - we must not forget - are excellent in their effectiveness, which is also what makes them so dangerous. They help in the short term, but in the long term everything comes back like a boomerang with an addictive disease.
medinlive: What signals in the daily routine of a practice or clinic could point to an addictive disease?
Musalek: The central phenomenon is the loss of control. When I can no longer control the drug intake and it gets regular. For example, with alcohol: If it becomes frequent, if you don't have any alcohol-free days, if you plan to drink less but don't succeed, then a risk factor is to be expected. The same applies to medication. If I notice that I need it regularly and then possibly an increase in dosage, then there's already fire under the roof.
medinlive: Do doctors perceive addiction differently because of their professional approach?
Musalek: That varies greatly from person to person. Most addicts can determine very precisely when they can no longer handle the addictive substance in a controlled manner. In that situation, they still try to sugarcoat it. Then there is a latency phase, where you know: This is not working, but I can't handle going into treatment. This span lasts between three and eight years on average with alcohol. The threshold is exorbitantly high and is particularly high among medical professionals. We have to distinguish between three stages here: When did the addiction start, when do you admit it to yourself - there is a latency here and then there is treatment. If we now had a special facility, this second latency could be reduced significantly. Probably already the first latency as well, because there would be greater awareness. Because the first latency is related to the attitude "only others get sick."
medinlive: Which addictions would you most likely locate in the medical profession?
Musalek: Alcohol is the number one drug and also the number one among physicians. Nicotine is still common, but here the numbers have decreased significantly. Then drugs also play a role because of their easy access, and then opiates for a much smaller group. With cocaine, the number of unreported cases is extremely high. That could also be because when you take it, you get the impression that you are enhanced in performance. In private practice, I treat an overwhelming number of physicians, partly because they know that there is a great amount of anonymity here. Alcohol and drugs play the biggest role for them, cocaine and morphines play a more marginal role. We estimate that there are 300,000 alcoholics and 200,000 to 250,000 drug addicts in the Austrian population. Where we have the best data, because everyone who is addicted sooner or later comes into treatment, is in the area of opiates, the classic addictive substances; there we have about 30,000 in Austria. With doctors, the percentage will be a little higher, because of the availability, because you can virtually prescribe it yourself and have direct access, while this is not the case in the population, but is almost only available on the black market.
medinlive: Are there mechanisms or programs in the area of self-prescription to control improper prescription of drugs?
Musalek: According to the Narcotic Substances Law, every prescription and every use must be recorded, which is also strictly controlled. But the chance of preventing addiction through control is not very high. You can curb the availability, but to prevent something with control mechanisms is not possible. Even in the Prohibition era, when alcohol was banned, people drank. The number of drinkers decreased, but criminalization increased consequently.
medinlive: Do addictive diseases manifest differently in the medical profession than in the general population? For instance, whereby suicides are more common as a result?
Musalek: Suicides are generally more frequent among physicians, especially among anesthesiologists and psychiatrists. This has to do with the fact that these are especially burdened occupational groups. But it also has to do with the fact that anesthesiologists have many suicides with fewer suicide attempts because they choose more effective methods. With psychiatrists, it is related to the fact that this issue is a permanent one in the specialty. Thus, it is not something extraneous that is not considered at all. Moreover, the chance of suicide is much higher when suicides occur in the surrounding area, also called Werther effect (when suicides occur more frequently as a result of a suicide known from media, literature or film, note). Someone who is constantly dealing with suicide attempts is at special risk. Under the influence of alcohol, the risk of suicide is increased ten to 15 times, because alcohol is a depressogenic and at the same time disinhibiting substance. Unfortunately, this is an ideal precondition for suicide. When inhibitory mechanisms fall away and a depressive mood prevails, this is an ideal ground for such terrible incidents.
medinlive: What recommendations would you offer to medical professionals for seeking help?
Musalek: The first thing is to accept that you can be ill and have an addiction. This is an fundamental attitude that should be passed on to everyone, even during their medical studies. There is a need for appropriate educational content, where future doctors learn how to deal with this. The second thing is to take the early warning signs seriously and not only apply them to patients, but also to oneself. The third thing is, when you realize that you are addicted, you should go and see someone where you know that it will not be publicized, where you can open up and begin a treatment. That is quite possible in the private outpatient sector, but it is much more difficult in public outpatient clinics because anonymity can no longer be maintained. And in the inpatient sector in Austria, it' s not really possible at the moment.
The Viennese psychiatrist and psychotherapist Michael Musalek is known internationally as one of the most prestigious experts on addiction. He was medical director of the Anton Proksch Institute and is chairman of the Institute for Social Aesthetics and Mental Health at the Sigmund Freud Private University in Vienna and Berlin, as well as chairman of the psychosocial advisory board of the Ministry of Health's Coronavirus Task Force.
* Estimates of prevalence in Germany are based on the results of North American studies (US study by Hughes et al. 1992 and Canadian study by Brewster et al. 1994) from the late 1980s early 1990s, as stated by the German Medical Association in mid-May of this year.
The Medical Chamber of Lower Austria supports addicted physicians strictly confidential in the immediate initiation of qualified inpatient or also outpatient withdrawal and detoxification treatment, information on possible reimbursement of costs for outpatient or inpatient therapy, and in the procurement of a practice substitute. https://www.arztnoe.at/arzt-sucht
In Germany, according to a 2019 survey by the German Medical Association (BÄK), all 17 state medical associations offer a structured intervention program for addicted physicians*, as the German Medical Association stated upon request in mid-May. However, the uptake of the intervention programs in the state medical associations varies greatly. According to the chamber the results would show that the intervention programs are more successful compared to general data of the addiction help system; the success rate would be between 60 and 100 percent. The survey also showed that chambers that have a structured assistance program and actively publicize it receive a higher than average number of SARs. In 2019, the 122nd German Medical Congress focused intensively on the topic of physician health. The papers on the agenda item can be viewed here. The German "Ärzteblatt" also addressed the issue.
The "Integrated Care Program for Physicians with Mental Illness" (PAIMM - Programa d'Atenció Integral al Metge Malalt), founded in Catalonia in 1998, is considered one of the first intervention programs for physicians with mental illness in Europe. The program is anonymous and is funded 80 percent by the Catalan government and 20 percent by the medical society. It includes interventions at a therapy facility in Barcelona, day hospital services, and outpatient care. In Norway, Villa Sana, a prevention program specifically for health professionals, has been established. Health professionals can participate in individual counseling sessions, group therapy over several days, lectures and activities. The program is funded by the Norwegian Medical Society. In the UK, an anonymous support program for medical practitioners was recently launched by the National Health Service (NHS). Under the Practitioner Health Programme, doctors with mental health problems, anxiety or depression can contact specialists in confidence for specialist help.
There is an increased suicide rate among physicians. A U.S. study in 2000 found a suicide rate of between 28 and 40 per 100,000 - compared to 12.3 in the general population. According to this study, physicians commit suicide more than twice as often as the U.S. population. It also showed how addictive behavior subsequently correlates with suicide: According to the study, 40 percent of suicides among physicians are related to alcohol dependence and 20 percent to drug abuse. Other studies from Western countries have even found that the suicide rate among female physicians is about five times higher than in the average population; and among male physicians twice to three times higher than among female physicians.
Experts emphasize that each suicide or suicide attempt is due to a variety of causes. There are a number of points of contact for people in crisis situations and their families:
Emergency numbers and first aid for suicidal thoughts can be found at www.suizid-praevention.gv.at.
Telephone help in a crisis is also available from.
● Telephone counselling 142, daily, from 0 a.m. to midnight.
● Crisis Intervention Center 01/406 95 95 (Monday through Friday, 10 a.m.-5 p.m.);
also personal and e-mail counseling: www.kriseninterventionszentrum.at.
● Social psychiatric emergency service / PSD daily, 0 a.m. to midnight, tel.: 01/31330.
Relatives can find information and materials at www.suizidpraevention.at
Background information:
Information brochure on burnout by the Medical Association for Vienna
Suicide Prevention Austria (SUPRA) Report 2016.
Interdisciplinary Pain Medicine (ismed) at MedUni Vienna.
Speeches of the 122nd German Medical Congress 2019:
Presentation [PDF] by Prof. Dr. med. Monika A. Rieger, Tübingen
Medical Director of the Institute for Occupational Medicine, Social Medicine and Health Services Research of the University Hospital Tübingen
Presentation [PDF] by Prof. Harald Gündel, Ulm, Germany
Medical Director of the Clinic for Psychosomatic Medicine and Psychotherapy at Ulm University Hospital
Presentation [PDF] by Klaus Beelmann, MD, Hamburg, Germany
Managing physician of the Hamburg Medical Association
Literature:
Working and staying healthy - knocked out by the job or fit at work Gündel, Harald; Glaser, Jürgen; Angerer, Peter Springer Berlin, 2014, ISBN: 9783642553028.
Working in health care: - (Psychosocial) Working Conditions - Health of Employees - Quality of Patient Care Angerer, Peter; Gündel, Harald; Brandenburg, Stephan; Nienhaus, Albert; Letzel, Stephan; Nowak, Dennis ecomed-Storck GmbH, 2019, ISBN: 9783609105666.
Working conditions and well-being of physicians - findings and interventions Report Versorgungsforschung Band 2 Angerer, Peter; Schwartz, Friedrich Wilhelm Deutscher Ärzte-Verlag, 2010, ISBN: 9783769134384
