Physician Suicide: We can’t fix a problem we don’t talk about
Adam Was, MD & Rebecca Margolis, DO, FAOCA
In ASA president’s Dr. Michael Champeau’s Monday morning outreach email he discussed physician suicide because of the recent suicide of an anesthesia resident. I asked Drs. Rebecca Margolis, Children’s Hosital Los Angeles and Dr. Adam Was, the University of Michigan who are members of SPA’s well being committee to further explore this issue for the PAAD readership. Myron Yaster MD
Physicians are at increased risk of burnout, depression, substance use disorder and suicide when compared to the general population.1 Descriptions of increased suicide risk among physicians date back nearly 150 years.2 The problem has persisted: a 2019 study found that 119 physicians die by suicide each year.3 This is almost certainly an underestimate, due to the study’s strict inclusion criteria and pervasive underreporting of death by suicide. Whatever the exact incidence, we are losing approximately one medical school class each year to suicide.
The causes of suicide are multifactorial, but it is generally associated with inadequately treated mental illness. Depression is common amongst physicians, affecting 12% of males and nearly 20% of females, which is at least as high as the general population.4 Gender-based differences exist within suicide rates as well; the suicide rate among male physicians is 1.4 times higher than the general population and 2.3 times higher among female physicians. The risk for suicide increases with self-medication and substance-use disorder.
Anesthesiologists are at heightened risk for death by suicide,5although the reasons we have higher rates than other medical specialties remains unclear. The American Society of Anesthesiologists is currently conducting a survey, led by Dr. Michael Fitzsimons, to better understand associated factors. "The fear of stigma associated with disclosure [of mental illness or struggles], the impression that seeking care is a sign of inadequacy, concerns about confidentiality, worries about disclosure on medical licensure and privileging applications and fear that patients and peers will lose respect for the are just some of the reasons for reticence to seek help.”6
Medical trainees, with elevated rates of burnout, depression, and suicide, are another vulnerable group. In one study, almost 10% of medical students reported having suicidal thoughts in the last two weeks.7 Among residents, suicide is the second-highest cause of death. The stresses of training are myriad – long hours, inexperience, lack of support among senior residents and faculty, difficult interactions with other hospital staff, financial stressors, displacement from friends and family, lack of autonomy, frequent changes in schedule, negative feedback during rotations, novel exposure to morbidity and mortality – and contribute to the risk of mental illness and suicide. Additionally, the stresses of the COVID-19 pandemic have exacerbated these issues for all groups listed above.
Recently, there has been increased public focus on physician mental health. In March 2022, the Lorna Breen Health Care Provider Protection Act was passed into law, in memory of the Emergency Department physician who died by suicide in April 2020 after an intense stretch treating COVID patients and contracting COVID herself. This act – which had bipartisan sponsors and was supported by over 70 industry sponsors – aims to reduce and prevent burnout, mental health conditions, and suicide among healthcare professionals. The act establishes grants for training healthcare professionals in strategies to reduce suicide, burnout, and substance use disorders and enables comprehensive study of healthcare professional mental and behavior health and burnout. As Former Virginia Governor Ralph Northam said, “I know that much good came from Breen’s life. Now I hope some good can come from her death, and that her loss raises our awareness around mental health in the medical community.”
What can you, the reader, do to help?
1. Educate.
a. Watch the 4-minute YouTube video by Mayo Clinic and AFSP on preventing medical trainee suicide
b. Learn the risk factors and warning signs
c. Use this SPA One-Pager: Having Each other’s backs: breaking the silence on physician suicide to start the conversation with trainees and colleagues.
2. Plan. Ensure that your group has a response plan.8
a. As described in an excellent episode of the ASA Central Line podcast by Drs. Michael Fitzsimons, Ronald Harter, Catherine Kuhn, and Adam Striker (https://asahq.podbean.com/e/physician-suicide/), it is best to proactively develop a response plan for physician suicide. You should know who will respond, when, where, and how. Include a mental health professional in your plan.
b. An comprehensive resource for navigating a trainee suicide: After a Suicide: A toolkit for Physician Residency/Fellowship Programs
3. Encourage self-screening. The Healer Education Assessment and Referral Program offers an anonymous and confidential assessment and recommendations for healthcare providers. (https://medschool.ucsd.edu/som/hear/Pages/default.aspx)
4. Know and disseminate your resources.
a. Dial 988, the National Suicide Prevention Lifeline
b. ASA suicide prevention resources (https://www.asahq.org/in-the-spotlight/suicide-prevention-resources)
c. ASA well-being resources (https://www.asahq.org/advocating-for-you/well-being)
d. AFSP healthcare professional’s website (https://afsp.org/healthcare-professionals-mental-health-and-suicide-risk)
5. Intervene. Discuss physician mental health, burnout, depression, and suicide within your organization. Talk with your colleagues at the first signs of distress. Build a supportive culture. Ensure that mental health support resources are readily available and accessible. Schedule time for colleagues to receive treatment. Encourage clinicians to voice their thoughts, experiences, and concerns.
PS from Myron: The Society for Pediatric Anesthesia’s well being committee is chaired by Drs. Norah Janosy and Rebecca Margolis. It provides resources, support and connections. All SPA committees are open so please consider joining. Norah and Rebecca have also just posted an open anesthesia podcast that is worth listening to.
https://www.openanesthesia.org/podcasts/society-for-pediatric-anesthesias-well-being-committee/
If you have thoughts about today’s PAAD send them to me and I will post in a Friday Reader Response.
References
1. Mata DA, Ramos MA, Bansal N, et al. Prevalence of Depression and Depressive Symptoms Among Resident Physicians: A Systematic Review and Meta-analysis. JAMA. 2015;314(22):2373. doi:10.1001/jama.2015.15845
2. Bucknill J, Tuke D. A Manual of Psychological Medicine, Containing the Lunacy Laws, the Nosology, the Ætiology, Statistics, Description, Diagnosis, Pathology, and Treatment of Insanity. 3rd Edition. J & A. Churchill; 1874.
3. Gold KJ, Schwenk TL, Sen A. Physician Suicide in the United States:Updated Estimates from the National Violent Death Reporting System. Psychol Health Med. 2022;27(7):1563-1575. doi:10.1080/13548506.2021.1903053
4. Schernhammer ES, Colditz GA. Suicide Rates Among Physicians: A Quantitative and Gender Assessment (Meta-Analysis). Am J Psychiatry. 2004;161(12):2295-2302. doi:10.1176/appi.ajp.161.12.2295
5. Dutheil F, Aubert C, Pereira B, et al. Suicide among physicians and health-care workers: A systematic review and meta-analysis. Abe T, ed. PLOS ONE. 2019;14(12):e0226361. doi:10.1371/journal.pone.0226361
6. Fitzsimons MG. Corporate Support Lifts Important ASA Efforts: Addressing Physician Health Through Substance Use Disorder and Death by Suicide Initiatives. ASA Monit. 2023;87(7):33-33. doi:10.1097/01.ASM.0000945132.88401.17
7. Goebert D, Thompson D, Takeshita J, et al. Depressive Symptoms in Medical Students and Residents: A Multischool Study: Acad Med. 2009;84(2):236-241. doi:10.1097/ACM.0b013e31819391bb
8. Shinde S, Yentis SM, Asanati K, et al. Guidelines on suicide amongst anaesthetists 2019. Anaesthesia. 2020;75(1):96-108. doi:10.1111/anae.14890