Out of the shadows: Shining light on physician suicide

PFSP Perspectives

September 30, 2016

Contributed by: Sara Taylor, MD, CCFP | Assessment Physician, PFSP

“The life so short, the craft so long to learn.” – Hippocrates

Canadian Indigenous communities are in the midst of a public health crisis related to suicides. Some of the newspaper headlines include: “First Nations’ suicide crisis focus of talks with Trudeau; PM to meet with chief in bid to solve mental-health woes at embattled Ontario reserve” (Toronto Star); “The Canadian First Nation suicide epidemic has been generations in the making” (The Guardian); “Five more suicide attempts made in Attawapiskat” (The Globe and Mail).

Widespread attention has grown around the number of suicides involving Indigenous Peoples, with focus on certain reserves and, alarmingly, on the pediatric population. This awareness has prompted a call to action.

Parallel to this awareness is a more hidden epidemic within the medical community that has also seen newspaper headlines, including André Picard’s November 2015 article in The Globe and Mail, “Suicide should not be an occupational hazard for doctors”.¹ Although conversations around physician suicide are happening, the true gravity of the situation is difficult to appreciate with the secrecy and shame that often goes along with suicide.²

Why is suicide more common among physicians than the general population?

The statistics around physician suicide are undeniable. Each year in the United States, 300-400 physicians commit suicide. The rate in male and female physicians is 40% and 130% higher than in men and women in general, respectively.² In an interview with CTV’s Canada AM, Dr. Derek Puddester, Associate Medical Director of the Ontario Medical Association’s Physician Health Program, said: “The concerns here mirror those in the United States. We’ve known for a number of decades that physicians have a higher risk of attempted and completed suicide.”

One would wonder if it is the proverbial chicken or the egg. According to Picard: “The very qualities that make someone a good doctor – empathy, caring, perfectionism – make them vulnerable to burnout, depression and suicide.”¹ In fact, a study found that when students started medical school, they actually had lower rates of burnout and depression and a higher perceived quality of life compared to their counterparts.³ Higher levels of burnout are independently associated with suicidal ideation which is concerning given that more than half of physicians are experiencing professional burnout.⁵

Some of the other reasons cited⁴ for an increased rate of suicide in physicians include:

• Not recognizing mental illness in themselves, self-treating a mental illness, or not seeking help because of the stigma surrounding mental illness.
• Fear that disclosing suicidal ideation (and the underlying cause) or a mental illness may result in professional consequences such as losing their medical license.
• Increased professional expectations from student to resident to practicing physician.
• Higher rate of completed suicide versus attempted suicide due to knowing lethal methods (not due to an increased rate of depression).
• Untreated comorbidity factors such as depression and substance misuse.⁶
• Impaired judgment from an underlying medical disorder such as substance misuse or depression.⁷
• Physicians often use denial as an ineffective coping means and are not good at tending to their own wellness needs.⁸

What are some of the warnings signs of possible suicide of a trainee or physician?

Many of these signs are applicable to the general population. However, certain personality traits such as perfectionism and workaholism are more common among physicians, which makes physicians at a higher risk when things go wrong. Intervention and support become crucial when any of the following signs appear:

• Escalating substance misuse
• College complaint, medical license suspension
• Separation/divorce or dissolution of an important relationship
• Death of a loved one
• Serious financial troubles
• Recent relatable suicide
• Withdrawing socially/obvious change in behavior (could present as contentment/euphoria)
• Apparent despair and hopelessness

What can be done to help physicians who might consider suicide?

As with most things in both medicine and in life, awareness is the key in order to identify ways to help our colleagues before suicide happens.

At the physician trainee level:

• Ongoing discussions related to self-care and personal wellness through courses, academic half days, retreats and conferences.⁷
• Access to supportive resources through medical schools and provincial health programs.

At the practicing physician level:

• Ongoing dialogue in the form of presentations to and publications for physicians to decrease the stigma of mental illness and stress-related conditions.
• Formal physician groups such as Balint groups which consist of between six and 10 physician members with one or two trained leaders. These groups focus on doctor-patient relationships with peers, improve empathy and improve resilience (both personal and professional). In a commentary by Dr. Michael Roberts that appeared in the Canadian Family Physician, he states, “The goal is to improve physicians’ abilities to actively process and deliver relationship-centered care through a deeper understanding of how they are touched by the emotional content of caring for certain patients.”
• Informal physician groups such as book clubs or journal clubs, which provide a supportive environment to promote expression of emotions.
• Reflection exercises such as narrative/creative writing and journal writing.
• Build physician resilience through various elements such as balancing work and family life, prioritization, organization, maintaining perspective and setting boundaries.

To anyone who has been personally touched by physician suicide

Unfortunately, I am sure most of us know of a colleague, either directly or indirectly, who has ended his or her own life. During my 16 years as a practicing physician, I know of a handful of physicians who have committed suicide, but I am guessing there are more that I am unaware of.

If you have been more personally impacted by suicide, you may experience feelings such as blame, shame and anger. Reaching out to health care professionals, your physician health program, colleagues, family and friends can make all the difference to your own emotional health. Shining light on physician suicide and having an open conversation about it can save the life of someone you know or even yourself.

We are physicians, but first and foremost we are imperfect humans. As Brené Brown says, “Imperfections are not inadequacies; they are reminders that we’re all in this together.”

Resources

• Physician and Family Support Program of the Alberta Medical Association – confidential support line 1.877.767.4637
• American Foundation for Suicide Prevention – Physician and Medical Student Depression and Suicide Prevention DVDs
• The American Balint Society
• The Canadian Association for Suicide Prevention
• Centre for Addiction and Mental Health

References available upon request.