Last night I had a dream about the funeral. My elder son was 5 at the time, and he was following the casket, crying about opening it so that he could see his dad.
Of course, they didn't open the casket.
Some days I still wake up hearing the screams of my son, when he couldn't see the face of his father one last time. John died by suicide in 2015 before starting a residency in pathology.
John was still writing music while he was in medical school. He still loved to go to the park with his kids. But he was exhibiting signs of stress. He tutored for the MCAT on the side and frequently told me that he was doing more than other medical students. He started acting differently. He was angry. I asked about it. People said all doctors were angry. People said school was the problem. That I was the problem. That this was normal.
Based on what people told me while John was in school, a lot of people thought most doctors are grouchy jerks who are terrible parents and partners. They said that is part of the “culture.” (KevinMD.com, Nov. 23, 2011; http://bit.ly/2LnrGPN.) But it was more than that; it can also be a warning sign for depression and increased risk of suicide, and family support is crucial.
I noticed John's classmates talking about ways to kill themselves; the references became particularly macabre when they started taking anatomy. Sometimes I earnestly couldn't tell whether they were playing memory games, committing difficult anatomical terms to memory, or making particularly dark jokes. I forgot the amount of propofol you need to kill someone, but I've heard it multiple times.
Were they just under a lot of pressure to remember things for pharmacology and too steeped in medical school to realize these jokes were not funny? Did they even stop to think what it might sound like to other people, non-physicians, even patients, to hear these jokes? Some doctors I spoke to had a daily ritual of thinking of ways they could die. Some find these conversations harmless, but they aren't.
Problems with the Culture
I also noticed how much a toll the job itself took on them. I noticed when the students would visit clinics in high-poverty areas, seeing such high need without much access to care. Between visiting rural Pennsylvania, where a physician asked parents how often they gave their infant whisky to induce sleep, to inner-city Philadelphia EDs to practice trauma surgery on gunshot victims, there were a lot of people they could not help. That feeling coupled with some shock about what life was really like for patients and how to survive that reality as a physician with your same sense of purpose intact wasn't a class in the curriculum.
There were other things wrong with the culture too. The jokes about dying and using Adderall to perform well were things that I noticed during medical school, but I think I grew up more sheltered than some. Was it that unusual to use a lot of drugs? Physicians have more substance abuse issues than the general population, but when they explain that they are maximizing their potential, it seems like taking an antidepressant—perfectly normal and actually good for your health.
One of John's classmates, an emergency physician, expressed it perfectly: “You would think that a lot of what doctors do is important to improving health. You would be wrong.” The realization that their dream or their job is different from the reality can be discouraging.
It was for John. He had issues with mental health and attempted to end his life more than once. He stopped talking to his kids; his brother tried to help him. It wasn't enough, and he passed in May 2015. The combination of stress and other factors was too much for him.
And it is not only John.
Forty-two percent of physicians reported burnout in the 2018 Medscape survey. (http://wb.md/2E58ouW.) Female physicians are 2.3 times more likely to die by suicide. (Am J Psychiatry 2004;161:2295; http://bit.ly/2LNOjsQ.) And many depressed physicians do not seek help because medical licensing forms ask about mental health in many states. (The DO, Oct. 25, 2017; http://bit.ly/2NJcYiY.) Physicians do not make great patients. Because your mental health history is part of your medical license in many areas, some physicians don't report mental health issues. No one wants to be the “crazy” doctor.
The reality of physician suicide and burnout is that patients are getting worse care. Physicians are quitting medicine. People aren't really sure how to help or when they should be worried. Mental health care in general doesn't have enough physicians to meet the need. This extends to personal care too. We aren't giving physicians in training the resources they need to meet expectations. Medical students and residents report being unprepared for how hard training can be. (Scientific American, April 2, 2018; http://bit.ly/2LHaNyS.) I wasn't sure how hard it would be, and I also didn't know where the line was of protecting myself and my children and what was normal.
The Sickness is the Disconnect
I did not understand the changes and the anger and the frustration John had in medical school. Humans tend to name a problem and try to understand what caused it. There are so many names for the problems physicians in training and in practice have. Compassion fatigue. Burnout. Depersonalization. Depression. Stanford Medicine recently published research about how physician burnout may contribute to large numbers of medical errors. (July 8, 2018; https://stan.md/2mJnrzA.) If you can't focus on your work, you don't do good work. If you can't connect with patients in the present, you miss important signs of future problems.
Much of the problem has to do with physicians obscuring their own symptoms from loved ones and from the medical establishment. A physician might hear a patient talk about wanting to die, and follow up on it. He might also hear a fellow physician joke about it the same day and pass it off or not know if it is real.
Hiding from the Problem
Most current physician wellness plans may help with physicians who need an inspirational speech and a yoga class to get themselves back on track after a stressful day's work. This might not be possible in a system where working unhealthy hours is the norm. Coping skills are helpful, but a major study found that the higher a doctor's level of burnout, the less likely he was to seek help. (J Am Coll Surg 2016;222:1230.) Some recovery programs place more burden on an already-overwhelmed system. They want to change as little as possible about the existing power structure and schedules. But if physicians work so hard they never sleep, they will have significant problems.
Pointing fingers of fault is difficult, but there is a lot of room for improvement for physician mental health. With the growing narratives about electronic medical records being components of or at fault for burnout, and technology vendors subsequently using the threat of burnout to sell new software, I wonder how much more medicine will turn into an echo chamber of academic papers and self-important peer-evaluated studies rather than actually solving any of the problems. (Harvard Business Review, March 30, 2018; http://bit.ly/2yjIW2g.) The current health care education and delivery system is failing to solve the problem of burnout. Our narratives aren't working, just like the narrative that “these things are normal” didn't work.
The way academic medicine evaluates for burnout and addresses the problem with “thought leadership” and academic inquiry is identical to the depersonalization we see from burnout. It desperately tries to separate itself from the real mental health issues by hiding behind a series of clicks.
We Can Have Hope
I never want other parents to raise a child with no father. We started the nonprofit Sharp Index to help reduce suicide attempts and get more support to physicians. (https://sharpindex.org) We also work with health care systems and communities so people can identify the warning signs. We need less pushback from people about what is “normal” in medicine and what is “necessary” to give great care. The less we hide, the easier it is to help. This means radical honesty and looking outside ourselves.
I have a profound hope that things will get better and that help is out there. I know because when John died, suicide-loss survivors helped me understand what was going on. We can help with tools for support. We can help with changing the work environment. We can help by telling family and friends where the line is between stress and suicide so we don't lose any more physicians to suicide, so no mother has to wake up from the nightmare of her child chasing a casket.
Raising Awareness about Physician Suicide
Sept. 17 is National Physician Suicide Awareness Day, and the Resilience Committee of the Council of Emergency Medicine Residency Directors (CORD-EM) is leading the way with the support of AAEM, AAEM/RSA, ACEP, ACOEP, ACOEP-RSO, EMRA, and SAEM in improving the wellness and resilience of residents and emergency physicians.
The committee, led by Chair Ramin Tabatabai, MD, and Vice Chair Loice Swisher, MD, is developing recommendations, programming, and curricula to address the ACGME well-being common program requirement and providing resources on a wide range of resilience and wellness subjects.
Estimates say that up to 400 physicians take their lives each year, according to CORD, with the relative risk for suicide being 2.27 times greater among women and 1.41 times higher among men than the general population. CORD's Vision Zero calls on individuals, residency programs, health care organizations, and national groups to commit to breaking down stigmas, increasing awareness, opening the conversation, decreasing the fear of consequences, reaching out to colleagues, recognizing warning signs, and learning to approach colleagues who may be at risk. (http://bit.ly/2LUzbKc.)
Current projects by the CORD Resilience Committee include 100 five-minute wellness activities, a resilience mini-fellowship, and a second victim toolbox. More information is listed at http://bit.ly/2mLOpWY.
Suicide Prevention & Postvention Resources
Need someone to talk to?
- National Suicide Prevention Lifeline: 800-273-8255
- Crisis text line: Text HELP to 741741
After a Suicide
- A toolkit for residency programs: http://bit.ly/2LRiOyb.
Time to Talk about It: Physician Depression and Suicide
- A video for interns, residents, and fellows: http://bit.ly/2NMp7n4.
- Sign up for updates and information on National Physician Suicide Awareness Day: http://bit.ly/2mQ8Imx.
More resources for suicide prevention can be found in a presentation created by Dr. Swisher and Christopher Doty, MD, at http://bit.ly/2AcD0sP, and on the CORD website at http://bit.ly/2mJnnja.