There is but one truly serious philosophical problem and that is suicide. Judging whether life is or is not worth living amounts to answering the fundamental question of philosophy.
-- Albert Camus
About 400 doctors per year die of a fatal but largely preventable malady in our country -- suicide. That's three times the size of the entering class at the University of Florida College of Medicine. These deaths deprive about 1 million Americans of their doctors annually. That's almost the number of all the Rotatarians in the world, every year. Almost every practicing physician personally knows one or more colleagues who have taken their own lives.
Doctors die by suicide at a rate twice that of active duty military members. The American Foundation for Suicide Prevention reports that the suicide rate for male doctors is 1.41 times higher than the general population, and for female doctors it's 2.27 times greater. We need to urgently identify and correct the oppressive elements in modern practice environments that lead these caring healers to take their own lives.
The largest single factor contributing to physician suicide consists of untreated depression. Depression generally includes sadness, pessimism, sinking mood, aversion to activity, and loss of the ability to experience pleasure. In the general population about one in ten males, and two in ten females, have depression. About 10 percent of depressed patients attempt suicide. Because of their specialized knowledge physicians succeed in suicide at a much higher rate than the general population.
Depression probably originates from genetic, biological, environmental, and psychological factors. Genes supply about 40% of the risk. The success of pharmacologic and electroconvulsive therapies implies significant neurochemical and neurophysiologic contributions to depression's underlying etiology. The success of cognitive behavioral therapy argues for a psychological contribution as well. In other words, depression has relevant etiologic factors spanning multiple conceptual levels of organization, from molecules to minds.
Environmental factors significantly contribute to depression in physicians. The stresses doctors experience on a daily basis can equal those of military personnel in combat. Emergency rooms can resemble war zones. Doctors often find themselves at the intersection of competing interests -- they experience pressure from countless parties with differing agendas and feel pulled in several directions. Well-meaning but naive bureaucrats pile regulations which do nothing to promote health upon already overburdened physicians. Electronic health records, better suited for billing than for patient care, perplex and frustrate doctors in most practice environments. Administrators try to direct, command, and cajole doctors into actions benefiting the corporation more than the patient.
Changes in social stature can contribute to depression. Most medical students earned rankings at the top of their class as undergraduates in college. In medical school they find themselves surrounded by other stellar performers, and realistically may need to self-assess as
average. They may find such a reappraisal demoralizing. Medical education demands many sacrifices, often including the sacrifice of attention to personal health and relationships.
Physicians who have practiced many years may also feel demoralized as a result of changes in social stature. The forced adoption of coding systems requiring pigeon-holing of diagnoses, cookbook conformity to ever-expanding
guidelines, and imposed limitations on available treatment options has stifled creativity and turned the practice of medicine from a profession into a trade. Employers, agencies, and health care systems now refer to
providers, making little distinction between doctors, physician's assistants, and nurse practitioners. Hospitals appear to consider doctors as interchangeable, based on filling specialty slots, rather than identifying the strengths and talents of individual physicians and encouraging them to flourish.
One must follow and understand this fatal game that leads from lucidity in the face of existence to flight from light.
-- Albert Camus
To the general public, it may appear puzzling that physicians often ignore depression, suffering in silence, until they reach a point of crisis and willfully end their lives. Why would anyone knowledgeable of the dangers of untreated depression not seek treatment? The answer to this question involves personal fears and cultural mores.
The culture of medicine affords low priority to the mental health of physicians. Doctors must confront human pain and suffering every time they go to work. Such exposure exacts an emotional toll. Everyone, including doctors,
buys into the image of the physician as being strong and resilient. In many medical circles, it is taboo to discuss the physician's own emotional issues. Many doctors have no place to discuss or vent their distress.
Even if a doctor recognizes the seriousness of her depression, fear can override the desire for treatment. Such fear is not irrational. Medical communities are close-knit, and gossip travels quickly. Doctors reasonably fear stigmatization, damage to their reputations, loss of collegial esteem, and indelible marks on their records affecting future employment opportunities. For example, the Florida Board of Medicine Medical Doctor Licensure Application asks,
In the last five years, have you been admitted or referred to a hospital, facility or impaired practitioner program for treatment of a diagnosed mental disorder or impairment? After dedicating a large part of one's life to training and the practice of medicine, anything that might interfere with licensing is a major threat.
Other fears blocking a decision to seek treatment include taking the necessary time off, financial concerns, loss of referrals, and loss of privileges.
Doctors, by nature, selection, and training are intelligent problem solvers. Unfortunately, with depression you can't think yourself out of your situation.
Physicians are smart, tough, durable, resourceful people. If there was a way to MacGyver themselves out of this situation by working harder, smarter, or differently, they would have done it already. -- Simon G. Talbot and Wendy Dean
Psychiatry is not an exact science. Even with psychiatric treatment some physicians will nevertheless proceed with suicide. Some patients respond well to particular medications while others prove ineffective. The period shortly after initiating antidepressants is particularly hazardous with regard to suicide. The suicidal doctor may trivialize the depth of his despair and convince the psychiatrist that his depression is not that bad. The psychiatrist may not ask tough questions out of deference to a colleague. The psychiatrist might withhold stronger medications or ECT because of concerns regarding cognitive effects on the physician-patient. The depressed doctor may cleverly provide just the right answers to short-circuit cognitive therapy. Reasons like these can result in less than optimal psychiatric treatment for physician-patients compared to the general population.
Even after treatment, the physician must return to the environment that contributed to his depression in the first place. Hence, relapses are common.
Many organizations have begun to notice the prevalence of suicide amongst doctors. There are a few, such as the American Foundation for Suicide Prevention, that aggregate resources addressing the problem of suicide in general. There are almost none specifically organized to counter the problem of physician suicide.
We started Doctor Lifeline, Incorporated, as a Florida nonprofit corporation dedicated to preventing physician suicide.
We intend to identify and correct the factors influencing the high rate of physician suicide. Some of these include a culture discouraging doctors from seeking help for burnout or depression. Others include increasingly hostile workplace environments, loss of societal stature, excessive documentation and regulatory demands, anxiety over litigious patients, inflexible poorly designed electronic health records, insurance company preemption of clinical decisions, and a general feeling of increasing powerlessness.
We intend to apply for 501(c)(3) status with the IRS. We are seeking experts to fulfill our education, intervention, and advocacy missions. We welcome collaboration with other suicide prevention organizations and professional societies.
Please visit www.DoctorLifeline.org for further information.