Suicide and homicide deaths of PAs

Analysis of the National Violent Death Reporting System

Abstract

Objective: 

This study describes physician associate/assistant (PA) deaths in the US CDC's National Violent Death Reporting System (NVDRS) from 2003 to 2020.

Methods: 

PAs' violent deaths were analyzed and summarized in terms of decedents' numbers and demographics, methods of death, locations of death, and relationships with assailants.

Results: 

The NVDRS identified 93 suicides and 9 homicides in this period. PAs who died by suicide were mostly White (93.5%) and male (67.7%); mean age was 49.7 years. A third of the PAs who died by homicide were Black; most were female (55.6%), and the mean age was 48.7 years. Firearms (41.7%) were most commonly involved in deaths by suicide, and blunt impact (33.3%) was most commonly seen in deaths by homicide. A plurality (46.1%) of suicides and homicides occurred in the South. Homes (72.5%) were the most frequent location. No homicides were reported in medical settings. Known perpetrators were mainly relatives and male; none were patients.

Conclusions: 

Incidence of PA death by suicide or homicide is low relative to the general population. These deaths generally are not related to PAs' work. Delineating the incidence of violent deaths is a step toward informing preventive efforts.

In the United States in 2020, an estimated 45,979 people died by suicide and 24,576 by homicide.^1,2 Some healthcare workers' deaths are attributable to both types of violence. Concerns about burnout, depression, and suicide among healthcare professionals have garnered increasing attention.^3,4 Healthcare workplace violence also has received increasing attention and is a major safety concern in healthcare settings.^5,6 The Bureau of Labor Statistics (BLS) has warned of the public health challenges of increasing violence in healthcare.⁷ Violence in the workplace takes many forms, including fatal attacks on health professionals.⁸

Increasingly comprehensive data have been emerging about the violent deaths of healthcare personnel since the CDC's National Violent Death Reporting System (NVDRS) was created in 2003. Its database of deaths by suicide and homicide has been interrogated for deaths of physicians, nurses, pharmacists, psychologists, and other healthcare professionals.^9-14 Studies have summarized decedents' demographics, methods of suicide, and homicide victims' relationships with assailants.

The incidence of healthcare professionals who die by suicide has been estimated by some researchers to exceed rates in the general population.⁹ Consistent with patterns of violent death in the general population, healthcare workers are more likely to die by suicide than homicide.¹⁵ A systematic review revealed that physicians are at risk for death by suicide and emphasized the need to implement studies investigating death by suicide in other healthcare professionals.¹⁶

The rate of homicides of healthcare professionals also is alarming. NVDRS data between 2003 and 2018 revealed that 56 physicians and 13 psychologists died by homicide.^12,13 Robiner and colleagues analyzed NVDRS homicide data for 10 types of healthcare professionals, summarizing demographic data and calculating homicide rates in those professions' workforces.¹⁷ Homicides of healthcare professionals are not limited to the United States. For example, more than half of 21 physician homicides in Italy were perpetrated by patients and their relatives.¹⁸

Such reports raise questions about the extent and characteristics of violent deaths of physician associates/assistants (PAs). Burnout, depression, and suicidal ideation have been reported in PA trainees and faculty.^19,20 PA students have reported higher anxiety and depression than the general population.²¹ Our literature search using the terms physician assistant, homicide, suicide, kill, murder, and death identified no previous studies of PAs' violent deaths. However, PA homicides have been reported in the media.^22,23 To bridge this gap in the literature, enhance understanding of the epidemiology of PAs' violent deaths, and raise awareness about them, we analyzed NVDRS data on PAs who died by suicide or homicide. This study sought to delineate the incidence of PAs' violent deaths, their demographics and associated characteristics, and to establish a baseline for future longitudinal research.

METHODS

The NVDRS was developed by the CDC in 2003 and incorporates data from coroners' reports, police reports, and death certificates. Researchers can use these data to develop initiatives to prevent violent deaths and to assess the effects of those initiatives. The system provides demographic data and other information about decedents (for example, factors involved in incidents, toxicology reports, methods of attack, history of personal problems) and, where known, about their relationships with assailants.

The number of jurisdictions participating in the NVDRS has increased from 7 states to 50 states plus Puerto Rico and the District of Columbia, but only 48 provided sufficient data to be included in the 2020 NVDRS dataset. Figure 1 presents the number of states reporting to the NVDRS. Incomplete data in two states in 2020 and other states in other years limited reporting. Using US Census Bureau data, we determined that the incomplete 2020 NVDRS data captured 85% of the US population.²⁴ Assuming that reporting and nonreporting areas had similar rates of suicide and homicide allowed calculation of extrapolated national estimates of PA deaths by suicide or homicide for 2020. These in turn were compared with BLS estimates of the PA workforce to derive estimated rates of suicide and homicide among PAs in 2020.²⁵

FIGURE 1.: Cumulative PA homicides and suicides and state participation in the NVDRS The completeness of data varied over years as the NVDRS evolved. Enrollment in the program was staggered, and some states submitted incomplete records at times. For example, in some years, Illinois and Pennsylvania collected data in a subset of counties representing only a portion of violent deaths in those states. Other examples include New York's exclusion in 2019 and Hawaii's exclusion for 3 years due to incomplete reporting. California only participated for 4 years, and in those years, only some counties participated; Texas participated only in 2020, reporting data for four participating counties. Florida has only recently participated, but data have not been sufficient for inclusion in the dataset. Consequently, the numbers presented underestimate the true incidence of violent deaths.

The NVDRS was queried for anonymized demographic and situational data about PA deaths by suicide and homicide between 2003 and 2020. Tables were created based on descriptive data in electronic spreadsheets. For the purpose of this study, both death by suicide and death by suicide following homicide committed by the PA were coded as suicide. Both authors reviewed recorded occupational classifications and the narratives of law enforcement and health departments provided in the NVDRS data to reach consensus in identifying PAs using the search terms physician assistant and physician asst. The study was deemed exempt by the University of Minnesota institutional review board.

RESULTS

Violent deaths of PAs were reported every year since 2004, the second year of the database, totaling 102 through 2020. Figure 1 presents the cumulative numbers of PA suicides and homicides. The 93 suicides and 9 homicides reveal an incidence of suicide nearly 10 times that of homicide (Figure 2). Three PAs died by suicide after having committed homicides. One death by suicide followed the PA's partner's death by suicide.

FIGURE 2.: PA deaths by suicide or homicide, NVDRS 2003-2020

Table 1 summarizes demographics of PAs who died violent deaths. Overall, modal age range was 50 to 59 years. The 67 males' age (M = 52.8 years) exceeded the 35 females' age (M = 43.7 years). Most (n = 91; 89.2%) were White, non-Hispanic; Black and Asian PAs accounted for 3.9% and 4.9%, respectively. Most (n = 61; 59.9%) were married at the time of their death, 18 were divorced, 18 had never married, and 5 were widowed.

TABLE 1. - Demographics of PAs who died by suicide or homicide

Totals may not equal 100% because of rounding.
	Suicide						Homicide						Combined
Demographic	Male (n = 63)		Female (n = 30)		Total (N = 93)		Male (n = 4)		Female (n = 5)		Total (N = 9)		Male (n = 67)		Female (n = 35)		Total (N = 102)
	M	SD	M	SD	M	SD	M	SD	M	SD	M	SD	M	SD	M	SD	M	SD
Age	52.7	11.4	43.6	12.5	49.8	12.4	55	6.2	45.5	11.5	48.7	10.7	52.8	11.1	43.7	12.3	49.7	12.2
Age range (years)
	n	%	n	%	N	%	n	%	n	%	N	%	n	%	n	%	N	%
20-29	1	1.6	4	13.3	5	5.4	0	0	1	20	1	11.1	1	1.5	5	14.3	6	5.8
30-39	8	12.7	6	20	14	15.1	0	0	1	20	1	11.1	8	11.9	7	20	15	14.6
40-49	14	22.2	12	40	26	28	1	25	1	20	2	22.2	15	22.4	13	37.1	28	27.2
50-59	23	36.5	6	20	29	31.2	2	50	2	40	4	44.4	25	37.3	8	22.9	33	32
60-69	12	19	0	0	12	12.9	1	25	0	0	1	11.1	13	19.4	0	0	13	12.6
70 and older	5	7.9	2	6.7	7	7.5	0	0	0	0	0	0	5	7.5	2	5.7	7	7.8
Marital status
Married/civil union/domestic partnership	45	71.4	10	33.3	55	59.1	3	75	3	60	6	66.6	48	71.6	13	37.1	61	59.9
Divorced	10	15.9	7	23.3	17	18.3	1	25	0	0	1	11.1	11	16.4	7	20	18	17.6
Never married	4	6.3	12	40	16	17.2	0	0	2	40	2	22.2	4	6	14	40	18	17.6
Widowed	4	6.3	1	3.3	5	5.4	0	0	0	0	0	0	4	6	1	2.9	5	4.9
Race/ethnicity
White, non-Hispanic	61	96.8	26	86.7	87	93.5	3	75	1	20	4	44.4	64	95.5	27	77.1	91	89.2
Black, non-Hispanic	0	0	1	3.3	1	1.1	1	25	2	40	3	33.3	1	1.5	3	8.6	4	3.9
Asian/Pacific Islander, non-Hispanic	1	1.6	3	10	4	4.3	0	0	1	20	1	11.1	1	1.5	4	11.4	5	4.9
Other	1	1.6	0	0	1	1.1	0	0	1	20	1	11.1	1	1.5	1	2.9	2	2

Suicide

Deaths by suicide were identified all years except 2003 and 2013, with the greatest number in recent years: 8 in 2017, 7 in 2018, 17 in 2019, and 10 in 2020. Men (67.7%) accounted for more than twice the number of deaths by suicide compared with women (32.3%). PAs who died by suicide were predominantly White (93.5%); 4.3% were Asian, 1.1% Black, and 1.1% other race or ethnicity. The mean age of men who died by suicide (M = 52.7 years, SD = 11.4) was a decade older than that of women (M = 43.6 years, SD = 12.5; t(93) = 3.52, P < .001). Most men had partners; the modal relationship status of women who died by suicide was never married (40%). Men were more than twice as likely as women to have partners. Smaller percentages of women (23.3%) and men (15.9%) were divorced. More men (n = 4) than women (n = 1) were widowed. Most were still working as PAs; however, at least two were unemployed and one was retired.

Homicides

Nine PA homicides were reported, five women (55.6%) and four men (44.4%). Homicides were reported in fewer than half (n = 7; 38.9%) of the years but had occurred in three of the five most recent years. The age distribution was wider in women than men. All men were over age 40 years (M = 55 years, SD = 6.2) and on average were 9.5 years older than women (M = 45.5 years, SD = 11.5). Nearly half (n = 4; 44.4%) of PA homicide victims were White, three (33.3%) were Black, and one (11.1%) was Asian, and the race/ethnicity of the last victim was not identified. More than half of the women and all but one man were married.

Regions of violent deaths

A plurality of PAs who died by suicide (43%) and a majority of those who died by homicide (77.8%) were in the South (Table 2). A quarter (24.7%) of the PAs who died by suicide, but none who died by homicide, were in the West. The Midwest and Northeast had fewer incidents, accounting collectively for nearly a third (31.4%) of PA violent deaths.

TABLE 2. - PAs' violent deaths by US region

Totals may not equal 100% because of rounding.
	Suicide		Homicide		Total
Region	n	%	n	%	N	%
South	40	43	7	77.8	47	46.1
West	23	24.7	0	0	23	22.5
Midwest	15	16.1	1	11.1	16	15.7
Northeast	15	16.1	1	11.1	16	15.7
Total	93	99.9	9	100	102	100

Location of death

Most (72.5%) violent deaths were in PAs' homes including 55.6% of the deaths by homicide and 74.2% of those by suicide (Table 3). No homicides were in work settings; however, at least four deaths by suicide were in work settings. Locations were not reported for four deaths by suicide.

TABLE 3. - Location of PAs' violent deaths

Totals may not equal 100% because of rounding.
	Suicide		Homicide		Total
	n	%	n	%	N	%
Victim's home	69	74.2	5	55.6	74	72.5
Public/in vehicle	11	11.8	2	22.2	13	12.7
Other/remote area	5	5.4	1	11.1	6	5.9
Institution property (hospital, clinic, etc.)	4	4.3	0	0	5	4.9
Unknown	4	4.3	1	11.1	4	3.9
Total	93	100	9	100	102	99.9

Method of death

A plurality (n = 42; 41.2%) of deaths involved firearms (Table 4). Guns were involved in a greater proportion of deaths by suicide (n = 40; 43%) than homicide (n = 2; 22.2%). The frequency of gun-mediated death by suicide was 38% greater than the next most common method, overdose or intoxication (26.9%). Half (n = 32, 50.8%) of men who died by suicide used firearms, compared with about a quarter (n = 8, 26.7%) of women.

TABLE 4. - Causes of PA violent deaths

	Suicide						Homicide						Combined
	Male (n = 63)		Female (n = 30)		Total (N = 93)		Male (n = 4)		Female (n = 5)		Total (N = 9)		Male (n = 67)		Female (n = 35)		Combined (N = 102)
Method	n	%	n	%	N	%	n	%	n	%	N	%	n	%	n	%	N	%
Firearm	32	50.8	8	26.7	40	43	2	50	0	0	2	22.2	34	50.7	8	22.9	42	41.2
Overdose/intoxication	13	20.6	16	53.3	29	26.9	0	0	0	0	0	0	13	19.4	16	45.7	29	28.4
Hanging/ strangulation/ suffocation	8	12.7	4	13.3	12	12.9	1	25	0	0	2	22.2	9	13.4	4	11.4	13	12.7
Laceration	4	6.3	1	3.3	5	5.4	1	25	2	40	2	22.2	5	7.5	3	8.6	8	7.8
Blunt impact	3	4.8	0	0	3	3.2	0	0	3	60	3	33.3	3	4.5	3	8.6	6	5.9
Carbon monoxide poisoning	3	4.8	1	3.3	4	8.6	0	0	0	0	0	0	3	4.5	1	2.9	4	3.9

The most common homicide method was blunt impact (n = 3; 33.3%) using a blunt instrument or a car. Firearms, laceration, and asphyxia each accounted for 22.2% of homicides. Most homicides were single-victim incidents (55.6%).

Factors associated with PA deaths by suicide

Two-thirds (66.7%) of female PAs who died by suicide were described as having mental health problems, including depressed mood (43.3%); fewer (36.6%) were receiving mental health treatment (Table 5). A third of these women had a history of previous suicide attempts.

TABLE 5. - Factors associated with PA deaths by suicide

	Male (n = 63)		Female (n = 30)		Total (N = 93)
	n	%	n	%	N	%
Known mental health problem	22	34.9	20	66.7	42	45.2
Known depressed mood	21	33.3	13	43.3	34	36.6
Receiving mental health treatment	17	27.0	17	56.7	34	36.6
Intimate partner problem	20	31.7	10	33.3	30	32.3
Previous suicide attempt	12	19	10	33.3	22	23.7
Alcohol/other drug problem	15	23.8	5	16.7	20	21.5
Physical or health problem	15	24	2	6.7	17	18.3
Job problem	11	17.5	3	10	14	15.1
Death or recent suicide of a friend or family member	5	7.9	3	10	8	8.6
Financial problem	1	1.6	3	10	4	4.3

A smaller proportion of men (34.9%) had known mental health problems, including depressed mood (33.3%); fewer were receiving treatment (27%). Men had higher incidence (23.8%) of alcohol or other drug problems compared with women (16.7%) and lower incidence of previous suicide attempts (n = 12; 19%) than women (n = 10; 33.3%).

Physical health problems were noted in 24% of men who died by suicide but were less common in women (6.7%). Similar proportions of men (31.7%) and women (33.3%) had intimate partner problems. Job problems were noted in relatively small proportions of men (17.5%) and women (14%). Recent death or suicide of a friend or family member were experienced by eight PAs who died by suicide; financial problems were noted for four.

Suspected assailants of PA homicide victims

Most (n = 7; 77.8%) victims were known to have had some type of relationship with the known or suspected assailant (Table 6). Relatives (sons or stepsons) (n = 3; 33.3%) and spouses/intimate partners (n = 2; 22.2%) accounted for more than half of assailants. Other assailants were friends or acquaintances (n = 2; 22.2%) or strangers/unknown (n = 2; 22.2%). No patients or family members of patients were identified as assailants. Most suspects were male (n = 8; 88.9%); one was female (n = 1; 11.1%).

TABLE 6. - Primary suspect relationship to PA victim (N=9) by sex

Totals may not equal 100% because of rounding.
	Total		Male suspect		Female suspect
Relationship to PA	N	%	n	%	n	%
Relative or step-relative (sibling, parent, stepparent)	3	33.3	3	33.3	0	0
Spouse/intimate partner	2	22.2	2	22.2	0	0
Friend/acquaintance	2	22.2	2	22.2	0	0
Stranger/unknown relationship	2	22.2	1	11.1	1	11.1

Extrapolated estimates and rates of PA death by suicide or homicide in 2020

At the time this research was conducted, NVDRS data was available through 2020, which had the highest number of participating states and covered regions in which an estimated 85% of the US population dwelled. In 2020, 10 PAs were reported to have died by suicide and 1 by homicide. Dividing these by 0.85 yielded a national extrapolated estimate of 11.76 PA deaths by suicide and 1.18 by homicide. These estimates were then divided by the BLS estimate of the US workforce of 139,100 PAs.²⁵ Multiplying those numbers by 100,000 derived estimated rates of 8.45 deaths by suicide and 0.85 by homicide per 100,000 PAs that year.

DISCUSSION

PAs are a critical, growing health profession, of whom 67.1% are women.²⁶ By virtue of their increasing numbers in the United States—a country with a history and current mounting reality, of violence—some PAs experience violent deaths. The 102 PA deaths reported in the NVDRS between 2003 and 2020 confirm that PAs, like other healthcare professionals, are susceptible to this violence. All deaths are lamentable losses for family and friends, and the premature, violent deaths of PAs are particularly challenging for colleagues, the profession, healthcare system, and society.

The increasing number of states reporting to the NVDRS over time offers increasingly comprehensive preliminary national estimates of PAs' violent deaths. These can be put in perspective by comparing them with US population data. The National Center for Health Statistics (NCHS) reported 7.5 deaths by homicide and 14 deaths by suicide per 100,000 population for 2020, based on data across all age groups.²⁷ The respective denominators of the full population differ from the workforce of PAs in terms of age range and other demographics that may limit their comparability. However, estimated PA deaths by suicide or homicide in 2020 were remarkably lower relative to the workforce of PAs than the NCHS findings for the US population: The rate of PA deaths by suicide relative to the PA workforce was about 58% the rate of homicides in the general population. The rate of PA homicide deaths relative to the PA workforce was lower, about one-tenth of the rate of homicides in the general population.

The demographics of PAs who died by suicide or homicide provide insights into patterns and potential risks of their violent deaths. Age is a factor: although the range was 25 to 78 years for deaths by suicide and 29 to 60 years for homicides, most PAs who died by suicide or homicide were middle-aged. PAs who died by suicide generally were older, consistent with findings from a systematic review that older age is a risk factor for suicide in physicians and with national findings that nearly half of US deaths by suicide are in people of middle age.^28,29 PAs who died by homicide generally were older than other US homicide victims.³⁰ The age variation suggests that it is particularly important for suicide prevention efforts in the profession to include outreach to demographic subgroups that may be at highest risk.

Race and ethnicity data of PAs who died violent deaths can be compared with the demographics of the PA workforce, overall US violent death statistics, and population statistics. The differential incidence may reflect under- and overrepresentation of some groups in the workforce. The proportion of White (89.2%), Black (3.9%), and Asian (4.9%) PAs who died violent deaths grossly approximates population demographics, with variable resemblance to the racial composition of the workforce and racial breakdown of violent deaths in the general population. In the United States, 73.7% of PAs are White, 9.07% are Asian, and 6.13% are Black.²⁶ Among all people in the United States who died by suicide, 77.1% were White, 9.9% were Hispanic, 7.2% were Black, and 2.8% were Asian.¹ The US Census Bureau estimates that the US population is 75% White, 13% Black, and 6.7% Asian/Pacific Islander.³¹

White PAs (93.5%) accounted for a greater proportion of PA deaths by suicide than their share of the PA workforce and of all US deaths by suicide. Black PAs accounted for a relatively smaller proportion (1.1%) of all PA deaths by suicide than their proportion of the PA workforce and of all US deaths by suicide. The percentage of Asian/Pacific Islander PAs who died by suicide was lower than their representation in the PA workforce and consistent with relatively lower US suicide incidence for Asian/Pacific Islander people.³²

A different picture emerges for homicides. White PAs accounted for a lower percentage (44.4%) of PA homicides than their share of the PA workforce, their proportion of all US homicides (41.1%), and of the US population (75%).^31,33 Black PAs accounted for a higher (33.3%) proportion of PA homicides than they did of the PA workforce (6.13%) and of the US population (13%).^26,31 A disproportionally high percentage (53.7%) of US homicide victims are Black.³³ More Black female PAs than Black male PAs died by homicide, a pattern contrasting sharply with US homicide statistics, in which Black male victims (86.1%) vastly outnumber Black female victims (13.9%).³⁴ The single homicide of an Asian/Pacific Islander PA was consistent with CDC findings of lower homicide rates for this group.³⁴ The relatively low number of homicides suggests that interpretations about race or ethnicity be considered cautiously.

Region and location of deaths

The greatest proportion (46.1%) of PA deaths by suicide or homicide were in the South. The West experienced fewer violent deaths. The Northeast and Midwest had comparable, relatively lower rates. The regional pattern for death by suicide mostly is consistent with the CDC's general population suicide statistics for the South (38%), West (25%), Midwest (21%), and Northeast (14%).³⁴

The South also had the most homicides, followed by the Midwest, Northeast, and West. This pattern is somewhat less consistent with US homicides in 2018-2019, in which homicides per 100,00 population were 6.1 in the South, 5.3 in the Midwest, 4.2 in the West, and 3.4 in the Northeast.³⁵ Here, too, caution is advised against interpreting regional variation because of the small numbers.

Other factors

Despite the disquieting incidence of violence in healthcare, violent deaths of healthcare professionals appear to be relatively rare in healthcare settings such as hospitals and clinics.^6,8,13,17 No PAs died by homicide in clinical settings. This is a partially reassuring bright spot in an otherwise sorrowful accounting. How much it may correspond to findings for other healthcare professions, reflect privilege and socioeconomic factors, the partial effectiveness of medical settings' safeguards and security measures, or might be a function of the low absolute numbers or other factors, is not known. The modest number of PA deaths by homicide may indicate that some features of PAs' work, which were not identified by these data, may create fewer sources of conflict with patients that might otherwise escalate to homicide, as has been reported for physicians.^12,18 This may be a fruitful focus for future research. The finding of zero job-related PA homicides should not be taken for granted and does not argue for minimizing security measures in healthcare settings. The overall high level of violence against healthcare workers in healthcare settings warrants sufficient security measures to mitigate all violence, not just fatal violence. As recognized for prevention efforts in general, the true effect of healthcare security measures and resources in preventing fatalities cannot be fully known.

Two of the four PAs who died by suicide on healthcare premises reportedly had job problems. They, and the other PAs who died by suicide, point to the need for violence prevention efforts including effective prevention, education, and other interventional measures to identify and support vulnerable clinicians and lessen potentially contributory work-related stresses to mitigate suicide risk.

Firearms and other methods

Consistent with other effects of US gun violence, firearms were the most frequent method for PAs who died by suicide.^36-38 Firearms were used in 41.2% of deaths by suicide, by half of men and more than a quarter of women. About a quarter of PA deaths by suicide were due to overdose or intoxication, and an eighth involved asphyxia. This pattern differs from overall US suicide statistics, which were respectively higher for firearms (51%) and asphyxia (24%) and lower for overdose or poisoning (16%).³⁹ The basis of the relatively larger proportion of PAs whose deaths by suicide were caused by overdose is unknown, but may reflect, in part, PAs' readier access to potentially lethal drugs.

Mental health

Additional factors included depression, seen in at least a third of PA deaths by suicide. Women had nearly twice the incidence of known mental health problems compared with men. About a quarter of the men and more than half the women were receiving mental health treatment.

Male PAs' more frequent use of firearms demonstrated the lethality of firearms compared with other less lethal and more rescuable approaches, likely contributing to men's high proportion (67.7%) of death by suicide. This pattern accords with research suggesting men who die by suicide are less likely to have known mental health problems, a pattern also seen in other healthcare professionals.^10,11,40

Little information about why PAs died by suicide is available, in part because follow-up inquiries are not possible. Various motives and drivers may be contributory. For example, physical or health problems (18.3%) or job problems (15.1%) were noted in a subset; the extent of their effect relative to other potential factors is not known. As has been discussed for other healthcare professionals, the stigma associated with mental health problems may deter some PAs from acknowledging or seeking help for mental health issues.^9,41 Initiatives to promote help-seeking and enhance collegial or system supports may prevent some problems from escalating to suicide.

Assailants

Nearly all suspected killers of PAs were male, consistent with national patterns showing that men perpetrate most homicides (88.8%).⁴² Relatives and current or former intimate partners accounted for most homicides. This accords grossly with FBI findings that in more than half of homicides, the assailant is a friend or acquaintance of the victim, and that family and intimate partners account for another quarter of the cases in which the perpetrators are known.⁴³

Effect

PAs' violent deaths are heartrending for their families, patients, colleagues, and others whose lives they touched. Because PAs are critical to the functioning of the healthcare system, the effect of their violent deaths is broad, affecting access to and continuity of care as well as the healthcare outcomes of the communities they serve.

These sobering findings emerge within a broader context of the relatively more extensive violent deaths in other healthcare professionals. The incidence of death by suicide reveals it to be a problem vexing the field, as it does for other healthcare professions.^9-11,44 In 2018, PAs had the lowest numbers and rates of death by suicide and in 2020 had among the lowest for homicide relative to nine other types of healthcare professionals.^11,17 The comparatively small number of homicides is both a source of reassurance that PAs' work is relatively safe and of concern that broader societal problems, such as gun and domestic violence, contribute to shortening some PAs' lives.

LIMITATIONS

Because this is the first study examining violent deaths of PAs, the findings should be considered preliminary. Although the objective was to obtain a truly national sample, the study was limited by the heterogeneous participation of states in the NVDRS during the observation period and likely underestimates true incidence. As state participation increased over time, tallies of deaths also increased. Variation in the number of participating states precludes discerning the extent to which increasing deaths reflect longitudinal variation in suicides and homicides or the greater number of participating states. Until full participation of all states (and all counties in them) is achieved and sustained, NVDRS data will not be able to provide a full accounting of PAs' violent deaths. The degree to which reports to the NVDRS underestimate the magnitude of the phenomenon is not known.

As the profession grows and the demographics of the workforce evolve, changes in the epidemiology of these phenomena can be anticipated. Future reports based on more comprehensive data will paint a clearer picture of PAs' violent deaths. Such data may contribute to the health and safety of PAs by leading to more targeted strategies for identifying PAs who may be at higher risk.

CONCLUSIONS

Mitigation of violent deaths requires recognizing them and taking effective action. Other healthcare professions' national organizations (such as the American Medical Association and American Nurses Association) are addressing their constituents' burnout and suicide risks. Similarly, the American Academy of Physician Associates' Blueprint for Addressing Physician Assistant Well-being and Burnout is a model resource addressing factors, such as mental health problems, that can contribute to PAs' violent deaths.⁴⁵ Programs are needed to address patient and healthcare professional safety and to mitigate stress related to healthcare professionals' work by streamlining workflow, improving service delivery, setting realistic performance expectations, enhancing support for workers, and promoting culture change. Self-assessments and resources to address burnout and psychosocial problems also are needed, as are programs to support survivors of colleague death by suicide or homicide. Multitiered national, regional, local, and institutional approaches can be envisioned with primary, secondary, and tertiary preventive programming and resources to attenuate the incidence of, and respond to, future violent deaths of PAs. For suicide prevention, more systematic publicizing of resources such as the national 988 Suicide and Crisis Hotline, Suicide Awareness Voices of Education (SAVE), and the American Foundation for Suicide Prevention may help prevent some deaths by suicide of PAs and their patients.

Most PAs' deaths reported in the NVDRS did not appear to be related to PAs' work in healthcare. Consequently, in addition to wellness-promoting efforts in healthcare professions and healthcare organizations, and enhanced security measures in the organizations that employ them, it is perhaps even more essential to confront the means and drivers that contribute to violence, including excessive availability of guns, domestic violence, and substance use disorders. Advocacy addressing a range of societal factors, including promoting violence-reducing policies and increasing resources to detect and mitigate risk, is needed to reduce violence affecting PAs, their patients, their colleagues in other healthcare professions, and their communities.