Saturday, January 2, 2016

Physician suicide

While no organization collects official data on physician suicides, Pamela Wible, a family medicine doctor in Eugene, Oregon, who writes about the phenomenon, says that at least 400 doctors kill themselves annually. That’s the size of an entire medical school class.

Wible believes that the numbers are higher than that, since doctors close ranks around each other and prod coroners to rule the cause of doctor deaths as “unplanned”—even when they are obviously not. “Accidental overdoses?” Wible asks. “You’ve got to be kidding me. Doctors calculate doses for a living.”

Because doctors have the knowledge of anatomy as well as access to lethal doses of drugs, they have a far higher suicide “completion” rate than the general population. A 2005 essay published in JAMA found that male doctors killed themselves at a rate 70 percent higher than other professionals; among female doctors, that rate ranged from 250 to 400 percent higher.

“Unfortunately,” says Bradley Hall, a Bridgeport, West Virginia, addiction medicine physician, “suicide is one thing doctors are pretty good at.”

The little-noticed, little-discussed trend has enormous implications. Since the average annual caseload of most family doctors is roughly 2,300 patients, 400 physician deaths could mean that a million Americans lose their doctors to suicide each year.

There are many theories about why so many doctors kill themselves. They face the pressures of “assembly-line medicine,” merciless scheduling demands, fights with insurance companies, growing regulations, and an explosion in scientific literature with which their knowledge must remain current. Their debt burdens often total hundreds of thousands of dollars, and they work in constant fear of malpractice suits.

Internists routinely screen their patients for depression and anxiety—it’s considered the standard of care for an annual physical. But doctors, Wible says, must live up to a different set of standards. In medical school, professors teach their driven young students to put their own emotions aside, even as they attend to tragedy. “In general, we’re in a profession that will shun you if you show weakness or suffering in any way,” she says.

But the taboo on discussing mental illness in medicine is beginning to waver. Wible’s 2014 “Medscape” story on doctor suicide had more than 100,000 readers and attracted 800 comments, the most in the website’s 20-year history. In a related article, she recounted the story of a retired surgeon whose medical school professor told his students that if they decided to commit suicide, they should do it right. He then provided detailed instructions...

In most states, doctors must disclose a mental health diagnosis or treatment history when applying for or renewing their medical license. A 2011 Current Psychiatry article notes that medical boards increasingly ask applicants about their mental health.

Doctors who acknowledge problems with substances or mental health are typically referred to a physicians health program, or PHP. These organizations evaluate, monitor, and treat physicians.

“Acknowledging a history of mental health or substance abuse treatment triggers a more in-depth inquiry by the medical board,” wrote Dr. Robert Bright, a psychiatry professor at the Mayo Clinic in Scottsdale, Arizona. “The lack of distinction between diagnosis and impairment further stigmatizes physicians who seek care and impedes treatment.”...

J. Wesley Boyd, a Harvard psychiatrist who left his post as assistant director of the Massachusetts PHP over a disagreement about practices there, says PHPs routinely intimidate their clients. In an article he co-wrote for the Journal of Addictions Medicine in 2012, Boyd noted that many doctors who seek or are referred by colleagues for treatment are mandated to attend pre-selected rehabilitation facilities for 60 to 90 days. Afterward, they must agree to monitoring and drug testing, typically at their own cost. When doctors resist PHP recommendations, they risk losing their livelihood and their licenses.


  1. Boyd JW, Knight JR. Ethical and managerial considerations regarding state physician health programs. J Addict Med. 2012 Dec;6(4):243-6.


    Many physicians are referred to state physician health programs (PHPs) for evaluation, monitoring, and treatment of mental health and substance use disorders. Most PHPs are "diversion" or "safe haven" programs, meaning that physicians who suffer from alcohol or drug problems can have their case diverted to the PHP in lieu of being reported to the state licensing board. If the physician agrees to cooperate with the PHP and adhere to any recommendations it might make, the physician can avoid disciplinary action and remain in practice. These programs are therefore quite powerful and yet, to our knowledge, there has not been any systematic scrutiny of the ethical and management issues that arise in standard PHP practice. Given our 20 years of service as associate directors of one state PHP we analyze and evaluate the standard operating procedure of many PHPs and offer ethical critique as well as suggestions for improvement.

  2. The fact is that each year we lose over 400 doctors to suicide—that's like an entire medical school gone. I lost both men I dated in med school to suicide. In my town, in just over a year, we lost three doctors to suicide. One doc in town lost seven colleagues to suicide! In what other profession can you lose seven colleagues to suicide?!

    This year over 1 million Americans will lose their doctors to suicide. Why? To know why someone has died, we perform an autopsy. With suicides, we perform a psychological autopsy..

    An unacknowledged predicament for physicians who identify their struggle with substance abuse and/or depression is that they are often placed under the supervision of their State Medical Board's Physicians Health Program. My son, Greg, was being monitored by such a program. He took his own life at age 29, one week before he was to enter an esteemed oncology fellowship. His final phone calls were to the PHP notifying them of his use of alcohol while on vacation, a disclosure he had previously described as a 'career killer.'

    These programs, which often offer no psychiatric oversight, serve as both treating and policing agencies, a serious conflict of interest. Threatened loss of licensure deters vulnerable physicians from seeking help and may even trigger a suicidal crisis. Medical Boards have the duty to safeguard the public, but the assumption that mental illness equals medical incompetence is an archaic notion. Medical Boards must stop participating in the stigmatization of mental illness. We cannot afford to lose another physician to shame.

  3. Pamela Wible Ted talk

  4. Sadly, although physicians globally have a lower mortality risk from cancer and heart disease relative to the general population (presumably related to self care and early diagnosis), they have a significantly higher risk of dying from suicide, the end stage of an eminently treatable disease process. Perhaps even more alarming is that, after accidents, suicide is the most common cause of death among medical students.

    In all populations, suicide is usually the result of untreated or inadequately treated depression, coupled with knowledge of and access to lethal means. Depression is at least as common in the medical profession as in the general population, affecting an estimated 12% of males and 18% of females. Depression is even more common in medical students and residents, with 15-30% of them screening positive for depressive symptoms. A 2011 survey of 50,000 practicing physicians and medical students in Australia demonstrated a dramatically increased incidence of severe psychological distress and a twofold increased incidence of suicidal ideation in physicians compared with the general population.

    However, because of the stigma often associated with depression, self reporting likely underestimates the prevalence of the disease in both of the above populations. Indeed, although physicians seem to have generally heeded their own advice about avoiding smoking and other common risk factors for early mortality, they are decidedly reluctant to address depression, a significant cause of morbidity and mortality that disproportionately affects them. (Depression is also a leading risk factor for myocardial infarction in male physicians.)

    Physicians are demonstrably poor at recognizing depression in patients, let alone themselves. Furthermore, they are notoriously reluctant to seek treatment for any personal illness. This may be especially true in the case of potential mental illness. A recent survey of American Surgeons revealed that although 1 in 16 had experienced suicidal ideation in the past 12 months, only 26% had sought psychiatric or psychologic help. There was a strong correlation between depressive symptoms, as well as indicators of burn out, with the incidence of suicidal ideation. Over 60% of those with suicidal ideation indicated they were reluctant to seek help due to concern that it could affect their medical license. Research suggests that 1 in 3 physicians has no regular source of medical care. (continued)

  5. (continued)Reluctance to recognize depression in a colleague is a tendency shared and imposed by other physicians, who may be well intentioned, chronically emotionally distanced, and/or feeling temporarily vulnerable themselves. Even when healthy, physicians find it difficult to ask for help of any kind. When they are depressed and feeling less than adequate, they find it even more difficult—and when they do bring themselves to ask, they sometimes find that the help they need is remarkably difficult to obtain.

    To some extent, however, physicians’ reluctance to reach out is self-imposed. They may feel an obligation to appear healthy, perhaps as evidence of their ability to heal others. Inquiring about another physician’s health can shatter this mutual myth of invulnerability, and volunteering assistance may seem like an affront to a colleague’s self-sufficiency. Thus, the concerned partner may say nothing, while wondering privately if the colleague has become impaired.

    Unconsciously defending against this painful vulnerability, colleagues or significant others may fail to notice significant depression or withdrawal, attributing behavioral changes instead to stress or overwork. Nearly every article about a physician’s suicide contains a quotation from some close contact, occasionally a spouse, saying something like, “I never had any idea that he/she was suffering.” Of course, many physician obituaries omit the fact that the “sudden death” was a completed suicide.

    Depressed physicians who do reach out may find that they receive only limited understanding or sympathy from colleagues. There is no specialized training for a physicians’ physician. Most physicians either shrink from this role or perform it poorly.

    For many experiencing depression, the early symptoms are physical. A physician unable to diagnose his or her own symptoms commonly feels incompetent. To admit one’s inability to diagnose oneself to another colleague is to admit failure. When this admission is met with avoidance, disbelief, or derision by a reluctant treating physician, it can only reinforce a depressed physician’s feelings of worthlessness and hopelessness. (continued)

  6. (continued)Physicians find it painful to share their experience of mental illness with others and know that doing so is somewhat risky; therefore, published accounts of physician depression are nearly impossible to find. However, in the author’s experience, private consultations with a trusted counselor reveal that symptoms of depression are surprisingly common among physicians...

    Many clinicians are uncomfortable treating fellow physicians, especially in the realm of mental health. The “VIP syndrome,” characterized by well-intentioned, but superficial or inadequate, treatment based on collegiality and concerns about confidentiality, can detract from the effectiveness of therapy.

    Mental health experts who have studied physician depression and suicide stress that immediate treatment and confidential hospitalization of suicidal physicians can be lifesaving—more so than in other populations. Yet, the specters raised by this approach—the fear of temporary withdrawal from practice, of lack of confidentiality and privacy in treatment, or of loss of respect in the community—are often the major impediments that hinder physicians from reaching out in a time of crisis and seeking effective treatment.

    Physicians who have reported depressive symptoms (even those for which they are receiving effective treatment) to their licensing boards, potential employers, hospitals, and other credentialing agencies have experienced a range of negative consequences, including repetitive and intrusive examinations, licensure restrictions, discriminatory employment decisions, practice restrictions, hospital privilege limitations, and increased supervision. (continued)

  7. (continued)Such discrimination can immediately and severely limit physicians’ livelihoods as well as the financial stability of their families. For this reason, well-meaning colleagues or family members who are aware of the depression sometimes discourage physicians from seeking help.
    Medical licensure applications and renewal applications frequently require answers to intrusive questions regarding the physician’s mental health history and may be out of compliance with the provisions of the Americans with Disabilities Act (ADA).

    Most states have physician health programs that are not associated with the medical licensing authority, and more enlightened states have regulations governing some state physician health programs that allow a physician enrolled in a physician health program who is compliant with treatment to check “no” on the mental health questions on licensure applications. However, physicians who are contemplating or in need of treatment are almost universally unaware of such provisions.

    Most physicians assume that any state agency or treating physician will share confidential information about them to the licensing authority...

    Prospective medical students and residents are extremely unlikely to report a history of depression during highly competitive selection interviews. The prevalence of depression in these populations and in medical student and postgraduate trainees is unknown, but it is estimated to range from 15-30%. After accidents, suicide is the most common cause of death among medical students. In one study, 9.4 percent of fourth-year medical students and interns reported having suicidal thoughts in the previous two weeks.

  8. Lindeman S, Läärä E, Lönnqvist J. Medical surveillance often precedes suicide among female physicians in Finland. A case-control study. J Occup Environ Med. 1997 Nov;39(11):1115-7.


    Official medical surveillance among Finnish physicians who had committed suicide in 1983-1994 was investigated. Definite cases of suicide (ICD categories E950-E959) (n = 50) were compared with a living age- and sex-adjusted control group of physicians (n = 200). All National Board of Health (NBH) documents relating to official surveillance in 1983-1994 were examined. Seven cases of surveillance (three males, four females) were found among suicide cases and only one in controls, the relative odds thus being 28 (95% confidence interval 4.3 to 636). All suicide victims had had several major problems, including mental and somatic disorders and difficulties in their personal relationships. The risk of suicide was especially high among female physicians under surveillance. However, only in one case did disbarment from the medical profession seem to be a crucial factor preceding a suicide.