A sense of angst was rattling students at the University of Southern California’s Keck School of Medicine. One of their peers had taken his life days before.

Professor Mikel Snow felt the dark undercurrent and knew he had to speak up. So, for the first time, he told his students about his decades-long struggle with depression. As word spread, students across the campus started contacting him to discuss the suicide — and to share their own psychological distress.

“The reaction has been astounding,” Snow said. “It crystallized that this is a much bigger issue than any of us really realized.”

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Suicide among medical students and doctors has been a largely unacknowledged phenomenon for decades, obscured by secrecy and shame.

Now, it’s beginning to emerge from the shadows.

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More than 62,000 people — many of them medical professionals and their families — signed a petition this year calling on medical associations to track physician suicides, provide confidential counseling, and require doctor training programs to address a “culture of abuse” too often characterized by bullying, harassment, and humiliation.

Those groups are responding. The Association of American Medical Colleges last month convened a meeting to address an escalating crisis of depression, burnout, and suicide among physicians. Among the ideas under consideration: encouraging medical students to join clubs so they feel less isolated; ensuring that counseling is more accessible and private; and more actively tracking the mental health of students and doctors.

“This is something that the profession as a whole needs to come together around and deal with as a shared concern,” said Dr. Darrell Kirch, president of the AAMC.

He knows the pain firsthand: He lost two students to suicide during his tenure as dean at medical schools in Pennsylvania and Georgia.

The Accreditation Council for Graduate Medical Education, which oversees the doctor training programs known as residencies, is also focusing on the issue. Officials are studying residents’ deaths to determine which might have been preventable, and how to respond. The group sets standards for residencies and is looking at how to strengthen them to protect young doctors’ mental health.

Hospitals, too, are racing to launch support groups, peer counseling, and sessions to teach doctors to manage stress by meditating or keeping journals.

The new attention to physicians’ mental health comes too late for Cheryl Collier, who had no inkling that her 25-year-old son, Sean Petro, had plunged into despair during his third year at USC’s medical school.

“If only he’d said, ‘I’m depressed, I’m unhappy, I don’t know what to do.’ Perhaps I could have helped him,” said Collier, weeping with grief and frustration.

In the weeks after Sean’s death in May, someone mentioned to Collier that medical students and physicians have a high suicide rate. “I had no idea that was even a possibility,” she said.

Sean Petro
Sean Petro at his Navy graduation. Courtesy Cheryl Collier

An epidemic of depression

The starkest sign of the crisis gripping medicine is the number of physicians who commit suicide every year — 300 to 400, about the size of three average medical school classes. Male doctors are 1.4 times more likely to kill themselves than men in the general population; female physicians, 2.3 times more likely.

The grim tally is probably an under-count, since many suicides aren’t listed as such on death certificates. And it doesn’t include suicides among medical students, which aren’t tracked systematically in the United States.

In one study of six medical schools, nearly 1 in 4 students reported clinically significant symptoms of depression. Almost 7 percent said they had thought of ending their lives in the last two weeks.

In another, more recent study, 29 percent of residents suffered from significant symptoms of depression. And those symptoms escalated within a year of starting training — a sign that residency programs themselves were contributing to the problem.

The stress starts in medical school, where students face pressure to master an overwhelming amount of material. Competition with peers can be brutal. Sleep deprivation is common. And students can face withering criticism from faculty who have little tolerance for ignorance, signs of weakness, or emotional displays.

Once they’re practicing, physicians face additional stresses: An immersion in human suffering. Long work hours. High expectations. A dread of making mistakes. They’re often profoundly uncomfortable with acknowledging vulnerability. And they must adapt to a rapidly changing health care environment.

Medical education and training are “a profoundly dehumanizing experience and it’s drilled into you: Do not show your heart or tears to anyone, ever again,” said Dr. Pamela Wible, a family doctor in Eugene, Ore., who has grappled with profound depression, written a book about physician suicide, and given a popular TEDMed talk on the topic.

By necessity, Wible said, doctors become “masters of disguise,” expert at concealing their emotions.

‘I never saw this coming’

Sean Petro must have learned to conceal despair and hopelessness at some point.

In an emotional interview, his mother described Sean, her only child, as caring, generous, smart, and sensitive. She used to run a small day care out of her house; Sean helped her feed the children and gave them toys he’d outgrown. “He treated them like brothers and sisters,” she said.

That love of children inspired Sean to declare in second grade that he wanted to be a pediatrician. He changed his preference to oncology after his father died of stomach cancer when Sean was 15.

When it came time to go to college, Sean decided to keep living at home in San Diego with his mother. Collier understood that he saw himself as her protector.

Sean did well in medical school at the University of Southern California; he had friends and he seemed well-adjusted. Though Collier didn’t hear from him often, she wasn’t concerned. He was living on his own for the first time, and he wasn’t a big talker.

Unexpectedly, though, Sean started calling regularly — and talking to his mom for an hour or more — during a month-long training Navy officer program in Rhode Island this past April. She thought he might be lonely.

He flew home after finishing the program on May 6 and spent the day with friends, hanging out in the hot tub and talking about his interest in becoming a Navy flight surgeon. “We had a wonderful, wonderful day,” said Dr. Roneet Lev, the mother of Sean’s best friend.

The following day was Mother’s Day. Sean was quiet but brushed off his mom’s concerns and gave her a warm hug before driving home to Los Angeles.

As promised, Sean texted his mother to tell her he’d arrived home safely. But he didn’t return texts she sent the next day. On Tuesday morning, USC police entered his apartment and found him hanging from an exercise bar at the top of his closet. There was no note.

“He never said anything,” Collier said. “I never saw this coming.”

Kevin Dietl
Kevin Dietl and his family at his White Coat ceremony, August 2012. Courtesy John Dietl

‘My career is over’

By contrast, John and Michele Dietl knew that their son, Kevin, needed help.

But they didn’t know how to interact with the medical school he was attending when his life began to unravel.

Kevin took his life on April 23, 2015, near the end of his fourth year at A.T. Still Kirksville College of Osteopathic Medicine in Kirksville, Mo.

“He was always stressed. He’d call and say, ‘We had this test and I missed the grade I wanted by one question,’” John recalled. “And he’d say, ‘I have no social skills any more because I’m studying all the time.’”

The Dietls urged Kevin to get help, but he told them he couldn’t risk seeking counseling because it could appear on his record and compromise his future. So the family decided to pay cash for therapy, off-campus.

In the middle of his fourth year, crisis struck. Kevin became agitated after questioning his decision to go into psychiatry. A few days after Christmas vacation, he drove his car off the road. Sleep deprivation, he told police, but they didn’t believe him and put him on a 96-hour psychiatric hold.

“My career is over,” Kevin told his parents.

“We had no idea what to do,” Michele said. Should they contact the school? Encourage Kevin to withdraw?

“As a parent, you’re afraid to call and say you think something is wrong with your 26-year-old young adult. You don’t know what your options are,” Michele said.

A month later, John and Michele decided to organize an intervention. Before they could do so, Kevin drove to a railroad crossing, intending to chain himself to the tracks. Again, police intervened. This time, he volunteered to go into inpatient treatment.

Kevin seemed “like a different person” after a three-week stay, John said. He called his dean and said he was ready to go back at the end of April. He told his parents, “I can do this.” But they knew he was upset about not graduating with his classmates.

Toward the end of April, John went into Kevin’s bedroom and sat down on the bed. “We know this is extremely hard,” he told his son, “But you’re taking responsibility for getting better and you are getting better. We just want you to know we love you and appreciate it.”

Arriving home from work the next day, John smelled fumes coming from the garage. Kevin was inside the car with the engine running, his head covered with a shroud, so his parents wouldn’t have to see where he’d shot himself.

Speaking out

The Dietls will appear in an upcoming documentary about physician suicide, “Do No Harm,” the first feature-length examination of the issue.

Robyn Symon, the director, came to the topic after two young doctors in New York City jumped to their deaths in 2014. She said she hoped the film will “break the code of silence around suicide that exists in the medical profession.”

The Dietls have also begun to travel across the country, speaking out about the need for change in medical education and training.

“You can’t just tell these students, ‘Well, we’re going to help you deal with stress and give you some resiliency training,’” John said. “The problem is bigger than that and something more needs to be done.”

Share your thoughts on depression in the medical profession

  • Addition to my rant
    A portion of patients take 0 responsibility for their health. Migraine patient complaining she gets 2-3x weekly migraines and refuses to quit smoking. People not showing up for prenatal till 3rd trimester. Diabetics who won’t lose weight. It goes on and on. Dentists have the same problem; people come in with trench mouth and 20 cavities and get upset at the high bill, disappear, end up screaming in pain in the ER.

    Of course, this is all somehow doctors (and taxpayer’s) fault.

    • Some of what you say is true, but we have been deceived regarding “diabetes”. Several studies show that diet and exercise have little or no influence on the course of the disease. See my textbook, “Disorders of Blood Sugar” (amazon.com) and my YouTube presentations. My documented point of view led to my being forced out of practice by insurance companies and angry mainstreamers. Glycemic indices (HgbA1c, FBS, 2 hr PP etc) are not accurate diagnostic measures. For example Nesidioblastosis patients sent to my office had A1c’s which varied between 5.0 and 10.5 (unpublished). Never heard of this have you? It’s on Wikipedia. It was first described in 1938. There are over 500 reports on http://www.pubmed.com. Not taught in medical schools. But is actually more common than Type 2 DM today. (Do C-Peptide testing, insulin assays and CGM to prove this). See 1982 path study showing over 36% of adults have this tissue in the pancreas. “A word to the wise…..” The hype and corporate control of information will astound you.

  • Nobody cares about doctors. All the problems of the medical system are blamed on doctors. The system is being crushed under its own weight and doctors get every bit of the blame. Everyone seems to be an expert in how competent doctors should be, what should be covered in medical school, what their responsibilities should be, etc etc. If they see a new patient every 15 min, they see 30 people in a day, plus all the paperwork and telephone calls to catch up on. They can’t go on vacation without worrying they forgot something or if Mrs. So-and-So is doing ok in the hospital. They are treated worse than animals in residency. If an Amish farmer tried to work a mule for 18 hours straight, animal control would be called. The respect of the field has totally evaporated. They are resented for their high pay… which after taxes, student loans and their long hours are factored in is actually often not that great.

    A similar situation is happening with public school teachers.

    • I’d add that doctors have nearly completely lost control of our industry. Hospital administrators, insurance companies, and demanding patients all own us now. We have no control of price, not even in private practice. It’s hard to find doctors who actually understand the economics of the payments and how things work. It’s certainly not something that’s taught to you in a class. We have lost respect, and we are middle class. We make more money than others in middle class but perhaps our happiness is lower. Healthcare is a wreck. My condolences to the families mentioned in this article. That elevated and underestimated suicide rate amongst doctors and med students is indeed a statistic that as we say is “significant.”

    • Thought it’s only in Nigeria we face such stuff! And you know you should thank God for what you have because lots of Nigerian doctors go to the USA to practice and do well there!

  • I went to Chiropractic college. This is a lot of work, and it is still less than medical school. I did 21-25 credit hours a semester for 4 years, including summers year round. The pressure to pass your boards is very high. You can’t ever ignore your patients, even when you have personal family problems, one’s that most people would take a few days off to deal with. You get yelled at by patients, by your superiors, and generally treated like dirt. I decided that teaching was for me.

  • Medical education and debt are truly brutal, but I managed to survive. However, I am now more miserable than ever thanks to Obama. I’ve become a second class citizen in this country because I am a doctor. I am told what I cannot own (section 6001 ACA doesn’t allow us to own our own hospitals anymore) and what I must own (Obama signed the HITECH act ramming electronic medical records down our throat) and I am told I will soon have to report in to my CMS overlords (MACRA/MIPS). Right now government interference in medicine is so bad that most doctors are selling their practice to hospital groups, retiring, or committing suicide. Suicide has crossed my mind, especially when insensitive ungrateful patients just decide to ignore their bill and disappear, but I fortunately have another way out. If Hillary wins, I won’t commit suicide, but I do plan to emigrate. Her plans will drive all solo practitioners and small practices out of business. The Democrats have turned my American dream into a nightmare. If she wins, welcome to assembly line medicine, but I won’t be here to suffer any longer.

    • Doctors have lost control of our own profession. We’ve become pawns sadly to people like administrators who don’t work overtime, weekends, or holidays and in a lot of cases make as much money as us and for the c suite guys make multiples of our salaries. Not true freedom in the industry when you the bureaucratic red tape is so bad and that only publicly traded companies can effectively make profits

  • They kill themselves when they see the bill from Medical school and all the money they had to borrow.

    • “carnac,” I am presuming you posted this thinking it was funny, but laughing over hundreds of people a year dying of suicide exemplifies the way we use humor (and other strategies) to dissociate emotionally rather than connecting through empathy. And that certainly contributes to the emotional isolation in the profession, and thus to the problem this article is trying to address.
      I don’t wish to get into the sort of flaming exchange that online comments too often generate, but thinking of the families devastated by physician suicide, I really felt compelled to address the toll when we succumb to an impulse to mock rather than being emotionally moved.

  • I did my MD PhD which was structured as 2 yrs of medical school complete the PhD and return to years 3 and 4. I found the first 2 years of medical school bad but manageable. My PhD years were rather pleasant but oftentimes I felt lost, alone and not sure why I was doing all of this. I went back to years 3 and 4 and a total horror. I had been 5 years out of medical school and of course I had forgotten most things. I was abused and had some residents came after me because I had a PhD. I had 2 newborn twins and my then wife was in residency. I remember my kids were sick and my wife was covering the ICU so I told my chief resident in surgery at the time I needed to pick them up. I will never forget what she said to me ” you have a wife and don’t you value your career?” She said I am sure you will make the correct decision and do your work. I told her my family comes first and she tried to fail me since I left to take care of my children. I then decided to leave medicine for 2 yrs and worked as a biotech consultant but when I got divorced I went into residency. I was lucky. I went to a great psychiatry residency with very supportive, kind and compassionate faculty and co-residents. Still, I would never ever do an MD PhD or MD again if I had a do over.

    • Thank you so much for posting this. I’m a 3rd year med student and single mom. After reading this, I realize that I am not insane. This is the first time I’ve ever wanted to be done with medical school. But your story has given me hope tonight.

  • Like Joe who comments below, my residency experience was truly horrible. I also completed my residency in the mid 90’s. And I also experienced extreme verbal abuse in addition to extreme physical and mental stress from the grueling hours and high pressure. Senior residents would abuse me and other junior residents for sheer sport. I even volunteered to work two call nights in a row after a scheduling mixup to spare my co-intern. Despite my selfless sacrifice, I was severely chastised when I grabbed a single hour of sleep during the ordeal. I only did so to avoid endangering patients due to my fatigue. There was no support system whatsoever for me either. I was often reduced to tears when alone at home. At the time, I felt shame for not being stronger. With time, I now realize I was quite strong but victimized by a terribly inhumane system. I survived but believe I developed PTSD from the entire experience.

    Post-residency, physicians are victimized as well by an inhumane system that expects not just perfection but superhuman or supernatural performance under the threat of lawsuits.

    We need reform of both the medical education system and the medico legal system. We need to recognize that physicians are human and deserve compassion and humane treatment from both the medical system and society in general.

  • I have been in practice for 21 years now. Medical School and Residency were very stressful and the most dreadful experience I have ever had. I don’t know how I made it. There was sleep deprivation. There was verbal abuse. There was remarkable stress. And there was no support system whatsoever. You were on your own.
    As I said, that was years back. I finished residency in 1995. Maybe things are different now. I was at the point, though, where I had a bottle of KCL (potassium chloride) and a syringe and was ready to just end it all. I ended up chickening out but I kept the bottle for months and months afterwards. I was that close.
    No one ever knew, this is the first time I have even wrote about it. I guess I am lucky to be alive.
    Once in practice things improved. I have tried to put the horrors of medical school and residency behind me. My 20’s I count as lost years. It was a nightmare. I make a good living now but if I could go back and talk to the idealistic young fellow who graduated from college in the 80’s I would tell him DO NOT take the medical career path.
    You will never find a more cruel, heartless, merciless group of people than those involved in medical education and training.

    • Thanks for sharing your story. My experience was quite similar and I shared it in the comment above yours. I believe that depression and anxiety disorders are rampant among physicians but veiled in secrecy. I think this comes from a sense of shame in physicians and also from a medical system hostile to open and frank discussion of these issues (and their causes) in physicians.

  • Fascinating that for doctors, their depression is understood as a reaction to high stress and isolation (though the article notably neglected to mention sleep deprivation so common in residencies as to be an expectation) and recommendations are things like: “support groups, peer counseling, and sessions to teach doctors to manage stress by meditating or keeping journals.” Yet these same doctors, when encountering patients, have been shown by study after study to be prescribing antidepressants as a first-line treatment and avoiding discussions regarding trauma and stress in the life of the patient. Where does this disconnect come from? Are only the privileged permitted to react to high levels of stress with depression and suicidal thinking?

  • I’ve written about this topic, in an article entitled, “The Hidden Dying of Doctors,” published by the LA Review of Books (you can find it online). I was struck that readers of WHEN BREATH BECOMES AIR, Paul Kalanithi’s memoir of dying from lung cancer, are so moved by his death but seem to take little note of the death by suicide of one of Kalanithi’s closest friends in residency, which is recounted in the book. In addition to the article, I had a series of very moving and eye-opening conversations with that man’s family, who are still reeling from the loss years later.
    We certainly need more honesty about struggling — with depression, with feelings of inadequacy, with the social as well as the academic pressures of med school and residency. The pressure for perfection, which I discuss in my article, is enormous. But the supports need to be career-long, because more mid-career physicians die by suicide than med students or residents. Beyond that, we need to treat physicians humanely. Doctors go into medicine to do meaningful work, but many feel like daily practice allows no time for the sort of reflection and connection that is meaning-making. These all apply to depression, but specifically on suicide, there’s another potential factor to consider: most people in the general populationwho attempt suicide do not kill themselves; medical students, residents, and doctors may have a higher rate of death by suicide because they understand what will be fatal. This isn’t proven, because no one is tracking attempts versus deaths, but it merits investigation.
    –Lois Leveen, Kienle Fellow in the Medical Humanities, Penn State University Medical School

    • I greatly appreciate many of the comments/stories above. Regarding a few of the individuals providing input, this forum should not be exploited for political commentary or apathetic input towards physicians, especially from those outside the medical field. As a resident in general surgery in my last year of training, I can relate to the article and many of the editorial comments above. In my past 4+ years of residency, there have been 2 suicides by residents in other departments that I’m aware of. And in my own department, we recently had to revamp the training program because it was discovered by the accreditation committee in anonymous surveys that 2 problems existed (which were common in other programs where I did electives): First, 1/3 of residents reported abuse by staff and ~1/2 of residents reported abuse by other residents. Secondly, there was an unofficial policy- an unspoken understanding- that work-hour restrictions were disregarded. Those enforcing the relatively new work-hour restrictions had not benefited from such a new policy, and so it was argued that a limited 80-hr work-week would leave us mentally weak and inexperienced. I personally experienced both abuse and constant, profound sleep deprivation. This eventually led to my being treated for depression as a PGY-3 resident. Being inside the same mind that was coping with depression is probably what led to my inability to use the same logic & objectivity that I do with my patients. Hence, for months I passed off the depression as “something biochemical” rather than environmental because I believed I was too mentally strong to allow environmental distress to influence me to an extent that I would require medication for clinical depression. However, after meeting with a psychologist who specialized in treating physicians (this is my only tip to anyone who might be experiencing the same), she sorted through my experiences and made it very clear that abuse & distress while working 100-120hrs/wk were responsible for my diagnosis. I could give countless examples of counter-productive experiences, but as just one example… I recall once being put on-call by my senior residents for 4 consecutive days/nights. At most hospitals this might be acceptable. But in a major trauma center, this meant being awake and on my feet for (and I calculated exactly) 102 consecutive hours without sleep. After that stretch was over I was actually admitted to my own ER for dehydration & sleep deprivation. In fact, because I initially refused to be admitted saying, the ER physician (on my behalf of course) threatened to document that I was AMA and report me to the university unless I stopped working & allowed him to treat me. So I called my senior residents upstairs in the OR to tell them I was now an admitted patient & therefore had to stop seeing consults. They oddly yelled at me over the phone because my absence implied more work for them. When they came down to the ER to do the consults that I couldn’t do, they refused to look at me while walking back and forth past my gurney. Upset that I had left them with extra work at the end of their day, and because it was noted that I was less efficient towards the end of not only that 102hr shift but also occasionally on the second consecutive day of being awake during our typical 36-40hr shifts (which is 100% true; I was less efficient when awake 36-40hrs because I’d recheck all my work in fear of making medical errors, and frankly couldn’t recall information as quickly), they therefore made sure that the staff gave me a poor grade for that period for inefficiency. Their treatment of me was a product of being treated the same way when they were junior residents. They were unfortunately too weak and lacking of integrity to acknowledge do differently. It’s because of doctors such as my own 2 senior residents years ago, that medicine is a self-perpetuating culture of inhumane treatment of peers or of those in training. Ironically, this treatment is by the very same people who vowed to dedicate their lives (medicine isn’t just a job- it’s a life) to improving humanity by sacrificing an extra decade to acquire knowledge and by using whatever talents/gifts we may have to offer in order to specifically heal strangers. Medicine is in itself a stressful, highest-of-stakes profession, but I strongly believe we can minimize some of the unnecessary distress outside of this one inevitability, such as by addressing our culture of apathy & even resentment towards each other.

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