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Emergentology

Physician Suicide is All Too Real

Walker, Graham, MD

doi: 10.1097/01.EEM.0000552793.87820.8d
Emergentology

Dr. Walker is an emergency physician at Kaiser San Francisco. He is the developer and co-creator of MDCalc (www.mdcalc.com), a medical calculator for clinical scores, equations, and risk stratifications, which also has an app (http://apps.mdcalc.com/), and The NNT (www.thennt.com), a number-needed-to-treat tool to communicate benefit and harm. Follow him on Twitter @grahamwalker, and read his past columns at http://bit.ly/EMN-Emergentology.

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I 'll be ashamedly and brutally honest: I always thought physician suicide was sad but ultimately someone else's nightmare. I've read the blog posts and tweets and lectures on physician burnout and the resident and medical student studies on depression and suicidality. I had mostly concluded, “Who didn't have a period where they felt depressed in medical school? Who didn't feel overwhelmed during internship?”

I have even struggled with anxiety, and my father is a psychiatrist, but it just felt like people reporting depression or even suicidal thoughts was a bit much. I was skeptical.

Last month I was aimlessly scrolling through Facebook when I saw a classmate of mine from medical school comment on a blog post entitled “33 Orthopaedic Surgeon Suicides. How to Prevent #34” with the note, “We miss you and love you, my dear friend.” Scrolling down, I couldn't believe it: It was my classmate, Steve Ortiz. Steve killed himself last year.

Steve's picture stared back at me as I clicked through to the article. We weren't particularly close, but all of us in my tiny medical school class of 86 ended up spending at least a little bit of time together. Shocked, I read about his life and the challenging path he had taken since we parted ways in medical school—orthopedics residency and a spine fellowship—and sat in stunned disbelief.

Steve Ortiz was one of those genuinely kind and giving people. Welcoming to all. Humble. He had had another career before medicine, and started medical school in his mid-30s. Despite being thrown into classes with a bunch of 21-year-olds and already having children and a family, he fit right in with everyone. He shared notes with everyone in his study group, wanting all his classmates to do better. I can't imagine the challenges of being a med student and a dad, but Steve made it look easy. He had a maturity and manner with people that 20-somethings just don't, and it always made me want to be a little more adult and wise and mature when I was around him.

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‘Heal Thyself’

Never in a million years would I have guessed Steve. He was always so happy. He always seemed to have everything figured out. But the more I read about physician suicide, the more I learned that Steve was exactly the guy to worry about and to whom we should pay a little more attention.

Physicians are similar to the rest of the public in some ways when it comes to suicide. Female physicians are more likely to attempt suicide; men are more likely to complete suicide. We lose seven male physicians for every female physician. People who seem happy aren't necessarily so; they may be suffering from deep, dark depression in silence. Doctors abuse substances to cope (or try to treat) mental illness or stress, just like everyone else.

But in many other ways, physicians are a special case. We have a higher suicide rate than the general population and the highest suicide rate among professionals. Medical training itself seems like it might be associated with mental illness—it's common even among medical students—and not just those in the United States. Studies in Europe, Asia, and Australia have all shown increased anxiety, depression, and suicidality in students and physicians. We often have a physician, heal thyself complex: Figure it out yourself, make it work, keep going. We may attribute the symptoms of depression to some rough shifts at work or a string of night shifts that we can't shake.

We don't seek medical or psychiatric medical care because we don't have the time, are in denial that we're sick, or because our medical training tells us to tough it out. We know what to say and what not to say to keep us out of trouble with therapists and psychiatrists even when we do seek help with mental illness.

Our own state licensure boards stigmatize mental illness, and we worry that admitting to any illness, especially a mental one, is viewed by the medical board negatively. To apply for medical licensure in California, for example, you must disclose whether you have ever been diagnosed with an emotional, mental, or behavioral disorder that may impair your ability to practice medicine safely. More recently, some medical boards are modifying these types of questions to ask if any medical conditions currently affect your ability to practice medicine safely.

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Third in Line

We also know that our day-to-day jobs as physicians are incredibly stressful: the challenging health care “system” in which we try to practice; bad outcomes and malpractice lawsuits that question our competency and dedication; exhausting call schedules preventing adequate sleep or shift work disrupting normal sleep patterns; and seeing pain and suffering day in and day out taking a mental, emotional, and spiritual toll on us.

Anesthesiologists and surgeons are most likely to die by suicide. Emergency physicians are third in line.

It's been a few weeks since I found out about Steve's death, and I just keep feeling like I wish I had known. I'm sure we all do. I hadn't talked to him since medical school, but I would have flown out to see him and to try to help him in a heartbeat. He was genuinely that kind and good-hearted. I have no doubt he would have done the same for me.

It's wishful—or maybe foolish—thinking that I could have saved the day. There I go again, trying to fix things. I hope that anyone reading this will reach out to me or one of their colleagues when they are feeling sad, upset, depressed, or suicidal. Check in with your colleagues. Grab a bite or a drink and have a chance to talk. Make some space to talk about the good and the bad. Until society finally wakes up—like I recently did—and realizes that suicide is a real and present danger to our colleagues, our patients, and ourselves, we have to step up to the challenge for each other, like we do every shift in the ED for everyone else. We lose at least 300 medical students, residents, and physicians each year to suicide.

You left us way too early, and I'm sorry, Steve.

Special thanks to Pamela Wible's dedication to this cause; many of my facts and insights are taken from her wonderful website, http://www.idealmedicalcare.org. Consider organizing a viewing of “Do No Harm,” a documentary about the epidemic of physician suicide in the United States, at http://www.donoharmfilm.com.

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