Physicians take their own lives when many diverse and overwhelming forces come together all at once—a perfect storm of biopsychosocial factors. There is no one reason why a physician might die by suicide and many factors can be at play. It is important that we are aware of these factors and understand them, so that we can try and support our colleagues.

One key factor that can contribute to physician suicide is the fact that physicians often devote a huge amount of time and energy to their patients and neglect their own health. Generally physicians dislike depending on others for help and eschew personal care. This could be, in part, due to the culture of medicine—that our job is to be the one who looks after others, not the other way around.

This culture can mean that physicians are often at risk of not receiving adequate treatment for their mental health problems. The irony is that healers of others often do not take advantage of treatments for themselves. I conducted a qualitative interview study with the relatives of physicians who died by suicide and found that 10-15 % of the physicians who died did so without ever consulting another physician or mental health professional. [1]

Physicians often do not fully understand or realise how ill they have become. I have found from my work that they minimize or rationalize their symptoms, such as poor mood, anxiety, insomnia, or a dependence on alcohol or other drugs. They may admit to burnout, because it “comes with the territory,” but are blind to their own constricted thinking. I have seen physicians become fixated on the idea that self-destruction is the only way out and this “solution” can arrive with perfect clarity and relief. [2]

The way that physicians receive treatment can also contribute to their risk of suicide. There is evidence to suggest that physicians do not receive the gold standard of medical treatment. This is because the physicians who treat them have an internalized stigma and therefore cut corners and miss things. Physician-patients are not managed with the same care, thoroughness, and vigilance as non-physician patients. [3-7]

Another issue is that often physicians do not—and cannot—take the medications that are prescribed for them or engage in psychotherapy, because they are afraid that seeking treatment will have a detrimental effect on their career. These fears are not irrational. Under the guise of protecting the public, regulators ask questions on licensing and credentialing applications that are unnecessary and intrusive. This is terrifying for physicians who have sought treatment in the past or are contemplating it for the future. Most policy makers do not grasp how tough it is to live with a stigmatized illness. It is lonely, alienating, diminishing, and very painful.

In situations where physicians are subject to a complaint, or have been called in front of their regulator, they may feel  shame and public humiliation. The pressures of dealing with this situation and any potential media exposure, coupled with the withdrawal of supportive colleagues and friends, can be overwhelming. [8-10]

Some physicians battling a progressively debilitating or terminal medical illness, and fully knowing what is in store for them down the road, will take their own lives. Their autonomy is precious to them and they have the medical knowledge and means available. Unlike other suicides, in my experience, these doctors usually have tacit approval or support from their families and close friends who, in spite of their own personal misgivings or anguish, respect their loved one’s wishes.  

Finally, there are physicians who die by suicide and the reason why seems like a mystery to all. They have taken the answer(s) with them. Even a psychological autopsy does not yield much clarity.  

Let these examples serve as a call to arms. The factors that contribute to physician suicide are many and varied, but there are things that we can do to tackle them. We can support our colleagues who work to fight for our rights, job satisfaction, and fair payment for our services. We can fight stigma around mental health by speaking openly about our personal experiences, rather than staying tight lipped (11).

We can acknowledge all those colleagues who publish their narratives by sending them a note of thanks. We can educate doctors—and their loved ones—about how to take better care of themselves. We can lobby regulators about modernizing and humanizing applications for medical licences. And we can work on treatment guidelines for those professionals who treat physicians to make certain that the care they provide is state-of-the-art and evidence-based.  

Michael Myers is professor of clinical psychiatry at SUNY Downstate Medical Center in Brooklyn, New York. He is a specialist in physician health.

Michael will be speaking at the International Practitioner Health Summit 2018: The Wounded Healer on 4 October 2018. 

Competing interests: Over the past 3 years, MM has given 3 grand rounds sponsored by Medical Education Speakers Network and received an honorarium for each. He has acted as an expert witness for the plaintiff in a physician suicide lawsuit. He writes a bimonthly blog on physician health for PsychCongress. He has received royalties for his books from Sage Publications, American Psychiatric Association Publishing Inc., and Amazon. He expects all of these to continue over the next 12 months except the expert witness commitment.

References:

1. Myers MF. Toward preventing physician suicide: incorporating the insights of those they leave behind. Paper presented International Conference on Physician Health. Boston, MA. September 19, 2016.
2. Myers MF, Gabbard GO. The Physician As Patient: A Clinical Handbook for Mental Health Professionals. American Psychiatric Publishing, Inc. Washington, DC. 2008.
3. Silverman MM Physicians and suicide, in The Handbook of Physician Health: Essential Guide to Understanding the Health Care Needs of Physicians. Edited by Goldman LS, Myers M, Dickstein LJ. Chicago, Il., American Medical Association, 2000.
4. Center C, Davis M, Detre T, et al: Confronting depression and suicide in physicians: a consensus statement. JAMA 2003; 289:3161–3166.
5. Worley LLM. Our fallen peers: a mandate for change. Acad Psychiatry 2008;32:8-12.
6. Gunter TD. Physician death by suicide: problems seeking stakeholder solutions. Archives of Depression and Anxiety 2016;2(1):20-25.
7. Myers MF, Freeland A. The mentally ill physician: issues in assessment, advocacy and treatment. Position Paper of the Canadian Psychiatric Association. Canadian Journal of Psychiatry. In press. 2018.
8. Iannelli RJ, Finlayson AJ, Brown KP et al. Suicidal behavior among physicians referred for fitness-for-duty evaluations. Gen Hosp Psychiatry 2014;36:732-736.
9. Finlayson AJ, Iannelli RJ, Brown KP et al. Physician suicide and physician health programs. Gen Hosp Psychiatry 2016;40:84-85.
10. Horsfall S. Doctors who commit suicide while under GMC fitness to practise investigation: internal review. Graduate Medical Counsel 2014. London.
11. Shooter M. Doctors’ diagnosis: depression. Brit Med Journal 2003;326:1324.