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Doctors suffer from high rates of depression and suicide. In 2018, a systematic literature review of physician suicide shows that the suicide rate among physicians is 28 to 40 per 100,000, more than double that in the general population. The review showed that the physician suicide rate was 28 to 40 per 100,000 while in the general population, the overall rate was 12.3 per 100,000 (American Psychiatric Association (APA) 2018. Abstract 1-227, presented May 5, 2018). Indeed, the physician suicide rate is higher than that of the military, a profession commonly associated with higher rates of mental illness and suicide.
This is not a new problem — the phenomenon of physician suicide goes back in the medical literature some 40 or more years at least. This is also not a COVID-specific problem, although a recent high profile case of an ER doctor who committed suicide under the strains of working on the frontline has given many of us pause to consider what the consequences might be of working in high-stress, high-risk settings and vicarious trauma due to the crisis.
While I can’t pretend to know every single reason that physicians are vulnerable — and there is data to indicate it’s not just physicians who are more vulnerable to this problem but also medical students, veterinarians, dentists, nurses, and other healthcare professionals — there are some obvious factors we can point to that could either cause physicians to suffer more than their non-physician peers or cause them not to receive the help they need.
Recent high-profile deaths of physicians and others during the COVID crisis have brought some increased attention to this problem and the idea that potentially the mental health crisis among healthcare professionals, including physicians, is at a critical point. Hopefully, our concern for this problem and for the wellbeing of our healthcare providers isn’t fleeting — and our care and interventions don’t go away when the COVID crisis does.
Here are some potential contributing factors to the physician mental health crisis, in no particular order:
- Presenteeism, meaning working while sick, is huge in medical culture. Physicians often work while sick and medical training and culture, which is very hierarchical in nature, has traditionally encouraged this, at times shaming physicians for putting their needs first. It’s true that a lot is asked of physicians, including a lot of sacrifice, and also that more is asked of physicians than others — for example, our oath includes an implied duty to society. In recent times of healthcare worker shortages during the pandemic, physicians, nurses, and other healthcare workers have been asked to work while ill, if they could, because there was was no one to step in to fill their shoes. This is a huge responsibility.
- High stress levels. Physicians are up against ever-evolving and complex landscape of issues in our system of care, including that the system itself is fractured. Other stressors include electronic records systems, reduced insurance reimbursements, increased paperwork including prior authorizations, all of which have been associated with an increased workload, higher burnout, inefficiency, and feelings of inadequacy.
- Denial. Physicians are people too! Not all physicians are trained or able to recognize the signs of mental health problems in themselves or others. Medical culture has normalized the signs of stress, exhaustion, and emotional fatigue as being part of the job.
- Shame. The culture of medicine has for a long time been very conservative culture and only shifting somewhat recently — for example, it was not acceptable to be openly "out" as LGBTQ without fear of discrimination until very recently.
- Secrecy. Goes hand in hand with shame. We don’t talk about this problem openly or enough. Physicians also tend to hold themselves to higher standards which may lead them to feel they should not face certain problems.
- Difficulty feeling confident their privacy and dignity will be preserved.
- Stigma. This is a tremendous moment of struggle and inspiration. We are waking up as a society and realizing we have been blind to the discrimination that is built into some of our systems and processes. Would you apply for a job if you knew you would have to reveal something embarrassing or possibly be rejected for that job based on something that trails in your past despite having made it right? Some states have banned employers from requiring job applicants to disclose their criminal history because it is a barrier to people who have served their sentences and repented for their crimes from being able to have a fair chance at employment. We can’t pretend that this measure has done enough to level the playing field but it is a statement that we believe as a society that people have a right to a second chance. Unfortunately, most state medical board procedures ask for disclosure of mental health history on their licensing applications — for example if a physician has a mental illness, a substance use problem, ever been arrested, ever had a malpractice suit, owes child support, and so on. These applications often request such information even if the problem may be distant, resolved, or well treated, causing physicians to worry about risks to their professional licensure or reputation if they have to report such concerns.
- Powerlessness. Some of the systems that are supposed to help physicians are geared towards protecting society from the risk of impaired physicians practicing medicine. Protecting the safety of the pubic is of course essential. The problem is that there’s a gap between this actually adequate treatment. By virtue of the power they can yield, these physician health committees are intimidating and powerful.
- Lack of access to good quality treatment. This one is shocking for most people to hear about, Shouldn’t physicians, who are healthcare system "insiders," know how to get good care or be able to seek the "best" resources out there?
- Lack of support and inability to normalize common challenges. Many physicians practice in isolation without peers with whom they can openly share their challenges, professional struggles, difficult cases, or bad patient outcomes. This creates a vacuum that can deepen the mental impact of setbacks and struggles as well as the feeling of shame.
Here is what we don’t know:
- We don’t know much about how to prevent this problem, nor how to intervene early in an impactful way. There are pilot programs addressing physician mental health needs and results are preliminary.
- We don’t know the full breadth and depth of this problem. It is not known how many physicians suffer in silence with untreated and undiagnosed mental illness, how many are have contemplated or attempted suicide.
- We don’t yet know the specific reasons physicians commit suicide more than other groups, or if the risk factors for physicians are different than for other parts of the population. Some possible reasons could be that physicians feel particularly stuck and helpless in their situations, that physicians may be more predisposed to there is no way out or for resolution, or that the decline in their status and quality of life due to their problems may feel particularly intractable. They may feel pressure to be "perfect" or may have faced stigma due to their illness.
- There are probably factors specific to physicians that put them more at risk of mental illness and more at risk of not getting adequate treatment. Further study is needed here.
- We don’t know what resources will work to address the problem of physician suicide, just that more are needed.
What can we do to help?
- Reduce stigma. Talk about the reality of this problem. We need physicians who are able to speak out and lead by example. Self-disclosing has its risks but potentially also rewards. Leadership in this area can be powerful. Reducing the stigma and negative consequences of having mental health problems will help encourage physicians to seek care. Reduce tolerance of discrimination for physicians who disclose their mental health concerns.
- Reduce other barriers. Create non-punitive systems to support physician access to mental healthcare. Reduce barriers to maintaining licensure for physicians who are proactive in getting help while at the same time continuing to maintain high standards for public safety. Improve ways to help physicians feel assured that they can have confidential and private care.
- Better education about mental illness among physicians, including how to recognize signs in themselves and others.
- Better education among specialists who treat physicians to address the specific needs of physicians and the systems they interface with. Psychiatrists treating physicians need to understand the greater challenges of managing work-related stresses, how to help physicians in need seek a higher level of care, and re-entry back into the workplace.
- Empowerment. Help physicians not only to recognize the signs of psychiatric illness, but also help them to identify ways to adapt to overcome or improve situations that have caused them to feel jaded, overworked, and burned out. While it’s not a solution for mental health problems per se, addressing other challenges in their professional lives can help to make a difficult situation more navigable.
- Support. As members, we need to demand more of our professional communities and organizations. It’s time to ask for better advocacy by professional organizations such as the AMA, APA, AMWA, AAFP, and others. We also need to address problems in our systems to prevent and reduce discrimination at the workplace, in professional societies, and in our government.
For more information about Physician Suicide Awareness and Suicide Prevention:
For urgent help:
To find a therapist, please visit the Psychology Today Therapy Directory.
References
American Psychiatric Association (APA) 2018. Abstract 1-227, presented May 5, 2018.
