Physician suicide is an issue close to my heart. In medical school two of my classmates died from suicide. Later on, in pediatrics residency, I myself became suicidal. This topic touches all physicians in one way or another. Here’s how it touched me.
But first, some facts. Physician mental health problems are ubiquitous. An American Foundation for Suicide Prevention Factsheet lists that 300 physicians die from suicide each year. I feel this is likely an underestimate, as often suicides are not identified as such. Compared to the general population, male physicians have a suicide rate 1.41x higher, and female physicians 2.27x higher. A survey discussed in this factsheet found that 28% of residents meet criteria for depression at some point in their training versus the general population rate of 7–8%. Compounding the problem is that physicians and trainees are less likely to seek mental healthcare compared to the general population. And due to their medical knowledge, when physicians are suicidal, their methods are often lethal.
My medical school had a robust mental health program. There was a dedicated psychiatrist for medical students who was not involved in psychiatry rotations or evaluations. There was a peer advising program, too. Despite this, two students died by suicide. Though I’m not privy to the details of their situation, I know there were warning signs in both cases. One had an unsuccessful attempt a couple weeks before the final attempt. The dean expressed to us, the survivors, that the school tried to reach out to both students, but they refused help and couldn’t be reached.
During my residency, the issue of mental health became personal. Pediatrics isn’t all giving children stickers and blowing bubbles. Terrible things happen to children sometimes, and pediatricians and parents are front-seat witnesses. My own experience with severe depression occurred in my second year of residency. One night, during hematology-oncology call, I was in the hospital with a young boy who was undergoing a brutal chemotherapy protocol. He was in pain and had terrible rigors. His parents were sleeping and oblivious to his suffering. I was keenly aware of the torture that was going on in the name of medicine and made numerous calls to my attending, who was at home. I asked for medication ideas to help the patient feel better. Over-the-phone support wasn’t quite adequate, and I hoped the attending would come in and help. Ultimately, he didn’t, and I was left to deal with the patient’s suffering — inadequately, in my mind. I felt like an unwilling party to medical torture of a child.
Shortly after, I was in my ER rotation, experiencing changing shifts, late nights, and awful sleep. An infant was flown in who had suffered a terrible accidental trauma. It was a small ER; there was only myself, the attending, an ER resident, and a nurse. We did our best, but we knew there was no hope. This was not a survivable injury. In the end, the parents withdrew care. Everyone was emotionally devastated: ER staff, anesthesia staff, the neurosurgeon. Because I needed to stay in the ER, I couldn’t attend a debriefing in the OR. Relatively alone, tired, and unsupported, I found it difficult to deal with the incident. Years later, I still have flashbacks to that night. Empathy and compassion bring people to the field of medicine, yet, at the same time leave us vulnerable to the traumas we witness.
Soon after that night, my depression grew worse. It was a long, dark winter when the snow never seemed to end. Trauma after trauma stacked up, and I sunk into depression. That’s when I created an elaborate plan. I had a shoebox of pills — as a physician I knew what combinations and doses would do the job. I planned to drive to an isolated beach near a narrow, deep, swift-moving ocean inlet, take the pills with copious alcohol, and walk into the current. On a rare day off, I was sitting with the pills and instead decided to call a friend. He came and took the pills from me. I called the on-call psychiatrist, a person I’m reasonably certain formerly rotated in the pediatric ward with me. I was able to get help and recover. Altogether, I never missed a day of work, and I never told my program.
I did, however, find that the barriers to seeking care are tremendous. I saw a mental health provider at my own hospital, since I couldn’t go elsewhere. This resulted in me having to share my mental state with a co-resident who was on call— a total loss of confidentiality. Seeing a provider at your own institution is difficult. It’s hard enough to schedule appointments as a resident due to limited free time. Am I supposed to stop in the middle of an admission and announce “Time to go. I have a shrink appointment.” I had to lie about my whereabouts and try to schedule appointments when I could more-reliably slip away. Many medical schools have dedicated mental health providers for students. Most residencies, on the other hand, don’t.
There remains a tremendous stigma about admitting you need help. There are professional consequences, too. Some state licensing boards inquire about mental health treatment and put such care under scrutiny. My current employer required me, under threat of termination, to disclose all my medications and reasons of use. A hospital across town has requested psychiatrist records from new hires. With challenges like these, many physicians never seek care, or they seek care paying cash to avoid any record. This is possible for attendings with income to spare but not for residents who have limited means.
Physician suicide is an epidemic. Our compassion and empathy leave us vulnerable. The stressful work conditions and sleep deprivation add to the risk. We see numerous traumas that we cannot share with others, yet there are tremendous barriers to seeking care. Sadly, suicide is seen by too many as the answer. There needs to be a comprehensive overhaul of mental health care of providers. These barriers and stigma must be removed. Lives are at stake.
