Here’s a woeful secret that most medical students don’t learn until it’s too late: Physicians are more likely to become depressed, burn out, and die from suicide than their peers in the general population. Sometimes depression and suicide are the result of slow-building and long-standing issues. Other times they seem to come out of the blue.
One of my roles at Northwestern University Feinberg School of Medicine is physician health liaison. One Friday afternoon, I got an urgent page from an anesthesiologist. When I called him back, he told me about a surgery that had gone terribly awry the week before — and how he was now thinking about suicide.
He and a senior resident had administered anesthesia to a young man undergoing a relatively routine procedure. Their patient had been discharged home at the end of the day. The next morning, the young man was found dead in his bed.
My colleague, who had built a stellar reputation over three decades of practice, was devastated. He had never before experienced anything quite like this patient’s death. He wasn’t able to sleep the night after getting the news, and hadn’t slept more than two or three hours a night since then. He had gone to work every day, but had trouble eating and concentrating on his clinical work. He reviewed the procedure over and over, trying to determine what, if anything, he could have done differently. He repeatedly remembered seeing the faces of his patient’s shocked and grieving parents.
With his confidence profoundly shaken, he questioned whether he should stay in medicine. He felt isolated, despite some outreach from his peers and his chairman. Most of all, he felt deeply ashamed — of what, he wasn’t quite sure.
We arranged for him to take a week off, and he started therapy. With the aid of some medication to help him sleep, and being able to process his experience with me, he began feeling better and no longer had suicidal thoughts.
Each year in the United States, 300 to 400 physicians die from suicide — that’s one a day, or the equivalent of two large medical school classes. Female physicians are 2.3 times more likely to die by suicide than those in the general population; male physicians, 1.4 times more likely. The terrible truth about physician suicide is that the great majority of these deaths are due to untreated depression, meaning they are preventable.
Stakeholders in American medicine are beginning to take notice of the emotional burden carried by medical students, residents, and veteran physicians. The new awareness stems, in part, from recent research in this area. (The PBS video “Struggling in Silence,” and the book “Physician Suicide Letters Answered,” by Dr. Pamela Wible, also helped bring the topic of physician suicide out in the open.) In addition, we are waking up to the fact that physician depression and burnout affects the quality of patients’ medical treatment.
Much of the chronic distress that physicians experience is due to the culture of medical education and practice, the nature of our work, and stress imposed by the current health care environment. We are supposed to see more patients in less time and provide much more documentation. We work daily with human tragedy, illness, death, and loss. Many of us don’t take time off or debrief after adverse events or patient deaths. Instead, we move on to the next patient. It’s no wonder that more than half of physicians report being burned out.
Even more worrisome, most physicians suffering from burnout or depression don’t seek treatment it. Although we should know better, physicians have longstanding internalized stigma about mental health treatment, believing that it represents weakness and vulnerability. Beginning in medical school, physicians in training tend to avoid mental health treatment because of fears about privacy, confidentiality, and how it might affect their future careers. Such attitudes persist, and even strengthen, through physicians’ careers.
A three-pronged approach is needed to help physicians cope with burnout and depression and to prevent suicide. First, we must destigmatize seeking help. That can be done through better education and policies to change the culture of medicine so it is easier to ask for help. Second, we must provide physicians with prompt and targeted mental health assessments, support, and treatment when they’re feeling burned out or depressed. Informing the entire medical community about how to recognize the signs of toxic stress, depression, and burnout, and how to refer colleagues who might need help, can accomplish this. Third, we must work to prevent burnout and depression by removing barriers such as intensely busy work schedules, the cost of mental health treatment, and the difficulty of finding resources during nonwork hours, which are often few and far between.
At Northwestern University, a psychiatrist is available 24/7 to our physicians in training. They can call just to talk, to get started with treatment, or to request a referral. It’s 100 percent confidential and free. Our attending physicians can page or call me at any time, and our risk management team notifies me of any adverse events that affect a physician so I can reach out to him or her.
Other institutions are also making huge strides in this area. Stanford University, for example, offers a range of supports and mental health services for its trainees and attending physicians. Brigham and Women’s Hospital in Boston operates a highly effective peer-support program.
It’s high time for us to recognize that the physicians who spend so much of their lives caring for us are often suffering in silence, and effective interventions would be good medicine for all of us.
Joan M. Anzia, MD, is a psychiatrist at Northwestern Medicine and a professor of psychiatry and behavioral sciences and medical education, and directs the residency program at Northwestern University Feinberg School of Medicine.
Share your thoughts on depression in the medical profession
Being an emergency medicine attending, I find the following conditions of the ED world problematic. Document more to avoid lawsuits which means spending hours after the shift doing charts. Being physically assaulted by patients. Being called a “fu$&in c&nt” more often than I like by patients. Having a desire to spend needed time with patients only to be unable to do so due to ED volume and a compensation system that will leave me without money if I don’t see more patients. Less and less specialities who are available… They are “on call” covering multiple hospitals and refuse to either see my patient in a timely fashion or tell me to transfer a patient for frankly unnecessary reasons. Absolutely unrealistic expectations from patients and family…no one should wait, things should be quick and ailments such as routine constipation are showing up with regularity. PCP lack of time leads to ED dumping. Medicaid cuts to funding for mental health causing psych ED holds that drag on for days. A general disrespect among patients and their families where many feel free to insult you, belittle you and even curse at you.
It is a generally unpleasant situation that fosters fatigue and misery.
What can be done?
No clear uniform idea. I have recommendations except to stop acting as if the entire world will collapse if an MD needs time off. We can’t even get maternity leave! Who is going to care about burnout? I wish it were different. Only larger institutions have the luxury of such care. Smaller organizations are literally giving up on feeding patients in the ED unless they already missed a meal and one I work for took away our plastic forks to save money. I find it doubtful that 90% of physicians truly care.
I have been corresponding with Dr. Jennifer Okwerekwu of STAT about programs used by emergency services personnel to inoculate against Stress related effects- pre event, services at the event and follow up services. Rather than reinventing the wheel, I believe that these programs can be easily adapted to the population you are concerned with. I would like to suggest that, and believe you both would benefit from putting your heads together on these topics.
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