by Zakari Tata, MD
Many articles have been written on physician suicides. Yet nothing practical has been implemented. The problem is probably much larger than reported, as families will try to avoid publicity where possible.
In medicine, just as in the rest of society, people diagnosed with depression are wrongly labeled as weak, and discrimination, especially the subtle passive type, exists. Physicians are probably exposed more to stress than other professions. As a result, unforeseen suicides occur much too frequently because there are no active mechanisms to detect these conditions in physicians.
In over 20 years of practice I have known at least ten physicians who died by suicide in Europe as well as the USA. In addition, I personally have been involved with near suicidal situations affecting two physicians. All had different ethnic backgrounds and religions and all were exceptionally bright with great futures. I am writing a series of articles dedicated to the memory of those lost physicians and to the courage of the physicians who were able to ask for help before they succumbed. Also, this effort is to also to inform and encourage families and friends of resident physicians to take a more proactive role.
These articles seek to help the public at large to understand why these suicides are common. I also hope that it encourages us to do more to address depression and mental illness more compassionately. Many physicians may disagree with my observations, for this is my individual opinion. I only seek to encourage more meaningful and effective interventions. In the eyes of the public, it may be difficult to fathom how these highly revered professionals; skilled in healing the sick may sink to the depths of depression. In this first article, I will write mainly about physicians in residency training. This is not a criticism of residency in any way.
Depression is the condition that leads to suicide in the general public. A large majority of the sufferers of depression remain undiagnosed, and they respond to their condition by either compensating positively initially, until they break down, or by immediately regressing depression may present in many different forms. Some examples are workaholism, obesity, tardiness, drug abuse, aggression, alcohol abuse, tobacco use and promiscuity. Changing schools frequently, intense religiosity and obsessive behavior are other possible signs as well. The response may tend to be guided by baseline self-esteem, insight and professional standing. Physicians will often try to respond by maintaining their expected societal roles while still struggling beneath. It is this struggle that eventually causes a breakdown if not addressed.
The principal symptoms of depression are severe sadness, intense guilt, fatigue and lack of self worth in spite of an outwardly very rewarding and productive life for some. A physician suffering from depression may continue to overachieve to correct the self-doubt and guilt brought on by depression. This creates a vicious cycle because he or she may lack the mental and physical energy to actually maintain their goals. These continuous efforts are usually not emotionally rewarding and may produce more frustration and usually even ensuing success fails to lift the dark clouds, which torment him or her. It is important to note that depression is not caused by stress although it can be brought on or worsened by stress in susceptible individuals .It is an illness like hypertension or diabetes, which anyone could develop. Like these other illnesses genetics, family history and the environment play a role in its development.
Physicians have unique social situations. They are highly respected in society and it is difficult for their friends and family to give them advice. The reason is usually because they feel the physician “ knows everything”. In addition, during the intense years of residency training, physicians may not be very accessible to their friends and family due to long hours of work and study resulting in relative social isolation for some. Residency is particularly stressful for many other reasons that I will attempt to explore.
While training in hospitals as residents, many of physicians encounter challenges that could be quite overwhelming. At times they may make simple errors at work and for such high achievers; any mistake at work is difficult to accept. Mistakes, no matter how minute are easily magnified in the highly precise nature of residency training. During prior academic studies before residency, errors did not have serious repercussions. Now, mistakes could result in a death or loss of quality of life. In addition, training hospitals closely scrutinize all work done by all physicians, including residents, to protect patients. All these factors begin to develop a high stress situation that could be quite unnerving.
In physicians prone to depression, things may start to deteriorate after a few errors and other stressors exaggerate the deep sense of failure that accompanies depression. The pressure of work and high expectations may magnify the impact of mistakes in someone plagued by self-doubt, sadness and guilt. The friends and family of such physicians cannot usually appreciate their issues. How could this talented intelligent person with a bright future worry about a small mistake? This larger than life person knows how to cure everyone so obviously they are able to fix themselves. They are so smart they can always find a way out and even if they should have a problem, they can find another career in medicine or excel in any endeavor they should choose.
Mistakes and errors are not always the culprits. The stress of dealing with life and death on a daily intimate basis rather than an academic level is new to residents. By the time they get to the stage of dealing with patients, they have already invested a lot of time in their training. It is easy for the resident physicians to blame themselves at this stage, for unexpected deaths and poor outcomes, which are actually a part of their development. The resident is usually the person delivering bad news like deaths on the hospital floors, as they are the ones physically present. In addition they have to speak and counsel distressed family members and patients quite frequently for difficult news. At times emotional family members or patients unintentionally blame the resident physicians directly for poor outcomes. These experiences are not easy. I personally remember my first death in medical school and it still evokes the same emotions. The death was inevitable, but the patient was 17 years old and I was first on the scene to confirm death. Prior to this, I had never seen a dead body. The culture is for the physician to appear strong and thus they feel embarrassed to discuss any stress they may be feeling with colleagues.
The fast paced, highly disciplined and self-motivational nature of residency training prevents the resident from having time for breaks and self-reflection. A resident cannot resort to alcohol or pursue other mind numbing activities due to demands of time and the profession. A professional milieu has to be always presented and time is highly rationed. The productivity of a disturbed resident may decline and this may result in a loss of self-esteem and interpersonal problems with colleagues. These problems could lead the other residents to view the actions of their disturbed colleague as incompetence. An incompetent resident adversely affects the effective teamwork that is necessary in a residency and as such, resentment may develop towards the disturbed physician who is struggling to keep up.
At many times, the resident physician may be aware that they are depressed and suicidal. The absence of a positive emotional outlet worsens the stress. They are afraid to seek medical help because of the fear they may be kicked out of their training program as well as the social stigma from colleagues. They may self medicate or seek help from unconventional sources. Sometimes they may be fortunate to find sympathetic physicians who may treat them in confidence. This is still difficult because the sick physician does not want depression in their medical records or proof that that they are being prescribed antidepressants.
My suggestion of a practical first step solution: residents should be required to attend at minimum, monthly counseling sessions throughout their residency. This should be encouraged even after the residency. This will result in significant frequent debriefing, loss of social stigma and a possible healthier mental and physical situation. This type of approach occurs in some residency programs. It may not be the “cure all” but will be a step in the right direction. It will also prevent these stresses and habits from following the resident through their career and hopefully lesson and prevent the occurrence of depression and suicides.
In addition, I think that medical students and residents should be prepared for the typical high charged emotional situations that develop in training. Through role playing, acting and other means they should be counseled in a realistic manner about the stresses they may encounter. Stress reduction techniques like yoga, are all options. The idea is not to find a perfect solution but to openly discuss and accept that physicians are vulnerable. The current culture that presents physicians as always being in control of their psychological health should be discarded.
Zakari Tata is a family physician.
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