What killed David? It was the gun, of course. But he was the one who pulled the trigger.
The medical student had been turned down for an emergency medicine residency, but he had clinched a spot in internal medicine, thanks to a mentor who cared deeply about him. Yet he relapsed into drugs, retreated to a hotel room, and eventually shot himself.
“I cannot help but believe that David's aloneness, his addiction, was worse for being in the medical profession, and not just because of ease of access, or stress, or long hours, but because of the way our profession fosters loneliness,” stated Abraham Verghese, MD, in his memoir of the young friend he lost. (The Tennis Partner. New York: HarperCollins;1998.)
It appears that conclusion might be right, although evidence thus far is either anecdotal, drawn from case studies, or tenuously concluded from practice surveys. In Canada, some physician groups have begun attributing career-related depression to changing organizational structures, which have affected autonomy and led to a “depersonalization” of medicine. (Can Fam Physician 2008;54:722.)
Physician identities are so closely tied to their jobs that occupational stress is ignored, and when other stressors occur — family tension, patient litigation — sudden depression may ensue, with tragic results. Consider the case of Jonathan Drummond-Webb, MD, an Arkansas heart surgeon featured in a television series that showcased his accomplishments. A few years later, in 2004, he overdosed and died. A suicide note reportedly cited his professional frustration.
Physicians as a group seem to have a hard time with workplace setbacks while denying that they do. In a survey of more than 2,000 medical students, a majority said they had been belittled or humiliated at one time or another during their training, but most thought these experiences too trivial to have any lasting effect. They were wrong. The incidents, which were considered emotionally depleting at the time, correlated with poor mental health. (BMJ 2006;333:682.)
In the 1970s, physicians were calculated to have twice the risk of suicide as the general population. Their suicide risk rose to two-and-a-half times that over the next two decades. (Psychiatry [Edgmont] 2009;6:18.) This increase occurred despite the fact that recognition and treatment of the leading precursor, depression, dramatically improved over those years. Though the methodology of suicide studies on physicians is subject to troubling sampling errors — even federal statistics are not wholly reliable — there is medical consensus that the suicide risk for any physician in a surgical or primary care specialty is significantly higher than that of the typical patients he sees on a daily basis.
Fear of discrimination in licensing and loss of hospital privileges remain formidable barriers to treatment for depression. (JAMA 2003;289:3161.) And this perceived obstacle is like blocking a rescue exit, according to some of those who attended a recent meeting on physician suicide in West Los Angeles, which was sponsored by the Los Angeles County Medical Association (LACMA) in the wake of self-inflicted deaths by two physicians.
Most doctors simply don't believe that their confidentiality will be protected, and they consider disclosure the opposite of a safe harbor. Any kind of help-seeking for mental health is supposed to be reported on licensure and renewal applications, explained Louise Andrew, MD, JD, an emergency physician who was a featured speaker at the LACMA conference. These “repetitive and intrusive examinations by medical boards in itself has triggered suicide,” she said.
Once considered ironclad in almost all therapeutic circumstances, confidentiality is now eroding, affirmed Kirsten Schwanke, a therapist in Portland, OR. She and some of her peers, however, draw their own ethical lines, standing by them in a less-penetrable shield for patients. “You can ask, ‘How are you treating this issue? What are the ethical standards you abide by?’” she advised.
Professional boards can demand that the therapist report to the police, protective service agencies, and family members if a serious threat is made by a patient, including a threat of suicide. And even the legal principle behind this statute, known as the Tarasoff Rule, can be subject to inconsistent interpretation by the courts. In fact, judicial responses to the Tarasoff Rule have been so varied, one analysis of them concludes by urging clinicians to rely on their own judgment rather than statutory guidance. (J Am Acad Psychiatry Law 2004;32:263.) Further complicating a guarantee of confidentiality is the fact that legal protection may vary from one jurisdiction to another. There are other exceptions as well, such as a judge-signed court order or a subpoena.
While the risk of physician suicide has risen over the past two decades, other professions have shown a downward trend. The rate of psychologists who commit suicide, for example, started declining during the same period that physician risk for suicide began inching up. (Arch Suicide Res 1999;5:11.)
Family and friends are considered one of the protective factors against acting on suicidal thoughts and plans, but “unfortunately, when people become severely depressed, they may isolate and push friends and family away. This only heightens their despair and hopelessness, and may crystallize their decision to kill themselves,” said Michael Myers, MD, the vice chairman of medical education and the director of training in psychiatry and behavioral sciences at SUNY Downstate Medical Center.
In her landmark book chronicling her battle with bipolar depression, Kay Redfield Jamison, PhD, recounted her own suicide attempt, and observed that she pulled away from her support system in just the way Dr. Myers described. She said she felt she was becoming a burden, and that no one could extricate her from the pain. “One would put an animal to death for far less suffering,” she reasoned. (An Unquiet Mind. New York: Random House; 1996.)
Precipitating factors to depression can include both overwork and psychological assaults like lawsuits or deaths of patients or marriage breakups or deaths of family members, Dr. Myers said. An American study of burnout among surgeons says much the same thing, finding that a national sample of surgeons shows “a substantial number of our colleagues are struggling with personal and professional distress at a level that should be of concern to all surgeons.” (Arch Surg 2009;144:371.) The American College of Surgeons subsequently warned that mental stress was strongly related to medical errors in this group.
There are signs of positive change. Licensure language in Arkansas was amended after Dr. Drummond-Webb's death. It now asks only if treatment for depression was recommended by a licensing or credentialing board, not whether counseling or therapy had been voluntarily undertaken. Medical schools are now taking a hard look at how they can be more sensitive to their students. (Perspect Biol Med 2008;51:392.)
The American Foundation for Suicide Prevention has a pilot project underway to help screen medical students, residents, and hospital physicians to identify those with serious depression and other problems that put them at risk for suicidal behavior. The University of Pittsburgh is kicking off the project, but it is expected to be expanded to four more centers.
Maria Lymberis, MD, the president of LACMA and a clinical professor of psychiatry at the UCLA School of Medicine, said she never knew the two women physicians whose deaths became a call to action for the recent conference. But their deaths affected her deeply, she said, just as they did for so many physicians who heard their stories. “We need to work to overcome stigma and ensure access to care for all,” she said. “Health, both mental and physical, is essential for life, and our profession is indispensable.”
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How to Find a Good Therapeutic Fit
- Expect initial relief, but know that hard work lies ahead, and the emotional pain may get worse before it gets better, said Kirsten Schwanke, the Oregon therapist.
- Discuss confidentiality up front. Many therapists will maintain confidentiality, even under subpoena, but a breach could come from an insurer, so know what information the insurer requires from the therapist. Paying out-of-pocket can guard against this.
- Be honest about what you want in a therapist. Does gender matter? Age? A particular approach? Consider the first session or two an “audition,” advised Dr. Carl Sherman.
- Do not let time be an obstacle. “Cognitive behavioral therapy has been shown to get results fairly quickly” in some patients, advised Dr. Sherman.
- Ask the therapist: What training have you had? How long have you been in practice? Have you ever been a therapy patient? What is the fee, and how are emergencies and missed sessions billed?