“It’s 4am. I’m exhausted but anxiously awake with a gnawing sense of dread in my gut. The peace of sleep evades me. Laying here in the dark coolness of my comforter is where I prefer to stay. I don’t have to hide my tears behind smiles. I don’t have to hide uncertainty behind confidence, I don’t have to hide my questions or their answers.
I know the hour soon will come when the expectations of patients, and family will rise like the sun expecting my exhausted hands and mind to serve, help and heal them.
With a tearful blink, I remember my first day of medical school. An attending physician came in wearing a starched white coat. I thought “they must have the absolute greatest life.”
Now here I am in the position I once dreamed of, yet I feel…nothing. Nothing except this clinging unshakable sadness. Nothing but the unsettling weight of persistent worry, nothing but guilt and grief for the life I once envisioned but despite my outward success, haven’t achieved.
I know the statistics. I know we lose over 400 physicians to suicide every year. I know, technically, I’m not alone, but here in the dark solitude of another morning, there are no other inhabitants. I have fleeting thoughts of ways to end the pain. I’d be better off if I wasn’t here, but if I stop things would be so hard for those I love.
Slowly I get up, get dressed, grab my limp white coat and prepare to serve from an empty cup…again.
I can’t keep doing this.” ~ Filling Our Cups Retreat participant
More than half of physicians know a physician who has either considered, attempted or died by suicide in their career.
Physician suicide has been a crisis long before the demands of the COVID-19 pandemic. Although, there is increasing awareness of mental health challenges among health professionals. Attention to depression and suicide in physicians is long overdue. As early as 1858 physi- cians in England observed that a higher suicide rate exists among physicians than the general population.
While studies suggest the rate of depression among male and female physicians is similar to that in the general population, the rate of suicide among male physicians is 1.4 times the rate of men in the general population. The rate of suicide among female physicians is about 4 times the rate of women in the general population.
In general women attempt suicide more often than men but men typically die by suicide at a rate 4 times higher than women. Despite the gender difference observed in the general population, suicide rates among male and female physicians are roughly equal. When a female physician decides to end her life, she is more likely to use fatal means. Suicide is a leading cause of death for medical students and young physicians. The ACGME collected data on 381,614 residents in training during years 2000 through 2014. Between 2000 and 2014, 324 individuals (220 men, 104 women) died while in residency. The second, most prevalent cause of resident death was suicide (66; 51 men, 15 women). Rates of clinical depression among interns is 30% and 25% of interns report suicidal ideation. Only 42% of depressed medical students with suicidal ideation receive treatment.
Risk factors for suicide correspond to risk factors in the general population. The highest being mental health and substance use disorders, most common- ly, major depressive disorder, bipolar disorder, and alcohol abuse. Other factors include being divorced or currently having marital disruption, widowed, or never married. Having a good support system is essential for wellness.
The Sotile’s medical marriage report commented that compulsive personality traits widely heralded as key for profes- sional success, may lead to more distant relationships. They described divorce rates among physicians as 10-20% higher than the general population and highlighted that couples including a physician who remain married report more “unhappy” marriages.
Ross’ psychological study described the high-risk physician as having issues with depression, problems with alcohol and drugs, and access to means – being driven, competitive, compulsive, and taking excessive risks – being individual- istic, ambitious, aged over 45 women and over 50 men, and the graduate of a highly-prestigious school – experiencing non-threatening but annoying physical illness, self-destructive tendencies, guilty self-concepts, or changes in status (especially a threat to autonomy or financial stability).
On the outside people wonder why those who seem to have the closest access to healthcare don’t get the help they need. Barriers to treatment include, but are not limited to, both physician personality characteristics and very real concerns about the consequences of seeking treatment.
Most physicians have a need for control which makes it difficult to accept a patient role and ask others (especially other physicians) for help.
Many physicians are “wounded healers” whose personal experience with loss, abuse, trauma, and family conflict attracted them to a helping profession. A profession where perfectionism, compe- tition, self-denial and workaholic stan- dards rule. The Expectation to be available may lead to a sense of obliga- tion that makes it difficult to set appropri- ate limits without great guilt.
Physicians in training are pushed to endure chronic sleep deprivation which leads to cognitive impairment, emotional fragility, and isolation from support systems. The medical culture rewards long hours, taking on additional work without complaint, and self-neglect. Setting time limits is often perceived as lacking in professional commitment. Physicians in training are taught to practice “compassionate detachment.” Distancing themselves from patients and compartmentalizing feelings enhances the development of defense mecha- nisms that make it difficult to ask for help.
Doctors often get special treatment with fellow physicians. The treating physician may be less aggressive in their treat- ment and being a V.I.P. may increase a physician-patient’s own sense of shame and stigma.
More commonly, physicians try to hide their condition to protect their careers. Insurance concerns like malpractice and disability, hospital policies, and practices by state licensing boards may lead to sanctioning regardless of whether there is any evidence of impaired function. These practices, aimed at protecting patients, discourage physicians from seeking help by inappropriately identify- ing physicians who are proactively accessing mental health resources as impaired. The Federation of State Medical Boards, American Medical Association, American Psychiatric Association, and other specialty boards have unanimously recommended regulatory agencies refrain from asking questions about physician’s mental health yet the practice continues.
Some physicians postpone evaluation because they believe they are experi- encing expectable reactions to stress.
Suicidality is both treatable and prevent- able through better detection of depres- sion. Most people are symptomatic several years before death and there is a window of opportunity to prevent suicide. We must better recognize depression and suicidality in our patients, students, colleagues, and ourselves. Approximately 15% of individuals with severe major depressive disorder will die by suicide. Look for warning signs like a decline in job/school performance, higher rate of absentee- ism, inability to take customary care of their appearance, frequent complaints of aches and pains, expressing concerns of illness, becoming noticeably more withdrawn, irritable, or argumentative, marital and family conflicts, loss of sense of humor, and lack of motivation. The culture of medicine accords low priority to physician mental health. No culture has ever changed without continual force. We must systematically inform medical students about stressors they will be exposed to in their later practice, have open discussion of the stress encountered in a medical career, encourage daily self-care habits, stay connected with support systems, and encourage provision of discreet and confidential access to psychotherapy at all career stages. We must take a preventive approach and acknowledge suicide as an occupational hazard encouraging physicians to establish a therapeutic counseling relationship before they need it.
We must promote the implementation of practices like Dr. Angela Chen’s 3-step advice of preemptively making a safety plan that you can use, when you’re in crisis to avoid self-harm. Step 1 – Recognize what triggers you into crisis Step 2 – Recognize what it feels like to be in crisis Step 3 – Provide a list of resources, places you can go, and people you can comfortably talk to when you are in crisis – so you can reference this when the time comes.
We must ensure that licensure practices are nondiscriminatory and require disclosure of misconduct, malpractice, or impaired professional abilities rather than a diagnosis (mental or physical) and educate physicians, state licensing boards, hospitals, insurers, etc. about the public health benefits of encouraging physicians to seek treatment for depres- sion and suicidality. Physicians need safe havens where they can seek care without the fear of repercussions.
As we acknowledge National Physician Suicide Awareness Day, we must celebrate the lives and accomplishments of our departed colleagues regardless of the manner in which they died. Recog- nizing that, as one of the professions with the highest suicide rate, we are all at risk. Use terms like “died by suicide” and “completed suicide” rather than “committed suicide” or “successful suicide.” No one is committed to suicide. As healers, we are committed to ending pain and suffering for those we serve, and for ourselves. Check on your colleagues using the double tap method. Ask “How are you doing?” Pause. Then ask “How are you Really doing?” The follow-up invites time for deeper disclosure. Emphasize how much you respect them and help connect them to treatment. We must invest in our own healing, create our safe spaces, and put the oxygen on ourselves first. If we don’t stand up for one another. No one else will.
“Fill Your Cup. Serve from your overflow!” ~ Lisa Nichols Hall
