By Steven Reames
“Objectively, to take one’s own life is a nonsensical act, unless you are that person and it is the only way you see out from your unrelenting psychological pain.”
I recently had the privilege of sitting down with two Boise doctors about the challenge of physician suicide with hopes we might learn something more about preventing it. It was a sober conversation, as one shared his story of a near-miss on his own life, and the three of us discussed a mutual physician friend who did complete suicide in 2017.
In the first case, you have a physician who went from O.K. one day to an acute suicidal state because of a bad medical outcome and the potential of losing his job. The ironic event that saved his life was being tased, arrested, thrown in jail, and then placed in an ICU on ventilator support after respiratory and cardiac arrest. Eight days later, he walked out.
In the other situation, a physician has wrestled the demons of depression for much of his life, but got tipped over emotionally through rough administrative handling and came to a point he could not see a viable future for himself anymore.
Listening and talking through these two stories, it came as no surprise to me that some of the same suspects emerged that I have seen over and over in my reading on the subject. I would like to propose four “buckets of hopelessness” that many physicians face.
Whether it is a bad medical outcome, a malpractice suit, patient complaint, or Board of Medicine inquiry, the fear that comes on physicians when their reputation is at stake can be very acute. Part of it may be due to the hurdles physicians have overcome to get into ‘the tribe’ and anything that puts that belonging at risk eats at the root of many a doctor’s identity: “I am what I do.”
The feeling of incompetence – whether internally or externally induced – is especially damaging. They can be greatly exacerbated by opaque administrative processes and attitudes that label doctors who grow cynical, demanding, or rude as “disruptive.” The alternative might be to see their edginess as an indicator that something about their work environment is not working for them or for patient care like it should.
“Physicians eat grief for a living, but how do they eliminate it?” was the first thought in my head after leaving lunch with the doctor who died. And I mean that in the biological sense of ‘eliminate,’ because grief is like a waste product of the experiences physicians have in caring for patients. Starting in medical school and residency, trainees have often been left on their own to deal with the trauma of their first patient death rather than being compassionately coached through the process of loss. Unaddressed, grief can create an "emotional constipation" that builds up and blocks the normal and healthy processing of these matters - until it explodes.
With so much focus on physician burnout over the last five years, it might be easy to miss what is really Major Depressive Disorder, according to a trio of physicians who wrote about the subject in JAMA. Although there is an overlap in symptoms between the two – such as emotional exhaustion – it is far easier for physicians to admit that they are burnt-out these days rather than taking on a psychiatric diagnosis. It is well documented that medical trainees experience high rates of depression. There is no reason to expect that it either just goes away upon becoming an attending or that they seek proper treatment in a culture where stigma is still so high.
The physical, emotional, and spiritual price paid to get into the profession is high enough. Add to that a few hundred thousand dollars in just student debt – let alone a mortgage and other expenses – and doctors can feel just as trapped as a person forced to use a payroll loan service. I personally urged my physician friend to look beyond his current employment and explore other options. But it never occurred to me the length of time it takes to get credentialed with a new hospital or Medicare, especially if you have been on administrative leave for a dozen weeks. “My death will take care of your finances” is a common rationalization to a spouse or children for a person looking for a way out.
I should pause to say here that even though these are fairly common experiences for physicians, to end up choosing suicide as the escape hatch is the exception. The vast majority of physicians successfully negotiate these difficulties and go on with the practice of medicine, contributing to their community, loving their families.
While it may be convenient or useful to bucket big stressors together like this, the greater challenge is to know how to address them effectively. There is no simple script one can recite to a doctor who has emotional tunnel vision like this. Frequently, some or all of these conditions will overlap each other, creating a complex Gordian knot.
Nevertheless, the more that physicians are aware of these factors, the better able they are to watch each other’s backs when these conditions converge in a colleague’s life. In fact, probably one of the best preventative efforts the tribe can make is to be available to listen, to ask difficult and direct questions when your gut tells you something is off, and learn what resources are available to lead somebody to.