Tennessee health professionals are continuing to feel the strain of the pandemic and resulting health system impact – some to the breaking point – and their mental health is suffering. That is the recurrent story told in anonymous comments left by physicians and other healthcare providers who have accessed the Tennessee Professional Screening Questionnaire (TN-PSQ) over the past three years.
More than 650 health professionals served by the Tennessee Medical Foundation have utilized the anonymous screening tool since it was launched in February 2020 to address rising mental health referrals to its Physician’s Health Program (PHP). Three years of results are now available; more than half of users scored in the high/severe risk category, including 20 percent at risk for suicide. One significant number: 83 percent of users were not already receiving therapy or treatment for their stated problem.
“Overall utilization and the high number of those not already getting help are big indicators to us that this tool is sorely needed, and that we are reaching our target population,” said TMF Executive Director Jennifer Rainwater.
“The large number reaching out for the first time is a solid indicator that stigma, shame, and fears of career implications or censure for a mental health condition are still huge barriers in the medical profession,” added TMF Medical Director Dr. Michael Baron.
User comments illustrate the pressure they are feeling to perform in workplaces dealing with a lack of help and resources for the existing patient load – even as they personally struggle with the impact of the pandemic, the economy, and what seems to be the “new normal” in health care:
“Job too stressful,” cited one health professional. “Patient panel is too large and administration is trying to keep me seeing more new patients. Late workdays mean not seeing my kids when I get home … Nighttime charting/documentation on the EMR mean little to no quality time with my spouse. It seems like there is no good way to fix the work situation and that it will worsen.”
“Job-related stress of too many patients and not having enough staff to help, having to do most of the work myself is never ending, insurances not paying enough for the work being done,” echoed another.
One user described working in a high-volume ER: “Constantly experiencing more clinical requirements, more hostility, aggression and lack of appreciation from patients, and bureaucratic boxes to check off for less compensation definitely adds to job dissatisfaction and overall stress and makes you question your professional choices.”
Multiple new providers reported feeling overwhelmed and inadequate:
“I am a recent fellowship graduate, working my first job as an attending. I am struggling with imposter’s syndrome and worry I am not doing a good enough job,” said one screener.
Another said, “I am a new graduate (PA-C) and I started working in a busy urgent care at the height of flu/cold season. It has been extremely overwhelming trying to switch from ‘student’ mode to ‘provider’ mode, especially when I am expected to see roughly 30-40 patients a day, and I suffer from imposter syndrome daily.”
From February 3, 2020, through February 6, 2023, a total of 652 health professionals utilized the TN-PSQ screening tool:
- 132 (20%) were Tier 1A (high/severe distress including suicidal thoughts)
- 217 (33%) were Tier 1B (high/severe distress with no suicidal thoughts)
- 268 (42%) were Tier 2 (moderate distress)
- 33 (5%) were Tier 3 (low to no distress)
- 652 (100%) received initial response from site MHP
- 460 (70%) reviewed the counselor’s response
- Of reviewers, 144 (22%) dialogued with MHP a total of 243 times
- Of dialoguers, 93 (66%) requested an appointment or referral
- 83% were not already receiving treatment or therapy for their mental health problem
*Regional Use as of February 3, 2023:
- West TN/Memphis – 93 (14.6%)
- West TN/Jackson – 31 (4.8%)
- Middle TN/Nashville – 175 (27%)
- Middle TN/Franklin – 31 (4.8%)
- East TN/Chattanooga – 63 (9.7%)
- East TN/Knoxville – 127 (19.6%)
- East TN/TriCities – 62 (9.5%)
- No answer – 66 (10%)
*Profession/Practice Type as of February 3, 2023:
- Faculty – 224 (34.6%)
- Employed – 219 (33.8%)
- Student – 33 (5.1%)
- Resident/Fellow – 37 (5.7%)
- Other – 107 (16.5%)
- Prefer not to answer/No answer – 28 (4.3%)
*As per responses to optional demographic questions
The Fear Factor
Dr. Baron reiterated that the reason for both the existence and high utilization of the TN-PSQ by health professionals is fear: fear of discovery and disappointing self and others; fear of being perceived as weak and incapable; fear of lost opportunities, punitive action, or other career implications. Cost and time are also barriers to seeking care for most health providers, especially early in their careers.
“We are the absolute worst about asking for help and following our own good health advice and are the hardest on each other when we do reach out. We have much work to do in this area,” he said.
In his lectures across Tennessee, Dr. Baron often invokes the “canary in the coal mine” metaphor in describing the mindset on provider health. Until recently, organized medicine was focused on fixing the “canary” – in this case, the provider – by emphasizing resiliency and self-care, when in many cases it is the system or environment that needs fixing. “Physicians are very resilient; this is not a canary problem, this is a coal mine problem,” he said.
Systemic changes are needed and are starting to happen, he said, citing efforts like the Vital Signs campaign by The Physicians Foundation, the ALL IN: Wellbeing First for Healthcare effort by the Dr. Lorna Breen Heroes’ Foundation and First Responders First, as well as coordinated efforts by organizations like the American Medical Association, Federation of State Medical Boards, Federation of State Physician Health Programs, the American Council of Graduate Medical Education, and many others. The TMF is active and/or in partnership with several of these organizations seeking to promote changes aimed at reducing or removing mental health stigma within the healthcare system.
Unfortunately, it has taken high-profile losses like that of Dr. Lorna Breen, a New York physician who died by suicide at the beginning of the pandemic, to move the needle, he said, and the work is just beginning. The landmark 2022 Dr. Lorna Breen Healthcare Provider Protection Act was a huge step but more is needed; legislation and bottom-up transformation of systems and processes, including licensure, credentialing, healthcare workplace structure, and medical school and training programs, may be required before health professionals start to see and feel a real difference.
In the meantime, the TMF and other organizations focused on health professional health are seeking out more effective ways to address what is being called the “parallel pandemic” among healthcare workers. For this reason, the TN-PSQ will continue to exist and serve as an early intervention tool for mental and behavioral health conditions among health professionals in Tennessee.
Even while sharing their current crises, many users expressed appreciation for the TN-PSQ as an anonymous resource:
“Two things I like about the TN-PSQ is being able to keep my anonymity – I’m scared to be seen as unreliable or unfit for the field, and I’m extremely prideful – but more importantly, being able to talk through writing,” one individual said.
“Most things I have experienced over the last few months: Lack of sleep, decreased appetite. Clinically not depressed but there is a degree of distress,” said another user, adding, “(I) want to say thank you for making this questionnaire. I hope it is helpful for your research as well as the patient population.”
Another grateful user submitted, “This is a great service to our state’s health professionals.”
About the TN-PSQ
The TN‐PSQ is a free, voluntary, confidential, interactive online mental health screening tool incorporating the PHQ‐9 — a widely‐accepted vehicle for self‐assessment of depression; it offers an initial response from and optional anonymous interaction with a licensed mental health professional for further assistance and connection to nearby mental health resources. The resource is separate and apart from the TMF, and its users are unknown to the TMF unless they contact the Foundation and reveal they have taken the screening.
Its target audience is health professionals who may not contact the TMF Physician’s Health Program directly; the goal is to reach them before a mental health condition leads to more serious problems affecting patient safety and/or results in a referral to the TMF or action by an employer or state health licensing board.
The resource uses a platform called the “Interactive Screening Program,” developed in 2001 by the American Foundation for Suicide Prevention. Cited as an evidence-based best practice in suicide prevention by the U.S. Surgeon General and other entities, the ISP is used by over 160 institutions and organizations across the country, more than 50 of those serving health providers or those in training.
The TMF was the first Physician Health Program in the country to utilize the ISP; its results have led PHPs in other states to adopt or explore adopting the platform for their health professional populations.
Access the TN-PSQ at tn.providerwellness.org. For more information, including frequently asked questions about the screening tool, visit e-tmf.org/tnpsq. To learn more about the AFSP’s Interactive Screening Program, visit afsp.org/interactive-screening-program.
TMF Development Coordinator Brenda Williams-Denbo: 615-467-6411; email@example.com.