By Robert P. Granacher Jr., M.D., M.B.A.
Last fall a central Kentucky surgeon called his family and then killed himself on the roof of a small town surgery center parking garage. Like many depressed patients who complete suicide, he had seen a physician or therapist shortly before his death. It has been estimated recently that on average in the United States, as many as 400 physicians die by suicide each year (the equivalent of at least one entire average medical school class). Physicians globally have a lower mortality risk from cancer and heart disease relative to the general population, however, they have a significantly higher risk of dying from suicide. Even more alarming for our future is that, after accidents, suicide is the most common cause of death among medical students.
Statistically, physicians have a far higher suicide completion rate than the general public with male physicians dying at a rate 70% higher than the male rate in the general population. Moreover, female physicians attempt suicide far less often than their male counterparts, but their completion rate exceeds female suicides in the general population by 250 to 400%.
It is assumed by experts that suicide as a cause of death in physicians is underreported. This is most likely due to sympathetic colleagues who may skew the reporting, and thus the real incidence of physician suicide is probably higher than published statistics. The most common psychiatric diagnoses among physicians who complete suicide are depression, bipolar disorder, alcoholism and substance abuse, but physician rates of these diseases is much less than in the general population while the physician suicide rate is much higher. The most common means of suicide by physicians is lethal medication overdose or use of firearms. Thus, for we physicians as colleagues or as treaters of other physicians, it must be remembered that suicide does not occur in the absence of a cause or contributing factor.
Problems with Treating Our Physician Colleagues
It is common among physicians who attempt to treat physician colleagues to see them as special patients, and thus the treatment develops into the “VIP syndrome.” This is represented by superficial or inadequate treatment, excess concerns about confidentiality and the suicidal physician’s own concerns about medical licensure applications, renewed applications for licensure, and other intrusive questions that may be involved in the relicensure process. Most states, including Kentucky, have physician health programs that are advertised as independent of the medical licensing authority.
However, it is not unusual for a suicidal physician, who is contemplating or in need of psychiatric treatment, to be almost universally unaware of these provisions or to perceive a lack of confidentiality. Even more extreme for the ill physician is the discrimination toward physicians with a mental diagnosis. Health, disability, and liability insurance have been, and may be, denied to physicians who admit to depression, or treatment for depression, particularly if they have been suicidal. It is known that some application processes require physicians to answer intrusive questions about their mental health history and diagnoses, and in some cases these requirements may be out of compliance with the provisions of the Americans with Disabilities Act (ADA).
Those physicians treating medical colleagues for depression and suicidal ideation or behavior, should be aware that many physicians attempt to treat themselves. The evaluation and history should include questions to determine whether this is occurring, as in Kentucky and many other states, boards of medical licensure frown upon this behavior and they may restrict or suspend a physician’s license for engaging in such behavior when depressed. It is not unusual for physicians who are depressed and suicidal to be so concerned about the ramifications of treatment that they believe that self-treatment is their only personal-protective alternative.
Prospective medical students and residents rarely will report a history of a prior depression during the competitive selection interviews for positions. The prevalence of depression in these populations is unknown, but it has been estimated to be 15 to 30 percent. Harassment and belittlement by professors, higher-level residents or fellows, and even nurses, contribute to the mental distress of students and physicians in training, and aggravate depression. Job stress has been found to be a major factor in high rates of physician suicide (General Hospital Psychiatry, published online, November 15, 2014). This study by Katherine Gold, M.D., noted that physicians who die by suicide are much more likely than non-physician counterparts to have antipsychotics, benzodiazepines, and barbiturates found by postmortem toxicology, but not antidepressants. She notes that there needs to be a much greater effort to address the stigma of psychiatric illness and the under-diagnosis or treatment of depression among physicians, and for greater understanding in how the stress related to physician work can be modified or reduced. Mental health treatment for physicians and students must be made more available, safer and more confidential.
The Culture of Physicians as a Contributor to Suicide Risk
What is it about physicians that can make them their own worst enemy when suicidal from depression or abusing substances? Dr. Gary Carr, a Tennessee family physician and addiction specialist has noted five cultural contributors to the risk of suicide and avoidance of seeking help [Journal of the Mississippi Medical Association 2008:49 (10)]:
Persons who choose medicine as a career typically will not admit weakness or seek help. Physicians see themselves as “care givers not care receivers.”
As a doctor, “I can’t have a problem; I’m a doctor.” Physicians fear, often for good reason, that acknowledging a substance use disorder or a mental illness (e.g. depression) will adversely impact their career or medical license.
Mental illness and substance use disorders are stigmatized illnesses.
The Profile of the Physician at Suicidal Risk (Kaufmann, Ontario Medicine Review, 2000, 67:20-22).
- Male or female
- Male 50+, female 45+
- Married, single, divorced or with partner discord
- Depressed, substance abuse/dependence, workaholic, excessive risk-taker
- Change in status, threat to status, financial instability, increased work demands, loss of spouse or partner, loss of or threat to medical license
- Severe symptoms of loss, sadness, anxiety, pain or immobilization
What Can We Do?
As a profession, we must strike a balance between licensure regulation and protection
of the public’s interests. Most persons knowledgeable in the field of physician suicide see a nexus between the intrusive nature of the inquiry language of the recurring regulatory processes and the reluctance of physicians to disclose their health status or seek treatment for fear of risk to their careers. There must be absolute nondiscrimination in medical regulation, licensure, policies and practices. Misconduct, malpractice, or impaired ability must be disclosed but not a physician’s medical or psychiatric diagnosis. State physician health programs should be “put in a silo” with independent leadership and in no way be cross-linked to state medical licensure functions or physicians will not trust them and will not use them for voluntary treatment or advice.
We must examine our physician culture and in particular the “boot camp” mentality of
training medical students, residents and fellows, for it is here that the harmful tendencies of physicians to ignore seeking personal help when needed is born. We are training medical caregivers not marines. We must teach prospective physicians that they can’t effectively care for others if they do not also care for themselves. We must teach how to support our medical colleagues in the same fashion that we are taught how to provide compassionate care to our patients. For the suicide rate to decline in physicians, we must provide this same care and compassion to our fellow doctors as we provide to our patients and also encourage doctor-centered changes to the regulatory procedures of physicians with mental illness and substance dependence.
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