Healing the Healer: How to Handle Physician Suicide
There’s a painful fact about medicine today, one practitioners and healthcare organizations are often hesitant to talk about: Physicians choose to end their lives at a rate of around twice the rest of the general population.
Exact numbers are hard to come by because of inaccurate or misleading cause-of-death coding and likely under-reporting. According to one study, for white male physicians in the United States the suicide rate is 1.87 times higher than in the general population, and for their white female counterparts it’s 2.78 times higher. America loses about 400 physicians a year to suicide.
“Patients feel the ripple effect, too,” writes Matt Hoffman and Kevin Kunzmann in MD Magazine. “Statistics show that the average physician in the United States is responsible for 2,300 patients. The more patients a doctor sees, the more the absence is felt when the physician is gone. The annual 400 physician suicides translate to almost 1 million patients losing their doctors to suicide each year.”¹
44% of physicians surveyed claim they feel the effects of burnout daily (www.advisory.com)
15% of physicians report substance abuse as a norm (www.mdmag.com)
2 out of 3 physicians who are experiencing depression say it affects their work (www.medscape.com)
2nd only to “accidents,” suicide is the leading cause of death among 24- to 34-year-olds in the nation (www.acgme.org)
1 physician dies by suicide every day, on average (www.mdmag.com)
Suicide is a vexing problem for psychiatrists and other health professionals who assist those in need, not least because, as Ronald Groat, MD, points out, “there are a multitude of factors which can contribute to it.”
Groat, a psychiatrist and peer coach for physicians, notes “Unfortunately, no one knows how to predict and prevent suicide. First of all, medicine has always been inherently stressful. Practitioners are dealing with illness, with life and death. But today we have to add to those stresses the many stresses of contemporary medical practice which can lead to burnout.”
These include demands for productivity, the charting challenges of electronic medical records, changes in the administration of healthcare organizations, sleep deprivation and others. Personal factors like family, finances, and his or her own health contribute, too.
“But the biggest factors pushing a physician from burnout—which doesn’t necessarily lead to suicidal thinking—toward the consideration of suicide are probably unnoticed and undiagnosed depression and substance abuse,” Groat says.
The American Foundation for Suicide Prevention supports his view: “Among physicians,” they write, “risk for suicide increases when mental health conditions go unaddressed, and self-medication occurs as a way to address anxiety, insomnia or other distressing symptoms. Although self-medicating, mainly with prescription medications, may reduce some symptoms, the underlying health problem is not effectively treated. This can result in tragic outcome.”²
Any description of the problem is incomplete if it leaves out the intense, sometimes demeaning, pressures of medical education and the traditional expectation for physicians to work long hours with little rest. “Harassment and belittlement by professors, higher-level trainees and even nurses contribute to mental distress of students and development of depression in some,” write the authors of a report on physician suicide on Medscape.³ And the physical and mental demands made on physicians in contemporary medicine have led one prominent physician suicide researcher and activist, Pamela Wible, MD, to claim physicians’ human rights are being violated. 4
Complicating the picture is the deep identification physicians have with their profession and the resulting perfectionism. “Physicians are more likely than others to see their job as integral to their identity,” Katherine Gold, MD, MSW, a mental health researcher and assistant professor of family medicine and obstetrics and gynecology at the University of Michigan tells ACP Hospitalist. “If something happens to threaten [their] identity, such as a mistake or a patient dying, they could be at risk for depression or suicidal ideation,” said Gold. 5
There’s the additional issue of the stigma depression and other mental illnesses carry in our society and the struggles working people face in finding the time and opportunity to seek care—problems physicians share with other Americans. “But doctors have added burdens around confidentiality and fear of discrimination when it comes to licensing and applications for hospital privileges,” notes Carolyn Crist in an article in Reuters Health. 6
What Organizations Can Do
Given the complexity of the problem and the challenges of prediction and prevention, what can be done? “First, focusing on spotting and addressing burnout is paramount,” says Groat. “This is where the organization can make the biggest difference.”
The VITAL WorkLife and Cejka Search Physician Stress and Burnout report details the institutional measures physician respondents favored most for reducing burnout, including better work/life balance, reduced legal/malpractice concerns, better work hours/less on call, more control over work and the way it’s done, and more help with administrative burdens or demands. 7 Further, Groat underlines the need for creating a culture of openness to physician concerns, communication, and follow-up when concerns are voiced.
At the same time, Christine Moutier, MD, chief medical officer for the American Foundation for Suicide Prevention, notes in an article in ACP Hospitalist how organizations can help prevent physician suicide by creating a culture eliminating the stigma out of mental health issues and treatment for physicians. Burnout, depression, and addiction in the medical community need to be discussed openly and there need to be resources available for physicians in trouble. 5
The Role of Colleagues
As for how colleagues can help physicians who may be at risk, Groat recommends noticing personality changes indicating burnout or even deeper trouble. “Are they beginning to isolate or withdraw, are they showing sadness?” he says. “Are they treating patients differently, becoming critical of them, less patient? Can you simply sense there is something wrong?” They may be taking less care of themselves and appear disheveled. And, he notes, colleagues are required by law to report a physician with alcohol on his or her breath.
If a physician is concerned about a colleague, Groat recommends what he calls “the soft sell” as the first approach. “You can simply express concern by saying something like ‘you seem a little silent these days. Is everything okay?’” Engaging in a conversation may be the first step in getting help for a physician at risk.
Wible warns, however, that a troubled physician at risk for suicide may not show signs of depression. “‘Happy’ doctors are dying by suicide,” she writes on Medpage Today. “Many doctors who kill themselves appear to be the most optimistic, upbeat, and confident people … Some of the happiest people—especially those who spend their days making other people happy—may be masking their own despair.”8 The difficult truth underlines one of Groat’s major points of emphasis: “It may be only a colleague who knows a troubled physician very well who can spot signs of trouble.”
Openness in the Aftermath
On the very sensitive topic of how to deal with the aftermath of a suicide, Groat recommends openness—if the physician’s family agrees. “The family’s wishes need to be respected at every stage of transparency,” he says. “But if they agree, being open about the suicide and discussing it can greatly reduce the likelihood of ‘copycat’ decisions by others, which can be a real danger as the news of the suicide spreads through word of mouth.”
He suggests the discussion begin in the physician’s department. It can then expand to the institution as a whole, and even out into the wider community—again, only if the family consents. “An open discussion can be a powerful way to reduce the stigma around mental health issues in general and suicide in particular,” he says. “And far from damaging the reputation of the organization, it can enhance it by showing the community the organization cares about its staff and is willing to engage with this important problem.”
Hard to predict and prevent, devastating in its impact, physician suicide challenges medicine to meet its responsibility to “heal the healer” by being caring, proactive, and honest.
Support can be found by contacting the National Suicide Prevention Lifeline: 800-273-8255.
- Hoffman, Matt; Kunzmann, Kevin. “Suffering in Silence: The Scourge of Physician Suicide.” HCP Live Network. Feb. 5, 2018. mdmag.com/medical-news/suffering-in-silence-the-scourge-of-physician-suicide
- American Foundation for Suicide Prevention. “10 Facts about Physician Suicide and Mental Health.” acgme.org/Portals/0/PDFs/ten%20facts%20about%20physician%20suicide.pdf
- Andrew, MD, JD, Louise B. “Physician Suicide.” Medscape. Aug. 1, 2018. https://emedicine.medscape.com/article/806779-overview#a4
- Build a Culture Optimal for All - March 4, 2020
- Healing the Healer: How to Handle Physician Suicide - September 11, 2019