When I learned the risk of suicide among doctors is the highest of any profession in the nation, including military service members, I was shocked at the lack of media attention. We lose about one doctor per day in the U.S. to suicide. The high levels of stress, lack of sleep, ease of self-medication, and reluctance to seek mental health treatment are among the reasons for these high numbers, but they are not the only reasons.

If you’re like me, you’ve been hearing recently about how physicians need to do more “self-care” to prevent burnout. This is being touted by health care organizations and administrators as something we have a responsibility to do, in order to prevent our own burnout. As if health care administration was not already a burden to physicians in a broken system that requires ever more paper work, charting, RVU counting, Maintenance of Certification hoops, standardized tests, quality improvement projects, 360 evaluations, and more.

Physicians are beginning to push back, as they should, at being told to do some yoga rather than having hospital administration participate in a meaningful conversation about how health care in our country has fallen off track. The doctor-patient relationship is no longer valued by those who pay the bills, or sadly, even by patients themselves who are told by Facebook “friends” that we are all in the back pockets of Big Pharma. This is so disheartening for those of us who genuinely chose to spend our twenties and thirties training to help people. But I’d like to make sure that as we push back against the “self-care” talk, we don’t forget about secondary post-traumatic stress.

Secondary post-traumatic stress is something most of us encounter and do psychological battle with every day in our jobs and training. This is the stress response that happens in your body when you hear the story or read the chart of someone who has been through a horrible tragedy. You can’t help but imagine what that was like, and then wade into the situation to provide support to the patient. This happens to law enforcement, first responders, counselors, therapists, clergy, and yes, doctors and nurses.

One silent, dark morning as I walked in the wee hours from one hospital to a neighboring one preparing for rounds as a medical student, I heard someone screaming, “My baaaby! My baaaby!” in the ambulance bay outside the ER. It was a gut-wrenching sound, and I could only imagine what had happened. I’m sure my heart rate quickened, and I had an emotional response. Should this make me cry in empathy? Or should I shut off my emotions and keep walking as if nothing had happened. I had to consciously bottle my emotions and keep going. I have also worked in a long-term care hospital for children, where a number of the children were admitted because of abuse or a terrible accident. One child had a heavy gate in a pasture fall on him. He laid there and was suffocated by the weight on his chest before he was found. Another baby was suffocated when her mother fell asleep while breastfeeding. When you hear stories like this every day and can’t help but imagine it happening to your family, you have a physical response to that knowledge, and you need to do something to bring your stress level back down.

Ironically, “self-care” is something we can do to keep our own stress responses, or cortisol levels, from becoming chronically high due to this constant exposure to stressful situations. Anything that helps reduce your cortisol response can help reduce or prevent secondary post-traumatic stress. Below are some examples ​of coping strategies:

• Exercise
• Mindfulness/Meditation - apps like Calm, Headspace, MoodTools, Abide
• Grounding exercises
• Tactical breathing
• Spending time with family
• Spending time with pets or animals
• Hobbies
• Gardening, hiking, time in nature
• Journaling - If you don't like to write a lot, you can write 3 things you are grateful for and 3 things you are looking forward to tomorrow. 
• Prayer
• Connecting with a faith community or church
• Talking to a colleague who understands 
• Humor, comedy 
• Make a plan for coping 
• Every day - exercise, mindfulness or prayer
• At work - talk to a colleague after your shift
• After work - spend time with pets or family, watch a comedy on TV 
• On days off - spend time in nature, attend church, work on a hobby

Psychiatrists have one of the highest suicide rates among physicians. That makes sense to me when I think about secondary post-traumatic stress. It is the nature of their job to empathetically listen to stories of personal trauma. But there are many other specialties or job situations that are also high risk. Those of us in helping professions are sometimes more likely to have survived Adverse Childhood Experiences or ACEs, which can have long term mental and physical health effects. It is important to know your ACE score and seek trauma informed mental health services to process any childhood trauma. A good resource to learn more about ACEs is www.TraumaInformedMD.com.

Physicians are also more at-risk during times of life transition – toward the end of medical school, toward the end of residency, near retirement, in planning for a family, etc. I’m going to bring up an elephant that is sometimes in the room. When a physician decides to work part-time in order to have a better work-life balance, especially those who are caregivers for young children or elderly family members, we need to be a support system as colleagues. We cannot support each other when we encourage systems of punishing a part-time colleague or a mother or father who uses their FMLA. We should not pressure those who have already set their boundaries to take on more and more work or to reduce pay and vacation. If you have an issue with your own workload then it’s likely time to set your own boundaries.

Let’s step up and look out for each other. Let’s encourage self-care and stress-relieving activities as a cultural norm. And let’s be aware of the resources available to us in the health care professions to access confidential mental health services and be ready to connect our friends to resources when needed. This is a really common problem, so a physician seeking mental health services should also be really common. It should not be a rare thing we are ashamed of. I once had to be evaluated for depression in residency just because I am not a morning person. Apparently, someone thought I looked grumpy in the NICU at 6 a.m., and rather than ask me if I was doing okay, they referred me to the residency director who had to have me evaluated! But really, 15-30 percent of residents do suffer from clinical depression at some time during their training.A good website with lots of links to more resources is The American Foundation for Suicide Prevention. www.afsp.org. Let’s help each other and not be afraid to reach out.

Dr. Shamblin is a Pediatrician and mom of 4. She completed medical school and residency at the University of Oklahoma. She now works for Kids 1st Pediatric After Hours Clinic and is the founder and editor of TraumaInformedMD.com and a member of the Board of Directors of the Oklahoma Health Care Authority and the Oklahoma chapter of the American Academy of Pediatrics. 

Illustration by Jennifer Bogartz