Jordan Taylor describes her mother as a driven woman, as many internists are. ACP Member Anita Lang, MD, focused on making sure Ms. Taylor and her three brothers excelled at whatever they did growing up.
“On the flip side of how much she cared about people,” Ms. Taylor added, “was that she was so fast to shrug off compliments or awards or accolades.”
Instead of focusing on her accomplishments, Dr. Lang focused on her mistakes. And amid the dual pandemics of COVID-19 and an opioid crisis that was particularly severe in her Cleveland practice, “I think it was a high-stress kind of situation where she must have been in her own head a lot,” Ms. Taylor said. Dr. Lang dealt more with death certificates than before. Her patients had poor outcomes. She had to reach out to her hospital's internal legal team about potential litigation.
Ms. Taylor asked, “And who do you talk to when you're fearful of that? Who can you talk to?”
Dr. Lang died by suicide on Dec. 8, 2020.
Experts agree that no one fully knows the scope of physician suicide. Some articles say physicians die of suicide at twice the rate of the general population, perhaps 300 to 400 deaths by suicide per year, but the few studies that have examined the topic have extrapolated figures from what data are available. A recent study from Mayo Clinic Proceedings concluded that 7% of U.S. physicians had thoughts of taking their own life in one year, that suicidal ideation was more common among physicians than among workers in other fields, and that while physicians were more likely to seek help for serious emotional problems, 35% of physicians with suicidal ideation reported that they would probably not seek help.
Suicide rates in the U.S. have generally risen, year to year, at least for the last 20 years, said Perry Lin, MD, FACP, co-chair of the Physician Suicide Awareness Committee of the American Association of Suicidology. “Effective suicide prevention strategies that work in other countries don't always appear to work here,” Dr. Lin said. “We are not certain why.”
A study published in April 2021 in Psychology, Health & Medicine reported the first updated numbers on physician suicides in 16 years. The study used 2010-2015 data from the 27 states that report suicide to the CDC's National Violent Death Reporting System (NVDRS). Of 63,780 overall deaths by suicide, 357, 307 men and 50 women, were physicians. The authors wrote that extrapolated data predicted about 119 physician suicides annually, a number not statistically different from nonphysicians.
However, the results likely represent the lower boundary of physician suicides, the authors wrote. And Dr. Lin pointed out that physicians may hide suicides on the death certificates of their fellow physicians, labeling them as accidents, while many states do not record suicide as a cause of death.
“The difficult part is we don't even have numbers,” Dr. Lin said. “And that's really an issue within our field.”
Opening a dialogue
After Dr. Lang's suicide, Ms. Taylor and her family reached out to her mother's practice partners and connected with ACP's Ohio Chapter. The family wanted to be open about Dr. Lang's death as a way of helping others. Funeral notices encouraged donations to suicide prevention services.
Ms. Taylor said, “I just really wanted there to be able to be an open discussion, especially where she worked, especially in the midst of a pandemic, when I'm sure things are stressful anyway.” (An electrical engineer by training, Ms. Taylor had been considering changing careers even before her mother's death and is now pursuing education as a grief counselor. For more on her journey, watch her video interview.)
The Ohio Chapter responded proactively and openly with an email from its Governor, Craig D. Nielsen, MD, FACP, to all its members explaining what had happened and listing resources for physicians who may need to seek help.
The letter stated, “[Dr. Lang's] family has requested that we use her death to bring awareness to physician suicide. Suicide is a complicated act due to a multitude of variables. It can represent the culmination of multiple health and life factors including depression. This can lead to feelings of overwhelming mental/physical pain and feelings of hopelessness. Individuals can display obvious changes or warning signs but sometimes these can go unnoticed. There are treatments that can help. Suicide should never be an option.”
It continued, “You are not alone. If you, or anyone you know is thinking of suicide, please reach out and connect with them with help. While the pandemic has resulted in physical distance from our family and friends, our office staff, our patients and each other, we must work to support one another through these trying times.”
An upcoming Ohio Chapter meeting will host an open forum and two lectures about the topic, including one by Dr. Lin, who is also assistant program director of the internal medicine residency program of the Mount Carmel Health System in Columbus, Ohio. Willingness to discuss suicide in an open way, giving experts on the subject a platform, and encouraging colleagues to watch out for one another are the first steps to changing the culture within health care when it comes to suicide, he said.
Dr. Nielsen, a general internist at the Cleveland Clinic, added, “We were trying to raise the bar and decrease the stigma associated with physician suicide and hopefully open up discussion.”
Dr. Lin pointed to ways that other organizations have addressed suicide. The U.S. Air Force Suicide Prevention Program implemented a comprehensive, multipronged prevention strategy in 1996. One study looked at data from the program from 1981 through 2008, 16 years before its 1997 launch and 11 years after, and published results in the American Journal of Public Health in September 2011.
The Air Force's 11-point system was associated with not just a 33% relative reduction in suicides, but also a 51% relative reduction in homicides, an 18% relative reduction in accidental deaths, a 54% relative reduction in severe family violence, and a 30% relative reduction in moderate violence.
Among the 11 points were gatekeeper training, essentially a peer-to-peer safety net. It's comparable to the mentoring and monitoring many medical schools implement, Dr. Lin said. The Air Force also had its chief of staff communicate every three to six months to all commanders, reminding them about the importance of suicide prevention; encouraging them to actively promote protective factors; and tracking training, assessment of skills, and knowledge of basic suicide prevention.
Dr. Lin said physicians and especially residents are similar to military personnel: self-selected and driven populations who don't necessarily always have control over what their day-to-day life entails. A system like the Air Force's, Dr. Lin said, “is something that needs to happen to all health systems.”
Breaking through barriers
For Marion McCrary, MD, FACP, her experience with the death of a loved one by suicide was one of the reasons she joined ACP's ranks of Well-being Champions, physicians specifically trained to sponsor peer support groups and activities, as part of her involvement with ACP's North Carolina Chapter.
“We've all unfortunately known individuals who have committed suicide,” Dr. McCrary said. Her medical school and residency classmate committed suicide last year after battling depression for many years. His family also wanted to be very transparent about his death to help other physicians at risk. “Addressing suicide risk in our profession is essential. Suicide is the ultimate failure of not addressing physician well-being,” she said.
While any one person's death by suicide is difficult to untangle from mental health issues or external pressures, something that especially drives physicians is a sense of responsibility and perfectionism “that just at some point can become so overwhelming that you just don't think you can continue,” said Dr. McCrary, an ambulatory outpatient internist at Duke Signature Care, a university-affiliated practice in Durham, N.C. “Doctors can be overly hard on themselves.”
Dr. Nielsen added that while physicians may be reluctant to seek mental health care or to report it to employers and licensing boards, “Younger physicians coming up are much better at this and thinking about their own wellness than established physicians. Their ability to be open and talk about these things is positive.”
Matthew DeCamp, MD, PhD, FACP, an associate professor in the Center for Bioethics and Humanities at the University of Colorado in Aurora, Colo., added, “Mental illness and mental health issues remain stigmatized in the population generally and also for physicians, who may be reluctant to seek help because they think it would affect their standing in the profession or affect their ability to continue practicing medicine. Stigmatization is probably one of the biggest barriers to overcome.”
Often, physicians apologize when they call suicide hotlines, Dr. Lin said. “And if that doesn't explain physicians, nothing else does,” he said. “The fact that when you are seeking help, to somebody that's helping, the first thing you say is, ‘Sorry, I'm taking your time.’ ‘Sorry, I'm calling you.’ ‘Sorry, I'm wasting your time, right?’ We believe our own mental health is not important.”
That sense of apology is ubiquitous among the physicians treated by Michael F. Myers, MD, a professor of clinical psychiatry at SUNY Downstate Health Sciences University in Brooklyn, N.Y. “When I call my cardiologist or my urologist, I don't say, ‘Sorry to bother you.’ I say, ‘I'd like to make an appointment. I'm having trouble with urinating,’” he said. “There's no apology.”
One way to overcome this reluctance and decrease stigma is to have physicians who have struggled with the issue write, lecture, and take to social media to tell their own stories. This encourages others to seek help too, said Dr. Myers. He noted that physicians have come to his office to seek help after reading or hearing from other physicians who have written or lectured about their own experiences in major newspapers or peer-reviewed journals.
“They'd say, ‘I read this article about this doctor in the New England Journal of Medicine. I thought, wow, his story is like mine, I guess I'm not the only one,’” Dr. Myers said. And the vast majority of physicians who receive treatment often bounce back, sometimes even better, because they understand themselves, he said.
Working toward wellness
Dr. Myers, author of the 2017 book “Why Physicians Die by Suicide: Lessons Learned from Their Families and Others Who Cared,” recalls the moment he chose a career specializing in treating physicians contemplating suicide. During medical school in the 1960s, a classmate died by suicide, and there was no acknowledgment or formal response. “We heard nothing at all from the dean's office,” he said. “I was the one that told my class that [he] had killed himself over the Thanksgiving weekend. And then we just buried ourselves in our books and carried on.”
Fariha Shafi, MD, FACP, is a docent, or mentor, for medical students and associate professor in the department of internal medicine at the University of Missouri-Kansas City School of Medicine. She mentors students from the moment they set foot in medical school. “Because you're their mentor, and you're working closely with them all the time, you come across these topics of emotional well-being quite a bit,” she said.
Dr. Shafi is also trained as an ACP Well-being Champion, applying that knowledge to her students when they flounder. She said she also draws on her clinical training to listen to what her students are saying, just as she listens to patients describe their conditions. “As physicians, we are taught to screen for depression and anxiety at every clinical encounter. Screening our students, colleagues, and staff is not very different. We know what to pay attention to,” Dr. Shafi said. “The problem in the case of physicians is that we also know exactly what to avoid saying so as not to get flagged as depressed.”
Dr. Shafi, too, knows someone who died by suicide. “She was a physician, a wonderful mother, a bubbly personality, life of the party, she had everything in everyone's eyes, and nobody would have guessed what was going on underneath it all,” she said. “Think about how bad it must have been that nothing, none of those positive aspects could save her. How miserable must she have been on the inside to think that the only way out she had was to end it all?”
She added, “There are so many factors, including the various cultures that we belong to, where discussing mental health issues is a taboo—most importantly, the culture of medicine, which makes it so hard to practice this art that we love if we acknowledge emotional fragility.”
Medical schools and residency programs have recently begun to implement wellness curricula that specifically include sessions on wellness, burnout prevention, and seeking mental health care when needed. Dr. Lin uses a program developed at The Ohio State University, which has invested significant resources into preventing death by suicide among its entire student body. The training, called Recognize, Engage, Ask, Communicate, and Help, is done during student orientation, because 21.2% of all suicides among residents are in the first three months of training, “which means that among resident physicians … I have to go quickly,” Dr. Lin said.
Dr. Shafi said that at the University of Missouri-Kansas City, all docent mentors conduct at least two formal semi-annual interview sessions with each student that include emotional and mental health checkups. Additionally, resources are continuously made available to students through ongoing communication.
Dr. McCrary added that during training, medical students and residents are prone to develop patterns of thought focusing on how they should conduct themselves that set them up for unrealistic expectations and imposter syndrome, or people feeling like they don't deserve their success. That perfectionistic tendency that helps get them into medical school and beyond can also be a driver for emotional distress, she noted.
More global calls to action are necessary, too. ACP's Ethics, Professionalism, and Human Rights Committee recently released a policy paper to bring physician suicide to the attention of physicians, health care organizations, and other stakeholders. Dr. DeCamp was lead author on the paper, which was published in the Journal of General Internal Medicine on June 2, and said it emphasizes the importance of the medical community, as a profession, supporting its members and physicians supporting each other.
“It can be a call to action for physicians within their own institutions, for the medical community as a whole, for graduate medical education, and so on, to take this statement and go to leadership and say, ‘Look, this is really important. Here are some actionable items that we think would be useful for continuing this dialogue and addressing the fundamental problems,’” Dr. DeCamp said.
He added that one unique part of ACP's statement is framed around the medical profession as a special moral community with members who have obligations and commitments to each other, to their patients, and to society. “And in the fast-paced, busy world, and medicine today, it can be easy to forget that,” he said.