Physician Suicide

A friend of mine killed himself recently. I wouldn’t say he was a close friend, as such; the frequently discussed “beer after work” never quite materialised. This wasn’t through a lack of trying, though life always got in the way; but we had worked together over a number of years, published together and repeatedly put the world to rights over the course of long emergency department night shifts, and his death has hit me far, far harder than I would have expected.

He was a classic Type A personality; energetic, motivated and passionate with a work ethic that puts most doctors (a cohort seldom described as work-shy) to shame. Unfortunately he also carried some of the more negative personality traits of a Type A, not least of which was being eternally self-critical. There was no celebration of that achieved, but a continuous drive to improve on near-perfection. This ceaseless self-improvement is, in part, what enabled him to have such an amazing impact on the many patients whose lives he touched, but I’m certain it will have also contributed to his own death.

As an aspiring academic, I feel guilty; this is the bit where I should provide a carefully referenced, methodical review of the literature on physician suicide, but I just don’t have the energy. In any case, this is a drum that has been beaten to within an inch of its life on many occasions; a quick Google search will highlight the many heart-breaking personal stories of suicide or suicidal ideation amongst doctors ^1–3. It will also show that doctors are more likely to die as a result of suicide than other professionals ^4,5 and more than twice as likely to take their own lives than the general population⁶. Given the ever-rising number of women working in medicine, it is particularly horrifying that the suicide rate amongst female doctors is up to four times higher than the average ^6–8, and in one study suicide was the most common cause of death for young physicians (under the age of 39), accounting for 26% of deaths⁹.

It’s an unfortunate fact that doctors are far more efficient at killing themselves than non-physicians, with a significantly higher rate of completion ¹⁰. They also have an alarming propensity to suicidal ideation (6.3% of surgeons within the preceding year ¹¹, 25% of trainee doctors generally ¹²). However, this comes as no surprise when we realise that chronic sleep deprivation ¹³, depression ¹³, divorce ¹⁴, alcoholism ¹⁵ and substance abuse amongst doctors are notably more prevalent than in other walks of life ¹⁴.

Even more distressing, it would appear that it is entirely predictable which doctors are going to commit suicide even whilst they are still at medical school ¹⁶. It’s telling that a number of colleagues, when hearing the recent news, stated “He was just like Dr X”, another doctor who took his own life a few years ago. It would appear that we as physicians are adept at identifying the potential predictors of self-harm in our colleagues, even if we do not vocalise (or even recognise) them until after the event.

Many possible causes for the high rates of physician suicide have been hypothesised; a recurring theme appears to be a culture of perfectionism, exacerbated by a fear of medico-legal consequences should we ever fall short of this ideal ¹⁴. The 96 doctors who have killed themselves whilst undergoing fitness-to-practise investigations by the General Medical Council in the UK in the last eight years alone would appear to lend credence to this theory ¹⁷. It has been written that doctors live under a “tyranny of perfection”, with unrealistic expectations beginning before they have even qualified; medical students are asked to absorb an ever-expanding and immense body of knowledge larger than any human being can realistically acquire¹, and this contributes to some 10% of them contemplating suicide before they have even earned their degree certificates¹⁸.

Above all this, however, are the exponentially increasing levels of burnout being experienced by our physicians, especially those on the hospital’s “front line” ^19,20; is this any wonder when UK emergency departments can legitimately be described as war zones ²¹? Nearly 50% of emergency medicine trainees resign prior to completing training ²² and consultants are leaving the NHS at an alarming rate ¹⁹. Burnout has unsurprisingly also been associated with suicidal ideation ¹⁸, and is linked with unprofessional conduct, a lack of altruism ²³ and increasing rates of medical error ²⁴.

As Ofri observes: “When trying to help our patients achieve their best health, we would never steer them toward situations associated with relentless stress. We would never subject them to impossible-to-attain goals that lead to a persistent sense of failure. We would never prescribe anything with side effects of depression, substance abuse and suicide. Why would we allow this for ourselves or our trainees?” ¹

“A friend of mine killed himself recently.” As I wrote this, I couldn’t help reflecting on the terminology available to make that statement; it all seems so personal and accusatory, as if the act occurred in a vacuum with no possibility of external input. “Took his own life” is similarly critical. “Committed suicide” alludes to a criminal act (and indeed it was, at least in the UK until 1961) but there are so many other contributing factors that even the terminology’s implicit criticism only serves to alleviate the responsibility that must lie outwith the individual.

I happened to read a beautiful quote that cuts to the heart of this issue; I hope it has been attributed correctly:“I’m tired of people romanticizing overexertion. Exhausted is not the new chic, coffee (though a delicious necessity) is not a food group, and running on fumes is not admirable.  Why do we hold pedestals for sleepless nights, breakdowns, and inner turmoil? Are those really things to aspire to? Self-care. Balance. The ability to know when your body, mind, and spirit need to take a step back. Those are things we should admire. We have to stop blurring the line between ‘commitment’ and self-endangerment because too many people are burning out before they have a chance to truly shine.” ²⁵

This holds an even greater gravitas given the excellent conclusion to a paper by Miller et al. on the subject of physician suicide, written over 15 years ago:

“Finally, these changes will not be possible unless the current implicit definition of professional commitment and competence is challenged. Physicians need to accept the notion that professional competence allows for compassion towards other professionals and towards themselves. Recognizing distress in others, offering support and assistance to those in distress, validating the setting of appropriate limits by self and colleagues, and reducing the conflict between work and family life could all further the cause of addressing these concerns.To implement such changes will require institutional and personal commitment as well as a change in attitudes and expectations that pervade the profession. Initially, it may be difficult to endorse a model of professionalism that is not based on workaholism. Much thought and discussion will be required before an alternative conceptualization can be established that incorporates the essential elements of professional practice without requiring unhealthy self-neglect. However, given the detrimental consequences of a failure to do so and the potential for improving the lives of professionals if such an endeavor is pursued, we think it is time for this discussion to be taken seriously.” ¹⁴

So this is a call to arms. “Much thought and discussion” has indeed taken place over the 15 years since Miller et al. constructed the above paragraphs; as a profession it’s time for us to wake up to this problem, and to act. We need to stop idolizing damaging working practices; they’re not good for patients and they’re not safe for us. We need to be more self-aware, and we need to be there for our colleagues when their self-awareness fails. We need to applaud those who are able to recognise when they require a little help, and we need to be able and willing to provide that help, whatever form it may take, in surroundings devoid of judgment or professional/reputational consequence. We need to abandon the macho persona that is often evident amongst doctors, especially those in acute specialties, and embrace well-being initiatives, wellness drives, career sustainability interventions, psychological tool-kits and anything else designed to help us cope with the inevitable stresses and strains that come when your job involves seeing birth, death and every facet of human existence in between, within a single shift.

We need to do this because my friend died recently and it should never have been allowed to happen. We aren’t just implicated as a profession through passive inaction; we have contributed to his death through the perpetuation of unhealthy attitudes, impossible expectations and a tyranny of perfection.

It needs to stop. We need to do better.

References

1. Ofri D. The Tyranny of Perfection. Slate Mag. 2016
2. Anonymous junior doctor. By the end of my first year as a doctor, I was ready to kill myself. The Guardian 2016
3. Wible P. The scary reason 1 million Americans can never see their doctors again. qz.com 2016
4. Rosenberg H, Burnett C, Maurer J, Spirtas R. Mortality by occupation, industry, and cause of death: 12 reporting states, 1984. Mon Vital Stat Report, Centers Dis Control Prev 1993;42:1–64.
5. Frank E, Biola H, Burnett CA. Mortality rates and causes among U.S. physicians. Am J Prev Med 2000;19:155–9.
6. Council on Scientific Affairs. Results and implications of the AMA-APA Physician Mortality Project, Stage II. J Am Med Assoc 1987;257:2949–53.
7. Hawton K, Clements A, Sakarovitch C, Simkin S, Deeks JJ. Suicide in doctors: a study of risk according to gender, seniority and specialty in medical practitioners in England and Wales, 1979–1995. J Epidemiol Community Health [Internet] 2001;55:296–300.
8. Pitts FNJ, Schuller AB, Rich CL, Pitts AF. Suicide among U.S. women physicians, 1967-1972. Am J Psychiatry 1979;136:694–6.
9. Samkoff JS, Hockenberry S, Simon LJ, Jones RL. Mortality of young physicians in the United States, 1980-1988. Acad Med 1995;70:242–4.
10. Glaser G. Unfortunately, Doctors Are Pretty Good At Suicide. J. Med.2015
11. Shanafelt TD, Balch CM, Dyrbye L, Bechamps G, Russell T, Satele D, et al. Special report: suicidal ideation among American surgeons. Arch Surg 2011;146:54–62.
12. Valko RJ, Clayton PJ. Depression in the internship. Dis Nerv Syst 1975;36:26–9.
13. Rosen IM, Gimotty PA, Shea JA, Bellini LM. Evolution of sleep quantity, sleep deprivation, mood disturbances, empathy, and burnout among interns. Acad Med 2006;81:82–5.
14. Miller MN, Mcgowen KR, Quillen JH. The Painful Truth: Physicians Are Not Invincible. South Med J 2000;93:1–5.
15. Oreskovich MR, Kaups KL, Balch CM, Hanks JB, Satele D, Sloan J, et al. Prevalence of alcohol use disorders among American surgeons. Arch Surg 2012;147:168–74.
16. Epstein LC, Thomas CB, Shaffer JW, Perlin S. Clinical prediction of physician suicide based on medical student data. J Nerv Ment Dis 1973;156:19–29.
17. Davies M. GMC launches internal review of suicides among doctors facing fitness-to-practise investigations. Pulse 2013
18. Dyrbye LN, Thomas MR, Massie FS, Power D V, Eacker A, Harper W, et al. Burnout and Suicidal Ideation among U.S. Medical Students. Ann Intern Med [Internet] 2008;149:334–41.
19. Hassan TB, Ben W, Magnus H, Fiona R. Stretched to the limit. London: 2013.
20. Shanafelt TD, Boone S, Tan L, Dyrbye LN, Sotile W, Satele D, et al. Burnout and Satisfaction With Work-Life Balance Among US Physicians Relative to the General US Population. J Am Med Assoc 2012;172:1377–85.
21. Ahsan S. On the NHS frontline: “being a doctor in A&E is like being a medic in a war zone.” The Guardian 2014
22.  The King’s Fund. What’s going on in A&E? The key questions answered. 2016
23. Dyrbye LN, Massie FSJ, Eacker A, Harper W, Power D, Durning SJ, et al. Relationship between burnout and professional conduct and attitudes among US medical students. JAMA 2010;304:1173–80.
24. Shanafelt TD, Balch CM, Bechamps G, Russell T, Dyrbye L, Satele D, et al. Burnout and medical errors among American surgeons. Ann Surg 2010;251:995–1000.
25. Amanda. I’m tired of people romanticizing over-exertion [Internet]. runningmandz.tumblr.com 2015 [cited 2016 Apr 6]

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