This article is about suicide, in particular about doctors and suicide. The themes are as relevant to any health professional, where work gives both purpose and meaning to their life.
Suicide is a difficult subject to talk about, but we must not shun it or hide it away in secrecy.
It is full of ambiguities. It is both distant and intimate. When told someone has killed themselves, we recoil in shock not bearing to get close to those who are bereaved in case we too become “contaminated.” Yet we also crave for details; where, why, how? Many have a personal experience of suicide—a friend, family member, colleague, or patient who has taken their own life.
Doctors have high rates of suicide. How high is difficult to determine accurately. But for female doctors’ studies suggest up to four times the rate of their non-medical peers and for male doctors around the same rate. [1] This belies that doctors do not have the obvious risk factors normally seen among those on national suicide statistics. [2] Instead, they have a host of protective factors and secure well-paid jobs. They are unlikely to have been brought up in unstable accommodation or foster care, and have good social networks even if they are all medics. These should protect doctors so the fact that they have high, or higher rates of suicide is worrying.
For the last 14 years I have been leading a mental health service for doctors and dentists with mental illness (Practitioner Health). It was set up to address the barriers doctors face in seeking help for mental health problems. [3] I also run a group for those bereaved following the death through suicide of a health professional. The group, now running for nearly three years, has around 70 members and 20 or so attend each time. Sadly, its membership continues to grow. Its unifying feature is belonging to the unenviable club where its members have had to bury someone who has died through suicide. [4] Each month, the group listens, supports, and together we try and answer the single question, “why did they kill themselves?” Why these loved ones used a permanent solution to a temporary problem is something which haunts me as much as those who attend the group. Some doctors seem to have killed themselves impulsively—made arrangements to meet friends for Sunday lunch, booked courses or holidays, yet instead suddenly changed plans and taken their own lives. Others appeared to have planned their act for weeks, methodically researching how to kill themselves, written wills, closed bank and social media accounts, bought the means and even rehearsed the method.
When the inevitable inquires have taken place what transpires is that some doctors have had underlying mental illness, most commonly depression, a few have had addiction issues. But at least 50% had no obvious mental illness or if they did, nothing severe or worrying enough to be noticed by those closest to them. Even if present, low mood, depression, suicidal thoughts are common, suicide by contrast is rare.
To try and answer “the why” I am drawn to the great philosopher and Nobel Laurette Albert Camus. His essay, The Myth of Sisyphus, written in 1942 starts with:
“There is only one truly serious philosophical problem, and that is suicide. Judging whether life is or is not worth living amounts to answering the fundamental question of philosophy.” [5]
Sisyphus was a Greek God, punished in the afterlife to the pointless task of pushing a boulder uphill only to watch it roll back again and to repeat this for eternity.
Camus uses this legend as a metaphor for an individual’s persistent struggle against the essential absurdity of life. If, as for Sisyphus, suicide is not a possible response, the only alternative is to rejoice in the act of rolling the boulder up hill and accept the meaningless of life—for at that moment, as the boulder rolls down, Sisyphus is happy. [5]
I have tried to apply this myth and Camus’ interpretation to the doctors who have killed themselves. Maybe Camus is right that life has no meaning, though I would attest this is not the case for doctors. Working as a doctor provides meaning akin to a religious vocation, as emphasised in the Hippocratic oath where doctors pledge to dedicate their life to the service of humanity. Caring for patients and dealing with the sick gives doctors purpose and identity. [6] Not surprising therefore, that for those who have killed themselves, often lurking in the background is a trigger relating to work; a complaint, an error, removal from work due to illness or especially powerful, disciplinary action leading to suspension or erasure [7-9] Even losing faith in the power of medicine can be debilitating.
Described as the most important book written about general practice, A Fortunate Man: The Story of a Country Doctor, is the story about the doctor, John Sassall. [10] Sassall defined himself by his work. When his long-term practice partner died, instead of acquiring a new one, he chose to split the patient list and run the practice single-handedly. He longed to be woken at night to do house calls and was incapable of doing nothing, and just “being”. Put simply, Sassall was unable to take on any identity other than that of the doctor. Sassall suffered from regular bouts of depression yet, as with many doctors, there is no evidence that he sought professional help. Instead, as Berger wrote, “Sassall needs to work in this way. He cures others to cure himself,” (page 79) becoming the classic wounded healer playing out his own wounds through caring rather than addressing his own needs. Despite his efforts, Sassall could not protect his patients from the impossible task of curing the incurable, a failure he took personally and felt deeply. Sassall could not deal with this and took his own life.
Being a doctor is not something that you do, but something that you are. [11] When work is taken away—which sometimes it will be, they must be supported to make the transition, if we are to prevent more doctors, as those remembered in the group, from taking their own lives.
Clare Gerada is chair of the Charity Doctors in Distress, whose aims is to reduce the rate of suicide amongst health professionals.
If you’re struggling, you’re not alone. In the UK and Ireland, Samaritans can be contacted on 116 123 or email jo@samaritans.org
References:
1] Dutheil, F., Aubert, C., Pereira, B., Dambrun, M., Moustafa, F., Mermillod, M., Baker, J. S., Trousselard, M., Lesage, F.-X., & Navel, V. (2019). Suicide among physicians and health-care workers: A systematic review and meta-analysis. PLoS ONE, 14(12). https://doi.org/10.1371/journal.pone.0226361
2] Appleby, L., Shaw, J., & Amos, T. (1997). National Confidential Inquiry into Suicide and Homicide by People with Mental Illness. British Journal of Psychiatry, 170(2), 101–102. https://doi.org/10.1192/bjp.170.2.101
3] Brooks, S. K., Chalder, T., & Gerada, C. (2011). Doctors vulnerable to psychological distress and addictions: Treatment from the Practitioner Health Programme. Journal of Mental Health, 20(2), 157–164. https://doi.org/10.3109/09638237.2011.556168
4] Gerada, Clare, & Griffiths, F. (2020). Groups for the dead. Group Analysis, 53(3), 297–308. https://doi.org/10.1177/0533316419881609
5] Camus, A. (1955). The Myth of Sisyphus and other essays /. Vintage Books.
6] Gerada, Clare. (2016). Work is central to doctors’ identity, and those unable to work need support. BMJ, i2014. https://doi.org/10.1136/bmj.i2014
7] Bourne, T., Vanderhaegen, J., Vranken, R., Wynants, L., De Cock, B., Peters, M., Timmerman, D., Van Calster, B., Jalmbrant, M., & Van Audenhove, C. (2016). Doctors’ experiences and their perception of the most stressful aspects of complaints processes in the UK: An analysis of qualitative survey data. BMJ Open, 6(7), e011711. https://doi.org/10.1136/bmjopen-2016-011711
8] Hawton, K. (2015). Suicide in doctors while under fitness to practise investigation. BMJ, 350 (feb13 3), h813–h813. https://doi.org/10.1136/bmj.h813
9] Horsfall, S. (2014). Doctors who commit suicide while under GMC fitness to practise investigation. 83.
10] Feder, G. (2005). A Fortunate Man: Still the most important book about general practice ever written. The British Journal of General Practice, 55(512), 246–247.
11] Gerada, C. (2019). The making of a doctor: The matrix and self. Group Analysis, 52(3), 350–361. https://doi.org/10.1177/0533316418823117