Leaders must watch for warning signs their stressed-out colleagues might exhibit, while providing more awareness through education and a greater emphasis on self-care.
Efforts to help health care leaders recognize suicidal behavior in physicians and other practitioners — and the factors that can lead to self-harm — are increasing as the industry strives to erase any stigma attached to seeking assistance.
“I get calls every single week from a hospital or medical school to see what they can do, so their physician population can get access to the best possible resources that are safe,” says Christine Moutier, MD, chief medical officer of the American Foundation for Suicide Prevention.
We will encounter all kinds of stressors, and some of us will be prone to depression. There’s no shame in that.
Christine Moutier, MD, chief medical officer for American Foundation for Suicide Prevention
Moutier says it starts by creating a culture of respect in which physicians feel comfortable receiving care for mental health conditions without punitive consequences. She says it’s a recognition that physicians are not immune to human frailties and that they need to support each other.
“We will encounter all kinds of stressors, and some of us will be prone to depression,” says Moutier, who practiced psychiatry and served as dean of a medical school. “There’s no shame in that.”
The suicide rate in the United States is at a 30-year high, according to a 2016 study by the National Center for Health Statistics. And while intense media coverage on celebrity suicides reportedly increases the number of calls to crisis hotlines, studies show the attention can also lead to a "contagion" effect and a spike in the number of people who take their own lives.
These statistical red flags are raised higher when focusing on physicians. A recent systematic literature review indicates the suicide rate among doctors is somewhere between 28 to 40 per 100,000 — or more than twice that of the overall population. The review was presented at the American Psychiatric Association’s May 2018 annual meeting.
“Our profession aims to make positive changes in the lives of others, and yet here we are, as physicians, dying in silence,” says Omotola T’Sarumi, MD, the review’s lead author and a third-year psychiatry resident at NYC Health & Hospitals/Harlem. “The passion to do our literature review came from this paradox.”
The investigators found that the most vulnerable physicians have inadequate support systems or are in transition — completing medical school, trying to obtain a residency slot or approaching retirement. Certain types of specialists — for instance, anesthesiologists and psychiatrists — are at higher risk. Other risk factors include being female, identifying as part of the LGBTQ community, having a history of mental or physical illness, and substance use, T’Sarumi says.
Taking such factors into account can help physician leaders identify groups or individuals who may be at risk for suicide. At NYC Health & Hospitals/Harlem, she says, an informal process encourages residents to offer peer support. Residents call it a “Code Lavender.” This process provides the attention and resources an individual needs before problems escalate. An appropriate intervention could consist of a session with a counselor through the employee assistance program.
In realizing the importance of physician suicide prevention, T’Sarumi says, many organizations are placing more priority on educating health care professionals about work-life balance, greater self-awareness and helpful resources. There is heightened screening of physicians for burnout as well.
“Discussions are leading to action,” says Zeina Saliba, MD, an assistant professor of psychiatry and behavioral sciences at the George Washington University School of Medicine and Health Sciences. For 24 years, the school has hosted the Seymour Perlin, MD, Grand Rounds endowed lecture, spotlighting major speakers on suicide research, treatment and mental health policy.
“Around the country, we are seeing that across the board there has been more of an emphasis on physician self-care,” Saliba says.
Medical schools are incorporating self-care into professional development curricula for students, physician residents and fellowship trainees. And they are teaching them to identify behavioral changes in their colleagues, she says.
In 2017, the Accreditation Council for Graduate Medical Education revised Section VI of its Common Program Requirements for residency and fellowship training programs to include an enhanced section on well-being. The revisions mandate that programs support residents with round-the-clock access to urgent and emergent care, confidential mental health assessment, counseling and treatment, says Timothy P. Brigham, MDiv, PhD, chief of staff and senior vice president of education.
ACGME-accredited institutions must educate residents, fellows and faculty members about fatigue management and mitigation. They must implement policies covering harassment and systems for monitoring and identifying any form of mistreatment, along with processes to resolve complaints in a safe and nonpunitive environment, Brigham says.
“The ACGME has been studying resident death statistics, burnout and depression for years, and has conducted research to better understand and address these issues,” he says.
To shed light on the magnitude and causes of resident deaths, the ACGME reviewed nearly 400,000 physicians who entered its accredited programs from 2000 through 2014. The results of the study, published in Academic Medicine in 2017, found that resident death rates were lower than in the age- and gender-matched general population.
The second most prevalent cause of resident death was suicide (66; 51 men, 15 women). Suicide is the leading cause of death in male residents, and the second most common for female residents. Most suicides (49 of 66; 74 percent) occurred during the first two years of training.
Physicians who are perfectionistic, lack external support networks and don’t take vacations might be particularly vulnerable, says Paul H. Earley, MD, DFASAM, president-elect of the American Society of Addiction Medicine and president of the Federation of State Physician Health Programs.
“They tend to see themselves as pushing through and ignoring symptoms and working harder in an attempt to bury depression, anxiety and emotional distress,” says Earley, who trained as a neurologist, observing that “suicide is the tip of the iceberg of other bad problems underneath.”
Susan Kreimer is a freelance health care journalist based in New York.