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Medicine grapples with physician suicide

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Shame undermines therapeutic alliance

As a specialist in physician health, I shout out that we can never have too many articles on this heartbreaking tragedy that claims so many lives each year - and leaves so many devastated people in its wake.

Dr. Michael F. Myers

It is sobering and frightening that despite the excellent institutional and systemic changes outlined by Dr. Reynolds and Dr. Moutier and the moving first-hand testimonials of Dr. Bright and Dr. Wible, despairing doctors continue to die by their own hands. The loss of so many intelligent, highly trained, and compassionate caregivers is mind-numbing and unconscionable. We cannot afford to let down our guard.

As part of my research for a book in progress "When Physicians Kill Themselves: The Voices of Those They Leave Behind," I have been interviewing the family members and medical colleagues of doctors who have died by suicide.

One theme that is ascendant is how commonly the ailing physician has fallen through the cracks. Initially, he may not recognize or accept that he is burned out, depressed, or abusing alcohol and other drugs. When she does begin to understand what her symptoms suggest, the internalized stigma is so harsh and relentless that seeking help is out of the question. This drives self-medicating, but even when this does not occur and he consults a psychiatrist, punishing shame colors and works against forming a therapeutic alliance, accepting the diagnosis, keeping appointments, disclosing dangerous suicidality, adhering to medication, engaging in lifesaving psychotherapy and maintaining (or regaining) hope. 

What makes matters worse is when the treating professional cuts corners (or enables self-defeating behaviors in the patient) and does not use the same judgment, monitoring, and vigilance that she uses with her nonphysician patients. 

What I have found most disturbing in these narratives of my interviewees is how often their attempts to access their loved one's caregiver have fallen on deaf ears. This has to stop. 

Dr. Wible says that she "had an epiphany" and changed the way she practiced medicine. It is our duty to reach out and help more physicians find their epiphany.
 
Dr. Michael F. Myers is professor of clinical psychiatry at SUNY Downstate Medical Center in Brooklyn, N.Y. He also is the coauthor (with Carla Fine) of "Touched by Suicide: Hope and Healing After Loss" and (with Dr. Glen O. Gabbard) of "The Physician as Patient: A Clinical Handbook for Mental Health Professionals."


 

References

One day in 1986, a medical school classmate handed Dr. Robert P. Bright a gun that she intended to use to kill herself. She asked him to hold on to it for her and to keep quiet about her sense of hopelessness.

“She didn’t want anybody in the medical school to know; it was all hidden and hush-hushed,” recalled Dr. Bright, who is now a psychiatrist at the Mayo Clinic, Scottsdale, Ariz. “I was trying to juggle that with the issue of safety.”

He honored his classmate’s request for confidentiality, but he sought advice from the medical school dean about what to do. Before long, his classmate sought help from a psychiatrist and got better with medication and psychotherapy. “It turned out well, thank goodness,” Dr. Bright said.

Dr. Robert P. Bright
Dr. Robert P. Bright

Similar stories of despair among medical students and physicians don’t always end well. The American Foundation for Suicide Prevention estimates that 300-400 U.S. physicians commit suicide each year, about one per day. Suicide deaths are 250%-400% higher among female physicians, compared with women in other professions, and 70% higher among male physicians, compared with men in other professions. Major depression is a common risk factor, along with bipolar disorder and substance abuse.

<a href="http://polldaddy.com/poll/8633862/" external="1">Has a colleague ever mentioned to you that he or she were having suicidal thoughts?</a>

Depression and other mood disorders may be underrecognized and inadequately treated in physicians because they may be reluctant to seek treatment, may attempt to diagnose and treat themselves, or may seek and receive “VIP treatment” from health care providers, according to a review article coauthored by Dr. Bright (Current Psych. 2011;10:16-30).

“Physicians struggling with these things are very much in the closet about it,” he said. “It’s a sad reflection on the stigma that’s still in our country that people can’t come forth and say, ‘I’m struggling with depression or anxiety.’ ”

Researchers led by Dr. Katherine J. Gold at the University of Michigan used data from the National Violent Death Reporting System to evaluate suicide among physicians and found that job stressors “may impact physician identity and be a particular risk factor for which more attention is warranted” (Gen. Hosp. Psychiatry 2013;35:45-9).

Work dissatisfaction sent Dr. Pamela Wible into a tailspin early in her career. In 2004 she found herself in a suicidal state for about 6 weeks, “I stayed at home, crying myself into my pillow and I never sought help from my colleagues,” recalled Dr. Wible, a family physician in Eugene, Ore., who currently leads training sessions in medical student and physician suicide prevention. “I was not depressed before entering the medical profession, but [I had developed] constant thoughts of ‘Can I just disappear? What’s the easiest way to do this?’ I got to a place of complete surrender but I didn’t have the gun. I didn’t have the stockpile of pills. I didn’t have a follow-through on the plan.”

Dr. Pamela Wible
Dr. Pamela Wible

Instead of taking her own life, she “had an epiphany” and changed the way she practiced medicine. She said that owning her own clinic empowered her to “become the doctor I had originally described on my personal statement when I entered medical school.”

According to Dr. Charles F. Reynolds III, a psychiatrist at the University of Pittsburgh, reluctance to seek treatment can also be driven by concerns about the amount of time that treatment could take.

“As physicians, we often don’t appropriately take care of ourselves when it comes to issues like depression,” said Dr. Reynolds, who also directs the National Institute of Mental Health–sponsored Center of Excellence in the Prevention and Treatment of Late Life Mood Disorders. “We may still see it as a character weakness rather than as a medical illness that can be diagnosed and appropriately treated. Concerns about privacy also figure into the concerns of some physicians as well.”

Practicing in a rural area or small community can also be an obstacle to treatment, not only because of limited access to psychiatrists, but because the “patient” may be the only physician in town.

“As much as there’s stigma for everybody being voluntarily or involuntarily admitted [for suicidal ideation], it’s a little different when you’re a provider within the hospital where you’re seeking care,” Dr. Bright noted.

He said that if he had the opportunity to counsel physicians experiencing suicidal thoughts, he would “remind them of the medical nature of depression, that the brain is just another organ and the organ is not making chemicals just like the pancreas doesn’t make insulin in diabetes,” he said. “I’d also encourage them to get the treatment that they need. I would encourage compassion for themselves that they would give to anybody else in the same situation.”

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