10 Steps to Prevent Physician Suicide for 2019

Each year, the graduating classes of three average size medical schools don’t add a single physician to the US workforce; they simply replace the 300 to 400 physicians the American Foundation for Suicide Prevention estimates kill themselves each year. We lose a doctor a day to suicide.

In a recent blog post a healthcare CEO asked, “Is the rate of physician suicide statistically different from that of other highly paid professionals?” Yes.

The American Psychiatric Association reported that physicians have the highest suicide rate of any profession at their annual meeting in 2018, higher in fact than active duty military personnel.

The same is true for Finland, Norway, Australia, Singapore and China.

The time to prevent physician suicide, rigorously document its occurrence, remove the stigma of seeking mental health care and to care for suicide victims’ workplace survivors is long overdue.

Physicians know how to stay healthy. This is why it is especially tragic that the only cause of death where the risk to physicians is higher than the general public is suicide.

Worse, we’ve been aware of this slow motion tragedy for generations and it is largely preventable. S. Dana Hubbard, M. D., Director, Bureau of Public Health Education, New York City Department of Health published the fact that physicians lead the list of suicides by professions in the American Journal of Public Health, in 1922.

Almost a century later mystery still shrouds the exact number of physician suicides each year as families and employers alike are reluctant to tell the truth in public, due to the fear of stigma. Medical examiners may have difficulty distinguishing intentional from unintentional traumatic deaths. Even when a suicide is accurately determined, there is no consistent reporting of the victim’s occupation.

Most experts agree the physician suicide rate is roughly twice that of the US population in general, and it is even worse for female physicians. A meta-analysis of physician suicide published in the American Journal of psychiatry demonstrated that both male and females physicians are more likely to die by suicide compared to the general population (1.41 times more likely for male physicians and 2.27 times more likely for female physicians).

The US healthcare system is killing physicians.

Students and young Physicians have been documented to be actually more resilient and less depressed than the US average. Then we are subjected to stress, moral distress and trained to ignore the symptoms of depression until it is too late. A study published in the Archives of General Psychiatry demonstrated that the rate of depression among physicians immediately prior to entering internship was 3.9%. During internship, this rate skyrocketed to 25.7%.

Factors contributing to the epidemic of physician suicide include:

1. Repetitive exposure to death and dying
2. Exact knowledge of (and ready access to) lethal means
3. Stigma associated with asking for mental healthcare and
4. Our profession’s excessive dependence on self-reliance.

While the first two factors above are likely inherent to the profession, the latter two factors driving suicide are amenable to mitigation.

Here are Ten Suggestions for 2019:

1. Put an end to the silent curriculum (“Don’t ask for help. Never show weakness.”) in physician training programs.

Part of the reason physicians don’t ask for help is that in training we were taught the unwritten rule: “Don’t ask for help and never show weakness.”

On my first day of surgical internship, I was naturally a bit apprehensive, given the enormous privilege and responsibility I was about to be given, caring for, and operating on some of the most ill patients in one of the finest academic medical centers in the US. I was shocked and taken aback by the advice the entire group of us surgical interns were given by the senior attending surgeon, tasked with orienting us. He said, “Always remember that while you are here… you are swimming with sharks. So don’t make waves, and if you are bit, don’t bleed.” It is this kind of abusive attitude which I am confident cost one of my female classmates her life, during her surgical residency when she killed herself halfway across the country in another surgical training program.

We must incorporate wellness into both the written (and silent) curriculum.

2. The Physicians need better access to mental health care without fear of punishment for admitting they need help.

Dr. Michell Hardison, a well-respected family doctor in Raleigh NC chose suicide over psychiatric care for his depression. His daughter Anna Hardison Severn revealed, “He was 100% positive that if he came forward and said he needed help that there would be a reprisal of some kind.”

State medical boards are responsible for licensing physicians and protecting the public by ensuring physicians meet high standards. There is nothing wrong with medical boards asking physicians if they have a medical or psychiatric condition which might lower the quality of the care they deliver. They should not however ask if a physician has ever been under the care of a mental health professional. For if they do this, physicians will forgo needed care which could harm the doctor and jeopardize the quality of the care for their patients.

The Federation of State Medical Boards (FSMB) Workgroup on Physician Wellness and Burnout made 35 recommendations to better address physician burnout. These recommendations should be adopted by all states. They advise against asking probing personal questions regarding a physician’s mental health. The FSMB specifically recommended that state medical boards indicate“it is not only normal but anticipated and acceptable for a physician to feel overwhelmed from time to time and to seek help when appropriate.”

3. Not only should the electronic medical record must be optimized, but processes and systems must be optimized in order to get the most out of this technology and improve user satisfaction.

How it is that healthcare is the only industry where digitization/computerization has decreased worker productivity? The epidemic of physician burnout, driven by administrative hassles, loss of professional autonomy and increasing workloads is contributing to physician burnout, depression and suicide.

It is inexcusable that for every hour physicians spend facing a patient in their office, they are forced to spend two hours tending to desk work and documentation in the electronic medical record.

At UC Davis Medical Health, Scott MacDonald, MD, FACEP demonstrated that by optimizing their electronic medical record’s use, the health system could both dramatically increase physician satisfaction with their EHR and improve their quality of life. They were able to eliminate over 25 hours of unproductive, unnecessary busy work from their physicians’ schedule each month! Imagine how much more time physicians could spend meaningfully caring for their patients and achieving work life balance if this innovation were to be adopted nationwide.

4. Stop the stigma. Employers of physicians, including hospitals, physician groups and residencies must encourage and normalize accessing mental health care.

We must destigmatize and treat physician depression in order to prevent suicide. One study found that access to residency positions was limited for fully qualified students who had requested psychiatric counseling! Only when seeking out a councilor is considered “normal” will physicians ask for help when they need it. All too often, physicians are encouraged to keep vulnerabilities hidden and not ask for help.

5. The practice of requiring medical students and residents to obtain mental health care at their own institution limits confidentiality and should be eliminated.

Until the stigma of obtaining mental health is completely relegated to the ash-bin of history, the confidentiality of accessing such services is critical, particularly for physicians in training. Some student and resident health plans require trainees to obtain healthcare at their own institution, limiting confidentiality for both physical and psychiatric conditions. This paternalistic and antiquated requirement should be eliminated.

6. Peer support should be available at times of great vulnerability:

Medical errors, patient injuries and patient deaths are obviously painful for the patient’s families. Less well understood is the fact that physicians also suffer emotionally in such circumstances, particularly if they believe they have somehow failed their patient and begin to second-guess their own competence.

In times of great stress, such as these or when facing a medical malpractice lawsuit, physicians are extra vulnerable to depression and suicide. It is at these times that confidential peer support, advice from a colleague who has endured the same stressor is most helpful. Employers should plan ahead for such events and offer well-structured and readily available confidential peer to peer support programs to their employed and affiliated physicians.

7. We must accurately keep track of suicide rates by profession. State medical examiners should record the occupation of all suicide victims, including what school they are attending if they are in college or graduate school.

Only then can we identify opportunities for improvement and evaluate whether our interventions are effective in stemming the tide of this horrific slow motion tragedy.

This would capture both the number of physicians / medical students who are committing suicide, and also spotlight any outlier institutions.

8. Postvention: Care for the bystanders after a physician suicide is essential.

Post-suicide counseling and peer support is especially important after a colleague has committed suicide. Toolkits such as the American Foundation for Suicide Prevention’s toolkits are available on line. There is even a toolkit specifically designed for medical schools to utilize after a medical student suicide.

9. Encourage all physicians to select their own trusted primary care physician (and regularly check in with that physician).

All too often physicians follow the dictum, “physician heal thyself.” Employers and affiliated institutions should encourage all medical students, residents and practicing physicians to choose their own trusted primary care physician. In addition to obtaining objective evidence based care from a personal physician, these trusted doctors represent another touch point from which distressed physicians can obtain emotional support.

10. Accessing medical care, whether physical or psychiatric, should be modeled by mentor physicians.

Organizational leaders should model self-care, access mental health care publicly and publicly reinforce the necessity of a healthy work-life balance.

Together we can end the epidemic of physician suicide. Let’s make it happen in 2019.