For people who deal with life and death daily in our work, you would think suicide among us physicians would not be an option. Sadly, it is — and not necessarily a new reality. Let me explain.
Sometimes we agree to do something and can never quite envision where that road may lead.
Here’s an example: For several years, I had written a pedestrian medical column for a respected Midwestern newspaper. Straightforward, noncontroversial advice about getting exercise, a good night’s sleep, eat fruits and vegetables — the life-saving messages that often fall on deaf ears of our patients.
A major medical journal was shifting from complex review articles to articles of about 1,000 words addressing a timely topic, adding a few pertinent references and being mindful that the audience was primarily general physicians and some specialists. I was asked to address the issue of professional burnout since I had been a medical oncologist at that time for 25 winters at the Mayo Clinic and apparently had some experience writing columns.
Hardly Pulitzer Prize–winning, my article was relatively easy to write because only one published paper at that time documented that 50 percent of oncologists fulfilled the burnout criteria. And this was directly related to continuous, almost daily patient care with no respite for teaching, administrative, or research opportunities.
The paper I wrote was published in 1993 and was the catalyst for multiple speaking opportunities throughout the world on the challenging problem of physician burnout. You see, this is not a new deal. But then, the focus of the literature shifted to the searing, soul-shredding issue of professional suicide.
This issue of burnout has never left us.
Yet I was not prepared for a recent speaking invitation on the topic. The audience was expected to be physicians in oncology, administrative leaders, and advanced practice partners (physician assistants). I was asked to address the reasons for burnout, the signs and symptoms of this pandemic, and solutions.
I took this invitation very seriously, updated the material, and had a crystal clear outline of this audience’s needs. But before I could deliver this collegial talk, everything changed.
Several days before the meeting, I became aware of at least three recent suicides among colleagues in major medical centers in our region.
The emails exploded off the screen — a gut punch. A highly respected clinician and researcher had died. A senior leader shared a thoughtfully worded commentary and acknowledged the availability of grief counseling. And the tone of the note was that this individual had taken his life.
During the same time frame, a younger colleague had taken their life.
As I waited for the elevator to the venue, a medical colleague whom I have known for many years opened up his app and showed me a tweet that another colleague had taken their life. I was stunned and saddened.
I arrived at the venue, and my host mentioned that she would begin the meeting with a prayerful reflection about these tragedies. All of a sudden, my carefully manicured, massaged, and orchestrated PowerPoint presentation became totally irrelevant.
I shared with the group that several years ago, my wife and I were touched by the horror of suicide. We had been close with a couple. She had been a beloved administrator, and he was an acknowledged expert in a narrow area of surgical expertise.
We tragically learned that he had jumped off a parking ramp to his death. We were devastated and mystified because we never learned what drove him to this precipice of despair. And was there a sign, was there a signal that we missed that he was planning to take his life?
The audience for my presentation weighed in with their reflections on the pressures, the demands, the expectations, and their observations about how medicine has changed. Themes emerged: The evolution of medicine from a mom-and-pop cottage industry to international health care delivery conglomerates where the leadership typically has a corporate business mentality; the rank and file health care providers have little input into their daily lives; and the notion of “profits over patients” has become a rallying cry for work stoppages throughout the profession.
The raw numbers are chilling. Although the exact numbers are elusive, an estimate commonly quoted is approximately 300 to 400 physicians per year. The loss of one doctor per day to suicide is a frightening figure. This is the equivalent of losing between one small and one large medical school class to suicide each year. That’s twice the rate of the general population.
Female physicians alone are three times more likely to die by suicide. Some of these individuals have been in the midst of notable careers but often do not have healthy boundaries. Their needs are secondary to everyone else’s.
Our profession has reached the point of Armageddon. Last year 350,000 health care professionals walked out the door, and this included 180,000 physicians. The perfect storm: The political and scientific chaos and conflicting recommendations about the management of COVID; the isolation fueled by telemedicine and working from home; a draconian health record whereby at the end of a month a typical practitioner might have spent an additional 25 hours satisfying the requirements on the computer with more face time with a screen than a patient; the changing perceptions by society of the health care professional; a tsunami of information in which the body of medical knowledge doubles every 73 days so no provider can be knowledgeable even in their own specialty.
How can we understand these tragedies without some acknowledgment of the scope of the problem?
A recent study is noteworthy. The frequency of burnout among health care professionals has been well chronicled. Depending upon the paper published, about 60 percent of physicians fill the criteria for burnout. Is this a risk factor for suicide? Let us look at the data.
In one reputable study, each standard deviation increase in burnout was associated with an 85 percent increased odds of suicide ideation. After adjusting for depression, there was no longer an association. However, in the adjusted model, each increase in depression was associated with a 202 percent increase in the odds of suicidal ideation.
Burnout was associated with medical errors. And the authors suggest that burnout represents an upstream intervention for targeting to prevent suicidal ideation by preventing depression. In other words, depression seems to be the culprit in physician suicides rather than burnout.
Health care providers are now caught in a conundrum. Training and expertise is focused on meeting the needs of the patient, but a carnivorous electronic health record is an impediment, as are increasing productivity and efficiency expectations. The camaraderie and the collegiality that fueled common goals and purposes have been eroded. There is virtually no time for those casual hallway discussions, that quiet cup of coffee to review complex patients.
Neither is the luxury of simply asking a colleague, “How are you doing?” and thoughtfully taking time to listen to the response.
Myriad articles have addressed potential solutions, and the key players have been Drs. Shanafelt, Colin West, Lotte Dyrbe, and Steve Swenson. They recognized that relatively small selected programs have provided some benefit, but overall, the landscape of interventions has remained inconsistent and cloudy.
One intervention is especially noteworthy. Mayo Clinic orchestrated a randomized prospective trial involving a study group of 74 physicians from the department of medicine. Data were collected from 350 nontrial participants responding to yearly surveys timed to coincide with the trial surveys.
The intervention involved 19 biweekly physician-facilitated discussion groups focusing on reflection, shared experiences, and small group learning for nine months. Time was protected for the study participants, and meetings were typically held in a local restaurant.
I was part of the study group, and seven of us met for one hour and followed a specific agenda. For example, What went well today? What is that “pebble in the shoe” that if removed could make our lives more positive? Why did I go into medicine? These meetings were fun, energizing, and collegial.
At the end of the study, there was an in-depth statistical analysis, and the findings were striking: The individuals in the study group who had the “free lunch” had statistically significant enhancement of empowerment and engagement at work. Rates of depersonalization were statistically improved in the study group, and the proportion of participants in the study group strongly agreed that the work was far more meaningful in the intervention group. The rates of emotional exhaustion and overall burnout decreased substantially compared to the nontrial cohort, who did not meet on a regular basis.
Burnout and physician suicide are now recognized as a systemic catastrophe, and the efforts of a single individual in the system are relatively ineffective.
A sense of shared purpose, community, and connectedness is crucial to the well-being of health care providers.
We each have a stake in this dilemma because the engaged, satisfied, and respected professional provides consistently better care than the individual distracted by the emotional toll of the profession.
Edward T. Creagan is a hematology-oncology physician.