Published in the July 2018 issue of Today’s Hospitalist
SUICIDE AMONG PHYSICIANS, residents and medical students has long been seen as the result of individual shortcomings and viewed with shame and secrecy. In our experience, this global issue has also been a very personal one.
For one of us—Dr. Leung—it was a well-loved medical school classmate who died of suicide. In the years since his death, online profiles and photos have formed a digital shadow of his life, a lingering reminder. Social media push notifications from his friend and colleagues, particularly around his birthday, triggering memories of his humor and laughter.
For Dr. Pendarkar, I was 15 when my cousin, a second-year pediatrics resident, took his own life, the first of several physician suicides that would have a devastating impact on me.
Few physicians seek treatment, due in large part to profound stigma in the medical community.
Six months before my residency ended, my friend and co-resident killed himself. Since residency, three more colleagues have died of suicide. Others have broken down and openly said in shared workspaces that they want to kill themselves. And this spring in New York where I practice, a medical student and a resident died of suicide a week apart.
When asked, many physicians we know can name at least one colleague who has died by suicide. Their deaths ripple through our communities, and every new report of a physician suicide reopens old wounds that haven’t healed. What is driving these thoughtful, caring people to this end, and what can we do?
A culture of silence
As many as 400 physicians die by suicide a year. Each death has far-reaching consequences for individuals, families and communities, and physician suicide is truly a public health threat.
Studies from the late 1990s found that male physicians had a 12% lifetime prevalence of depression, while women physicians had a 20% lifetime prevalence.[2,3] In 2012, 37.8% of surveyed physicians screened positive for depression, and 6.4% endorsed suicidal thoughts within 12 months prior to the survey. A 2015 meta-analysis showed that almost one-third (28.8%) of residents had depression or depressive symptoms, a rate that increased with calendar year.
Lifetime prevalence of substance use disorders among doctors is 7.9%, compared to between 8% and 13% for the general population. Alcohol use disorders are higher, with about 12.9% of male physicians and 21.4% of female physicians meeting diagnostic criteria for alcohol abuse or dependence. Suicide risk is especially elevated in anyone with comorbid mood disorders and substance use disorders, and physicians are no exception.
Yet few physicians seek treatment, due in large part to profound stigma in the medical community. The culture of medicine continues to promote the physician as a “lone hero,” and physicians are still held to excessive standards. More than one-half of state medical licensing boards ask about mental health disorders in license applications in a manner not consistent with the American Disabilities Act. This exacerbates fears about seeking professional mental health treatment and promotes a harmful culture of silence.
Then there’s the real risk of burnout, with 45.8% of physicians reporting at least one burnout symptom: exhaustion, cynicism or dehumanization, and sense of ineffectiveness or lack of accomplishment. A 2010 study found an association among burnout, hopelessness and suicide risk. A position paper published this year reported that burnout-related turnover for hospital-employed physicians costs up to $1.7 billion a year and $17 billion for all U.S. physicians. The financial cost of each physician suicide, aside from the immense emotional burden, is an estimated $1.5 million.
Fortunately, dialogue about physician suicide and wellness is gaining momentum. The National Academy of Medicine is consolidating existing knowledge about wellbeing through its Action Collaborative on Clinician Well-being and Resilience. Among its initiatives, one is a knowledge hub with compiled references, toolkits and resources. And many health care organizations are targeting physician wellness to prevent burnout, beginning to confront systems-level problems as a source of burnout instead of blaming individual failings or lack of resilience.
Family physician Pamela Wible, MD, a powerful grassroots advocate who began a suicide hotline for physicians, has brought much-needed attention to physician suicide through social media and public speaking, including a TED talk.[14,15,16] Dr. Wible also partnered with Robin Symon, a writer and producer who directed “Do No Harm,” a documentary that chronicles the physician suicide epidemic. 
Michael Myers, MD, a frontline psychiatrist who treats physicians as patients, published a book on physician suicide that chronicled his perspective and those of physicians and their families. At State University of New York Downstate and internationally, he is a leading voice in raising awareness about mental health disorders and suicide among physicians.
Meanwhile, individual residents, attendings and others are starting their own initiatives. At The Brooklyn Hospital Center in Brooklyn, for example, internal medicine resident Ansi Hakkim, MD, with Dr. Pendharkar’s support, formed a group for residents that has successfully developed a resident wellness series and is open to all.
We are engaged in ongoing research into physician suicide, funded by the Arnold P. Gold Foundation. We’ve presented our initial findings from a literature review, and our next steps include publishing our final results and exploring means for measuring the impact of physician suicide and of factors like gender. We also want to highlight interventions that may effectively prevent suicide among students and physicians.
The demands on physicians are greater than ever, and supporting each other is essential. If you are in distress, please reach out to friends or family, or call the National Suicide Prevention Lifeline at 800-273-8255. Remember that you are never alone.
Tiffany I. Leung, MD, MPH, (email@example.com) is an assistant professor of medicine at the University of Maastricht in the Netherlands.
Sima Pendharkar, MD, MPH, (firstname.lastname@example.org) is an assistant professor of medicine in the Icahn School of Medicine at New York’s Mount Sinai and chief of the division of hospital medicine and medical director at The Brooklyn Hospital Center in Brooklyn.
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