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Presidential Address
Sept. 10, 2023
David R. Diaz, MD

Good morning, friends and colleagues. It was once a cliché to begin a speech by saying, “Unaccustomed as I am to public speaking …” In my case, I have been a psychiatrist for more than 30 years. The nature of my work means I spend the bulk of my time listening, and much less time talking. I hope you will be patient with me as I attempt to reverse roles.

Thank you for the great honor of representing you as your president for the coming year. I also want to thank my predecessor, Dr. Pardeep Kumar, for his leadership over the last year. He has done an outstanding job of guiding the ISMA through the issues that have always faced the practice of medicine, as well as new issues brought on by pandemics and politics.

Let me tell you a little about myself, and how my background shapes my approach to the responsibilities with which you have entrusted me. While I have spent my professional career in Indianapolis, I grew up in Newburgh in far southwest Indiana, and I am a proud alumnus of the University of Evansville. I still return to southwest Indiana eight or nine weekends a year to see patients in Jasper.

I bring this up not to sell a few season tickets for the Purple Aces, but to emphasize to you my commitment to a fundamental point: we are the Indiana State Medical Association. This organization is here to serve physicians in every part of the state, from Evansville to Angola, from Gary to Jeffersonville, and everywhere in between.

When I was growing up, my father used to complain every so often that “Indianapolis” – meaning the state government – was shortchanging southwest Indiana in building infrastructure. If you go to the Statehouse in 2023, you may hear similar complaints from legislators representing other parts of Indiana. Like my father, they may use a shorter and blunter word than “shortchanging.” 

I don’t know to what extent my father’s analysis those many years ago was correct. I suspect that many of you may have similar concerns as it relates to health care. When we gathered for convention one year ago, Dr. Kris Box appeared at a special Friday night session to explain the Holcomb administration’s plans to seek an unprecedented investment in public health infrastructure. While the final budget cut the size of that investment roughly in half, the appropriation of $225 million is still far beyond anything Indiana has ever done. And that funding is expressly designed to get more resources to those counties my father would say have been neglected. While they may not have been neglected, they have certainly been under-served: nearly half of Indiana’s 92 counties spend less than 10 dollars per person on public health. As president, I pledge to you that the ISMA will continue advocating for patient health and the practice of medicine not just in our state capital, but in every Indiana community.

The public health bill was not the only health initiative to emerge from the statehouse this year. Legislators took a $100 million first step toward expanding access to mental health care in Indiana. As you can imagine, this is an issue of great importance to me, and I hope the state will build on this foundation. Mental health is a critical public health need, and this investment is important to the wellness not only of patients but of physicians. In the three-and-a-half years since the start of the COVID-19 pandemic, physicians have faced challenges not seen for more than a century. Every physician in this room remembers all too well the tsunamis of patients who filled emergency rooms and hospital beds. Many of you treated those patients and felt the strain of a death rate that sometimes was more than 100 a day for days at a time. 

The mental health toll of the pandemic cannot be ignored, and we should not assume that our training as physicians makes us somehow immune to the effects of isolation, illness, and loss. In fact, there is some evidence that physicians may be more vulnerable, not less. Medscape’s annual survey on physician suicide finds one in 14 physicians have had suicidal thoughts – nearly double the rate in the general population. Tragically, the rate at which physicians do in fact take their own lives is also double that of the population at large. The estimated number of physician lives lost in the U.S. each year is equivalent to the IU School of Medicine’s annual number of graduates.

Sept. 17, one week from today, is National Physician Suicide Awareness Day, a day set aside to make sure we educate ourselves about what is literally a life-or-death issue. We need to be able to recognize the signs in ourselves and others that can indicate thoughts of suicide, and we need to be aware of where to get help.

Some of the highest rates of suicidal ideation among physicians are in specialties such as oncology and emergency medicine, which bear witness to a greater proportion of patients who do not survive. The pandemic placed all of us in that position. The Medscape survey found 36% of physicians report feeling unhappy at work, more than double the rate before the pandemic. 26% are unhappy away from work, more than triple the pre-pandemic number. 

The most troubling statistic may be this one: the same survey finds 60% of physicians report they look after their own health only sometimes or rarely. For centuries, mental illness has carried social stigma. Even with the advent of modern psychiatry, that stigma has not disappeared, but has attached itself to the act of pursuing mental health treatment. As anyone could predict, that has had the effect of discouraging people from seeking the help they need. 

The original “Catch-22,” as described in Joseph Heller’s novel, directly concerned itself with mental health: pilots could only be excused from dangerous missions if they were mentally ill, but a desire to avoid dangerous missions was proof the pilot was mentally sound and had to fly them. As the character Yossarian says in the book, “That’s some catch, that Catch-22.” 

Implicit in that Catch-22 is the heart of mental health stigma: the assumption that anyone who is mentally ill must be unreliable. The persistence of that stigma continues to create its own real-life Catch-22: those who would benefit from mental health treatment are often afraid to seek it.

For physicians, that stigma takes a concrete form. Some physicians know they need help but are unwilling to follow through because they fear consequences to their licensure. Nearly one in six physicians who take their own lives never seek help beforehand. Some psychiatrists have speculated that the licensure implications are a significant contributor. Later this morning, this House will discuss a resolution that asks the Medical Licensing Board to revise its licensing questionnaire to make clear the importance of pursuing appropriate treatment.

Physicians must demand proper support from their employers, and each of us must communicate with colleagues we believe are struggling. We all know about this problem. During my presidency, I pledge to look for additional ways ISMA can support the mental health of physicians, and I look forward to seeing the important work of our new physician wellness committee. 

In medicine as in any other profession, mental health lays the foundation for our ability to do our jobs effectively and to function at home with our loved ones when the workday is over. The ISMA’s Physician Assistance Program provides indispensable, confidential help to those who have fallen into abuse of drugs or alcohol. But substance use represents just a sliver of physicians’ mental health. We need to be able to get along with our fellow physicians and with non-physician providers. 

Finally, I want to urge you to take the opportunity to be leaders in the ISMA and in your communities. In June, we lost one of our past presidents. Fred Dahling was the son of Dr. C.W. Dahling and began practicing alongside him when he got out of the Army in 1960. Between the two of them, the Dahlings took care of the citizens of New Haven for 60 years. One of those New Haven residents was our colleague, Bill Pond. Dr. Pond says when he was eight years old, the compassionate care he received from Fred Dahling was what inspired him to become a physician. 

The 1960s are a long time ago, but it remains true that physicians command respect in their communities. Ninety percent of Indiana’s cities and towns are smaller than New Haven – 73% are smaller than Newburgh. Even in our larger cities, where the concept of “the town physician” is something out of Mark Twain, our patients recognize that our work is the product of years of knowledge and dedication. The annual Gallup poll asking what professions Americans most trust continues to rank physicians among those at the very top. That trust means addressing our communities’ immediate health needs is only the beginning of our work. Our patients and communities may not always follow our advice, but they are likely to listen. And, if we are lucky, some future physicians may be among them.

I began my address to you by observing that I am more accustomed to listening than to speaking. I want to assure you that I am here to listen to your concerns at any time as we move forward together in the year ahead. Thank you for your attention, for the trust you have placed in me, and for your commitment to making Indiana a healthier state, and an even better state in which to practice medicine.