“Raising Awareness Concerning Physician Suicide,” Jackson & Coker’s latest survey, addresses these troubling questions.  During May, our research department e-mailed an 18-question survey to a nationwide cross-section of physicians and healthcare providers, with 985 participants responding.

Demographics

The majority of respondents were male (55%).  Only 3% were under 30 years of age, whereas 16% were over 60.  There was a fairly even distribution of responses among age categories from 31 to 60.  For the most part, the respondents practice medicine in a wide variety of specialties. 

Level of Awareness

Although the vast majority of respondents (69%) are generally or somewhat aware of issues concerning physician suicide, 30% admit that they are “not very much aware” of the issues. 

Even among doctors who have some awareness of physician suicide, there is a tendency not to discuss the topic very much.  Forty percent of respondents discuss the topic occasionally, but 55% said that they “never” discuss the topic with professional colleagues or professional acquaintances. 

The majority of participants believe that, given the statistics concerning physician suicide, there needs to be greater awareness of the causes and preventative measures that can be undertaken.  Ninety-two percent feel that not enough is being said about physician suicide, although it is certainly not an easy topic to discuss.

Another question focused on respondents’ personal knowledge of doctors who have committed suicide or at least made the attempt.  Whereas 12 percent of respondents knew of someone who has attempted suicide, 47% knew of colleagues who actually took their own lives.  The majority of victims were male (87%).  Thirty-three percent were in age categories 31-40, and 17% were age 51 or over. 

The vast majority of suicide victims (both male and female) held an M.D. degree, but a slight number were D.O’s. 

The gender breakdown was significant.  Most female physicians who committed suicide were age 41-45 or younger (although a small percentage of female doctors over 60 were cited).  By contrast, male doctors were represented in all age categories listed, most notably in the 41-50 year range. 

Gender was a significant factor in another key respect.  Over twice as many female doctors attempted suicide compared to those who actually took their lives.  By contrast, the survey shows that most male physicians completed the job once they have made the determination to commit suicide.

It is interesting to note the percentage of medical specialties represented among suicide events.  The greatest incidence of suicide attempts or completions is associated with the following specialties (in descending order from 16% to 4.5%):    
 
Family Practice
Internal Medicine
Anesthesiology
Psychiatry
General Surgery
Pediatrician
OB/GYN
           
On the other end of the spectrum, the specialties cited least frequently (all under one percent) were:

Physical Medicine & Rehab
Thoracic Surgery
Geriatrics
Neonatology
Occupational Medicine
Vascular Surgery

The survey also focused on likely causes—“precipitating factors’—that led to the suicide attempts or completions.  Sixty-seven percent link suicide with workload or occupational stress and burnout.  Another 56% of participants cite severe depression, whereas 26% name alcoholism or substance abuse as risk factors.

Respondents speculated on what might have been factors that pushed suicidal doctors over the edge.  Here are some of their comments: 

“HIV infection”

“Social isolation, poor self-esteem, inability to meet people”

“Obesity, lack of mobility, [multiple sclerosis]”

“Dealing with hospital problems as chief of staff”

“Disillusionment due to the corporate practice of medicine”

“Waning age and appearance, troubled relationship”

“Just arrested for sex crimes”

“Stress of deciding which patients would be moved out of ICU”           

What were the warning signs?  Thirty-six percent mentioned withdrawal from social connections.  In equal percentages (21%) respondents cited either the doctor’s lack of interest or commitment to professional responsibilities, or self-abusive habits or behavior. Somewhat surprisingly, 44% of participants checked “no particular warning signs.”

According to the survey results, 49% of physicians who attempted suicide are no longer practicing medicine, but 23% are still treating patients.  It is believed that 32% of those who attempted suicide are receiving regular psychiatric or psychological counseling.

At the heart of the survey was this question:  “To what extent is the healthcare profession capably addressing the problem of physicians who are at risk concerning suicide?”

Fifty-one percent believe that not enough is being done to help doctors at risk, whereas 45% believe that discussing suicide is a taboo topic and not often discussed at all. 

Why don’t doctors who are at risk seek professional help from mental health professionals?  Concerns regarding professional reputation topped the list (32%), followed by fear of loss of job or hospital privileges (22%) and societal stigma (15%).

Comments provided by participants offer some special insights as to why physicians are hesitant to seek mental health intervention: 

“Trying to diagnose and treat their own problems; the hopelessness that is part of depression makes treatment seem futile.”

“There is the ‘MDeity complex’—any good doctor should be able to handle these issues by [himself].” 

“Alcoholism is protected by law.  A suicidal thought or attempt is not.  [The] physician would be labeled for the rest of his/her career.”

“Physicians don’t know how to ask for help.”

“An important target of peer review blackmail, the physician is already isolated by his peers [and doesn’t] want to be targeted next.”

“[The doctor] will always have to put that on paperwork for privileges, and [doesn’t want the resultant] stigma. 

The survey concluded by asking:  “What more could the healthcare profession do to address the problem?”  The number one response (37%) is to reduce the stigma attached to doctors who receive mental health care.  Secondly, 20% of respondents favor discussing risk factors with residents.  Another suggestion is to minimize the pressures put on doctors in busy hospitals (11%).

Respondents offered specific suggestions for raising awareness and, hopefully, preventing future suicide events:

“Protect physicians who come forward and admit to suicidal ideations.  By protection, a law that protects against litigation, loss of privileges, etc.”

“A combination of awareness in residency and mandatory counseling yearly.”

“Discuss risk factors as part of training AND reducing stigma to accessing mental health care.”

“Physicians should reach out to physicians.”

“Make mental health counseling commonplace and mandatory when certain ‘signal events’ occur.”

“Educate the public about current legal work hours for physicians, because no one else in the medical profession will be able to challenge [that] expectation.”

Commentary by Credentialing Professional

Marlene McIntyre, CPMSM, serves as Director of Quality and CVO Services for Jackson CVO, a credentials verification organization.  The firm provides credentials verification and hospital privileging assistance to locum tenens physicians.  She reviewed the survey results and offered her professional perspective on why physicians are reluctant to seek mental health care in terms of the possible consequences concerning their ability to practice medicine.  Her commentary: 

Anything that would impact a physician’s ability to practice medicine effectively—including depression, substance abuse, etc.—must be reported to the licensing agency (board of medicine).  Often the board will learn of an issue only after the issue has become so significant that it is reported by another physician or hospital. 

A medical board may impose monitoring of a physician with a depressive disorder that can include enrollment in the state’s ‘impaired provider program,” as well as drug screenings, counseling sessions, etc.  It is important to realize, too, that once actions are taken, this information often becomes public knowledge and is easily uncovered through the credentialing process.  Thus, physicians don’t have the same benefit that other patients have in being treated anonymously—their treatment is known at all levels of their trade.

As a result, physicians and other healthcare providers are often reluctant to seek care for physical ailments, and seeking care for psychological ailments is even more difficult.  Many physicians ‘self treat’ their physical conditions and many make the same decision to self treat depression and other psychological ailments.  Doctors feel the need—albeit a self-imposed psychological one—to appear strong, healthy, and whole for their patients—so reaching out for help first requires a physician to admit that he/she is not whole and needs help.

The healthcare industry needs to highlight the fact that depression is often a ‘normal’ state of life and physicians are people first and physicians second.  Medical staff programs that educate physicians on how to recognize depression symptoms in colleagues and a system that makes it ‘okay’ to reach for help without repercussions will go a long way in bringing the problem out of the closet and into the light of day where it can be effectively addressed.  Healthy physicians are a requirement for healthy patients—we can’t have one without the other. 

Analysis

Physician suicide is more prevalent than one might think, as our Special Report and this survey indicate.  In fact, nearly sixty percent of survey respondents knew of someone who committed suicide or at least made the attempt. 

Although the topic is apparently not discussed at great length among healthcare practitioners, the reality sets in when doctors learn of colleagues who take their own lives.

As clinical studies point out, there are numerous risk factors for suicide.    Warning signs include ongoing depression, withdrawal from customary interaction with family or colleagues, loss of enjoyment of life, feelings of futility and hopelessness, and unexplained impulsive behavior, among others.

Even when these signs are present, persons in close association with potential suicide victims are often reluctant to say anything.  There is undoubtedly some degree of awkwardness that many physicians would feel in advising a fellow clinician to seek medical help.   

Furthermore, it is generally believed that physicians who are suicidal are hesitant to discuss their problem with anyone, for a number of reasons.  Along with the general societal stigma attached to suicidal tendencies is fear of job loss or concerns for their professional reputations as a result of reporting personal problems.  For many doctors, their whole life revolves around their occupation.  If their occupational future is severely threatened, their fundamental reason for living comes into question.   

Without doubt, the healthcare community is well advised to do more to spotlight the problem and provide ample support for those caregivers who appear to be at risk.  Addressing the issue as early as residency training is one practical step in raising awareness.  Providing safeguarded outlets to discuss the onset of suicidal thoughts is another helpful preventative measure. 

As Ms. McIntyre mentions, it is also beneficial to “normalize” the reality of depression as it is viewed by society in general and by clinicians who may suffer from it.  If doctors who experience the onset of depression feel more comfortable seeking mental health care before depression leads to more self-destructive thoughts, this would be an important step toward minimizing behavioral patterns that lead to suicidal events.    

Lastly, showing genuine support and care for those who are reaching out for help is the singlemost important interventional step anyone can take.  If even one life can be saved as a result, certainly it is well worth the effort made.