Self-Perceived Mental Health and Perceived Discrimination in Family Physicians and Residents: A Comparative Study Between Men and Women

Professional Adversities

It is likely that the exposure of family physicians to aggression events is related to, as mentioned in several studies, a dissatisfied patient with very long waiting time (to receive care or specialized interconsultation) and insufficient listening time to express their pain or suffering. Waiting time, attributable to organizational reasons and institutional processes of the health system (little known by patients and their families), is often unrelated to the physician's work and a poor understanding of the health system by patients and their families might direct their frustration toward the attending physician. Other factors could be unrealistic patient expectations of care, insufficient resources of the health institution, and communication problems during the consultation^27–28. This probably explains the high number of attacks reported in our study population, particularly verbal aggression. Although we found that men were more verbally attacked than women, we need to highlight that more than 90% of them reported this kind of aggression. We hypothesize that the difference found between men and women may come from the current special attention Mexican society is paying to aggression toward women and how, in many cases, this aggression is exposed on social media. In addition, we cannot rule out that many attacks do not come to light, in men and women, because health professionals do not report them, either due to the minimization of the violent act, the normalization of violence, or even because they think filing a complaint is pointless²⁸. Although violence committed by coworkers was less frequently reported, it is no less important. The culture of abuse in the family medicine workplace can be perpetuated through patterns of abuse that begin in medical school and continue through residency, and into the workplace. It can be further exacerbated by the lowly position of family medicine in the medical hierarchy and the stress caused by the shortage of family doctors^{10,29⇓–31}.

In addition, caring for patients with suicidal ideation or who committed suicide or being the treating physician of a patient who died under their care, can negatively impact family physicians (graduates and/or trainees)^12,32. Adaptive coping strategies can be decisive in protecting against the stress generated by this adversity³³ and may differ between men and women. Previous studies report that women are more likely to seek support as a strategy, while men are more likely to use avoidance strategies (such as denial, alcohol/drug use, distancing themselves and behavioral disengagement)^{22,33⇓–35}. Our results show that both men and women often fail to seek care since just over 50% of family physicians seek professional help.

Distress and Self-Reported Mental Health Problems

In the present study, family physicians reported experiencing high levels of stress, a finding consistent with other studies^{36⇓⇓–39}. The evidence shows an increase in the prevalence of common mental disorders among physicians compared with the general population, with marked differences by sex^40–41, which was supported by our results. Women may suffer the double burden of balancing professional work and family responsibilities (such as caring for children, sick relatives and the elderly) with limited social support networks and, in many cases, with an unequal distribution of household chores^41–42. Workplace training programs should improve work-life balance with healthy work schedules that allow adequate time for rest or recreation.

Although a high proportion of family medicine residents and family doctors who seek professional help had received pharmacological and/or psychotherapeutic treatment for their self-reported mental problems, approximately 20% had self-prescribed their pharmacological treatment. As various studies point out, several factors contribute to self-prescription, such as lack of time to attend a consultation; difficulty finding a replacement, a backlog of work if absent, and the prevailing assumption in medicine that doctors must be resilient^12,43,44. In addition, stigma, and the fear of being considered weak, vulnerable, or flawed by peers and supervisors may also influence self-prescription and the reluctance to seek help^12,40.

Perceived Discrimination

The levels of discrimination found, which should be taken with caution as no cutoff point of the instrument is available, may be related to the symbolic structuring in medicine, reflected in the hierarchies based on criteria such as the prestige of the specialty, the institution to which doctors are affiliated and the shift in which they work^8,9,45,46. Professional hierarchies between other specialties and family medicine are not uncommon and seem to be multifactorial^27–28. Some hospital-based specialists believe that family physicians are “the same” as general practitioners, that family physicians do not have their own body of knowledge and, moreover, that many of them are family physicians because they had no other professional choice or that it is a female specialty because of the possibility of a controllable pace of life. Moreover, there are institutional stigmas in medical schools against the specialty of Family Medicine such as underrating the specialty, encouraging students to choose other specialization programs or the perception that family doctors do not occupy high-profile positions^30,47.

In Mexico, there is an increased need for Family Medicine physicians. Medical education offers the opportunity to influence physicians in training to address health needs through undergraduate training in underserved areas such as family medicine. In Mexico, the aim is to counteract this problem by: 1) contact from the first year of the career with services at the first level of care, 2) mentorship with family physicians, 3) promotion of the true identity as a medical specialty, visibility and acknowledgment of specialty competencies, their scope of action, skills and abilities and how they fit into Mexican health system, 4) maintaining the family medicine residency as a 3-year course, without prerequisite of another specialty and with greater contact with the area of professional performance, 5) recovery of the prestige of the specialty in academic and professional circles, where the family physician is the center of the primary care team to identify and meet the health needs of the community, also, by improving the perception of Mexican patients about the benefits family medicine to dignify the work of this specialty; and 6) feasibility of offering the specialty as an attractive economic option, recently increasing the job offer for physicians of the specialty and offering facilities to general practitioners to specialize without losing their job.

Limitations

The limitations of our study stem from 4 main sources: (1) self-reported mental health rather than active assessment, as this is likely to include other issues that may not meet clearly defined diagnostic criteria, (2) lack of randomization of the sample, which could bias the interpretation of our results. We cannot rule out the possibility that those who answered the survey were people with clearly identified mental health problems, 3) their retrospective nature makes it impossible to determine how accurate these diagnoses are or whether the problems are currently present, and, 4) for the maintenance of confidentiality, we do not have personal data to be able to guarantee the certainty that the questionnaire was answered by family physicians and trainees, which is a common limitation found in studies using online surveys. However, in the informed consent and at the beginning of the form we asked whether they were family physicians or trainees, in case of a negative answer we did not allow them to continue with the form. Furthermore, in the process of self-diagnosis, qualitative studies have shown that physicians tend to underreact or overreact to their symptoms, going from diagnosing diseases with the worst prognosis to ruling out a disorder altogether^40,45. Medical culture can encourage both underreporting and underrecognition of mental illness and burnout. Although the anonymous nature of the survey may encourage more accurate self-reporting, given the design of this study, it is impossible to determine the degree of underreporting^{12,43⇓–45}.