Physician Suicide: Stigma Still Holds Sway
‘The next thing they know, he’s dead’
Like so many stories of suicide, this one begins with a haunting memory and an unanswerable question. Why would a young student,“Bill,” having passed the rigorous tests and trials to get into medical school and about to begin the education and career that is his seeming life’s purpose, go home for Thanksgiving break and kill himself?
One of the student’s roommates was shocked by the event, and in the aftermath of awkward silence and stifled grief, he saw firsthand how stigmatizing suicide is among physicians. It made a life-long impression.
Today, Michael F. Myers, MD, is the author of a recently published book, Why Physicians Die by Suicide: Lessons Learned from Their Families and Others Who Cared. Myers treats physicians and medical students as part of his practice as a professor of clinical psychiatry at SUNY Downstate Medical Center in Brooklyn, NY.
The American Foundation for Suicide Prevention (AFSP) estimates that some 300 to 400 physicians kill themselves every year, Myers notes in his book. Male physicians kill themselves at a slightly higher rate than men in the general population, but female physicians die by suicide at a rate of two to three times that of other women.
“To some degree, the higher-than-average rate for women physicians could be explained by some of the same gender inequalities that we see in the general population,” Myers wrote. “Although women account for approximately half of all medical students and residents today, there remain vestiges of institutional sexism in our medical centers.”
Of note, male and female physicians have a very similar suicide rate, in contrast to the general population where men are four times more likely to die of suicide than women. Thus, being a doctor seems to trump gender to some extent for women, but other elements of the female persona may make them vulnerable to self-harm.
“We know that women in medicine tend to ‘give more’ to their patients, which translates to spending more time with them and addressing their psychosocial issues more than men in medicine usually do,” Myers says. “It is possible that these particular qualities, while obviously good for their patients, do not necessarily serve women well when coping with the day-to-day realities of [practice].”
Employee health professionals are well-positioned to raise awareness of this issue. Hospital Employee Health asked Myers to discuss some of the themes raised in his book about physician suicide.
HEH: You describe a profound sense of stigma among the many issues you raise on physician suicide. Is this book, and encouraging more open conversations about suicide, a way to overcome this stigma?
Meyers: Yes, just the title of this book for some people is a shocker. In the healthcare field certainly people know more about this, but in the general interviews I have done it often starts with, “We had no idea that physicians might actually be at risk of taking their own lives. We’ve just never really thought of that sort of thing.” That gives me an opportunity to explain that we are human — like everyone else. For various mental health reasons, we can be a risk to ourselves.
The second thing is when doctors themselves tell their stories about this, it has a huge impact. Whenever I read an article — whether it is in a newspaper, a magazine or a medical journal — where a physician is disclosing that he or she has been treated for alcohol or depression or bipolar illness, I try to get their email — some way of reaching them — and thank them for doing that. Not only do these stories reduce the stigma, but they make it easier for other physicians to go for help. They read a story like that and think, “Wow, I am not alone. I am not the only one.” I have even had patients come to me in my own practice, saying, “I have been putting off seeing you for so long, but I read this article about this young doctor who disclosed that he had depression in medical school, but now he is doing good. If he can do it, I can do it.”
HEH: We have covered a lot of mental health issues in physicians and other healthcare workers, including stress, burnout, opioid addiction, etc. Is there any kind of linear path or progression of these states to suicide?
Meyers: The general belief about suicide — and this isn’t just in doctors — is that there is never just one factor that drives a person to end his or her life. Can some doctors with burnout kill themselves? Yes, but there has to be something else. We use the term “biopsychosocial.” What are the biological factors that could be putting this particular physician at risk of taking his life? It could be something like a genetic family history of major depression, bipolar illness, severe addiction, suicide in a [close] relative. Then there are other physical things — did this doctor have a traumatic brain injury from sports, or serving in the military? Is this doctor on a medication that could be putting him at risk?
You also have to look at the underlying history — an anxiety disorder in the past, or perhaps PTSD. Then there are social factors — could this be somebody that has been discriminated against because of their ethnic group or their country of origin, their sexual origination, their gender identity? Have they been named in a recent lawsuit? Has it just been reported in the newspaper that they have been charged with sexual abuse of their patients? These are all of the kind of triggers that you want to be looking for to try to figure out if this is somebody who could hurt himself.
HEH: You describe the “tyranny of perfectionism,” which seems to mean some doctors don’t have a safety net — they have left no room for failure.
Meyers: Yes, that is considered a risk factor, but obviously it is not a risk factor in everyone or doctors would be ending their lives all over the place. It’s a double-edged sword. It is a kind of perfectionism that gets us into medicine in the first place. It’s so competitive and hard to get into [the field]. Then you get into medicine and have to work hard, do well, get through your residency, get a decent job, and then you want to have a good practice.
Most doctors ride with that — they realize we are all sort of perfectionists. They know they have to make sure they have hobbies in their life, get to the gym, and watch how much they drink. But there are some people who have a lot of trouble cutting themselves any slack. They get really upset if they make a mistake or if something happens to one of their patients. They may have not even been responsible, but they kind of obsessively blame themselves.
HEH: What you describe as “fear of medicalization” seems also to be an aspect of stigma.
Meyers: Doctors have a lot of difficulty letting themselves be patients, letting themselves be treated. Obviously, we prefer to be in the role of healer. To make that transition from healer to needing to be healed is real tough for a lot of physicians. When I am looking after doctors, sometimes they don’t want to come back, they are not cooperating with taking their medications. I try to use medical analogies and say, “Look, if I were an oncologist and I am prescribing 12 chemotherapy treatments over the next two months, would you take them?”
They always say yes. I tell them you are not going to get better without taking your medication, and then we can talk about lowering it down the road. But right now you need this stuff because your brain chemistry is off.
HEH: You describe a phenomenon among some physicians after a colleague’s suicide, which seems to be some refusal to mourn, a kind of blocked grief. Is this a kind of defense mechanism?
Meyers: Yes. I am sometimes contacted by the CEO of a community hospital after a suicide by a physician, asking me to come in and talk and participate in groups. I learn a lot in those groups. There are physicians who come who are really grieving. There are others who are kind of wooden. They are not sure why they are there — they were sort of sent there. Some of them — if I can get them to talk — are quite angry. That is a defense response, too. It is a defense against coming in touch with these feelings, so they become angry at the doctor for killing themselves. Maybe they don’t like what is happening to the physician’s family, or they are angry that they suddenly have all these additional patients. The emotions that anybody feels after suicide can get pretty primitive. That’s why I always tell everybody not to judge.
HEH: Another fascinating issue you raise is physicians “dying as doctors,” a sort of last act of professionalism. In one instance, you describe a physician who put on scrubs before ending her life. In another instance, a physician was found by his wife, lying on his own exam table, having administered himself a deadly IV that is still hooked to his arm.
Meyers: He had started an IV on himself. He even injected heparin first so his blood wouldn’t clot, then he injected himself with a lethal dose of this toxic [solution] he had ordered over the internet. It was a very medical way of killing himself. I think what he was looking for was a rapid and largely painless type of death. [His wife] spoke to the medical examiner, who said he probably didn’t suffer. He probably fell asleep within seconds and then his heart would have stopped in a minute or two. That gave her comfort.
HEH: Is this medical approach to suicide part of the reason physicians have a higher “success rate” — if that is the right term?
Meyers: I’m glad you touched on that. For the last five years we have really been looking at language, and a lot of this comes from survivors — family members who have lost someone to suicide. Most of them don’t even like the word ‘commit.’ They want us to get rid of the term “committed suicide.” They are OK with died by suicide, killed themselves, took their lives. I think why they don’t want to use the term “commit” is that, historically, suicide was a crime — like committing a crime. It was morally also a sin — “committed a sin.” You used the term “success rate,” and we do use that in psychiatry and medicine so much. They say, “Thank God she wasn’t successful — she lived.” I have heard a psychiatrist say, “Unfortunately, this time she was successful and her body was found in the river.” But we are now trying to say “completed” suicide or something of that nature.
Back to your question — it is true that we have lower rates of attempted suicides. When a physician attempts suicide, most often they really mean business. Very few of them survive. They use lethal methods. A surgeon patient of mine took a massive overdose. Fortunately, her husband found her, she was taken the hospital, and she lived. She blamed herself. She said, “What kind of a surgeon can’t even kill herself?”
HEH: You describe some suicide prevention and awareness training that could be done in medical schools. It would involve an interview with a physician (or an actor in a simulation) addressing personal experience with depression or other issues. Has this been trialed?
Meyers: Yes, it has been, and I’ve even done it myself. One time, a medical student just admitted to everybody basically that she struggled with depression. After that, she always volunteered to come to orientation for our first-year medical students. And a couple of times I interviewed her in front of groups, asking her what that was like. It was so powerful because she was able to explain how she went from wellness to illness — all the subtleties of that. The medical students and residents who were sitting listening to this were gripped and on the edge of their seats. It was galvanizing.
This may not be possible in all medical schools, so we need some recorded interviews with someone who has actually been through this, or do a simulation. But you would have to get a very good actor to get buy-in from students and residents. The reason I like this format is it is just more tangible, and it gives an opportunity for the observers to ask questions.
HEH: You open your book with the shocking suicide of your college roommate, Bill. It seems like he had everything going for him. Have you come to any theory of which of the various themes and factors you mention in the book may have been behind his suicide?
Meyers: Well, I wish I knew because I’ve been kind of guessing all my life since Bill’s death. His family did not want to talk about it. My hunch is that maybe there was something going on in his personal life. I didn’t know a lot about him, and whether he may have been struggling with something that had never been discussed with me. The whole thing didn’t make sense. At that point, we were all so grateful to be in medical school after a competitive process. My classmates felt the same way — “Oh my God, we’re just getting started, and Bill has killed himself.” It’s like when you see some physicians who die by suicide — you can’t pin it on their work. They loved what they were doing and you read between the lines you think, “No, they weren’t burned out.” There is stuff going on in their personal lives that is devastating and overwhelming, and that tips the balance.
HEH: You do end the book on a note of hope, saying some progress is being made on the issue. What would be the measure of that — when you look at data, and suicide rates in physicians have actually fallen?
Meyers: Yes, that would be it. And when it is a subject that no longer needs to be talked about. My colleagues and I that work in suicide prevention [agree] that our goal should be to reduce suicide by a measurable amount. The AFSP has set a goal to reduce the deaths by suicide by 20% by the year 2020. That, to me, should be doable.
You started this interview by bringing up stigma. The final thing I should say to you is one of the things that came out of interviewing all these grieving families: I was shocked that 10% to 15% of them said their loved one never sought any help at all. Nothing. They didn’t go to a primary care doctor, a psychologist, a nurse, or the clergy. They didn’t talk with anyone. These families were desperate. They could see that their loved one was imploding. The [physician’s] fears were catastrophic — “I’ll lose by medical license, I’ll lose my job, my malpractice insurance.” The next thing they know, he’s dead.
Like so many stories of suicide, this one begins with a haunting memory and an unanswerable question. Why would a young student, having passed the rigorous tests and trials to get into medical school and about to begin the education and career that is his seeming life’s purpose, go home for Thanksgiving break and kill himself?
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