An obstetrician is found dead in his bathtub; gunshot wound to the head. An anesthesiologist dies of an overdose in a hospital closet. A family doctor is hit by a train. An internist at a medical conference jumps from his hotel balcony to his death. All true stories.
What are patients to do?
When they call for appointments, patients are told they can't see their doctor. Ever. The standard line: "We are sorry, but your doctor died suddenly."
In most towns, news spreads fast no matter how veiled the euphemisms.
About 400 doctors commit suicide each year, according to studies, though researchers have suggested that is probably an underestimation. Given that a typical doctor has about 2,300 patients, under his or her care, that means a million Americans will lose a physician to suicide this year.
So what's the proper response if your doctor died by suicide? Would you deliver flowers to the clinic? Send a card to surviving family? What's the proper etiquette for dealing with this issue?
Physician suicide is rarely mentioned - even at the memorial service. We cry and go home, and the suicides continue.
I've been a doctor for 20 years. At 46, I've never lost a patient to suicide. But I've lost friends, colleagues, lovers - all male physicians. Four hundred physicians per year are lost to suicide, according to a Medscape report, which pointed out that "perhaps in part because of their greater knowledge of and better access to lethal means, physicians have a far higher suicide completion rate than the general public."
What can we do? To start, let's break the taboos that have kept this topic hidden.
Physician suicide is a triple taboo. Americans fear death. And suicide. Your doctor's committing suicide? Even worse. The people trained to help us are dying by their own hands. Unfortunately, nobody is accurately tracking data or really analyzing why doctors may be depressed enough to kill themselves.
I'm a family physician born into a family of physicians. I was practically raised in a morgue, peeking in on autopsies alongside Dad, a hospital pathologist. I don't fear death, and I'm comfortable discussing the issue of suicide. In fact, I spent six weeks as a suicidal physician myself. Like many doctors, at one point I felt trapped in an assembly-line clinic, forced to rush through 45 patients a day, which led to my own despair and suicidal thoughts. Then I opened my own clinic, designed by my patients. I've never been happier.
Despite my own trouble, I was clueless about the issue of physician suicides until one beautiful fall day in Eugene, Ore., when a local pediatrician shot himself in the head. He was our town's third physician suicide in just under a year and a half. At his memorial, people kept asking why. Then it hit me: Two men I dated in med school are dead. Both died by "accidental overdose." Doctors don't accidentally overdose. We dose drugs for a living.
Why are so many healers harming themselves?
During a recent conference, I asked a roomful of physicians two questions: "How many doctors have lost a colleague to suicide?" All hands shot up. "How many have considered suicide?" Except for one woman, all hands remained up, including mine. We take an oath to preserve life at all costs while sometimes secretly plotting our own deaths. Why?
In a TEDx talk I gave to help break the silence on physician suicide, I pointed out why so many doctors and medical students are burning out: We see far too much pain; to ask for help is considered a weakness; to visit a psychiatrist can be professional suicide, meaning that we risk loss of license and hospital privileges, not to mention wariness from patients if our emotional distress becomes known.
Internist Daniela Drake recently addressed this topic in her article-gone-viral "How being a doctor became the most miserable profession." She identified underfunded government mandates, bullying by employers and the endless insurance hoops we have to jump through as a few of the reasons. "Simply put, being a [primary-care] doctor has become a miserable and humiliating undertaking," she wrote. "It's hard for anyone outside the profession to understand just how rotten the job has become."
In a rebuttal article, "Sorry, being a doctor is still a great gig," pediatrician Aaron Carroll disputed the misery claim: Doctors are well respected, well remunerated, he writes, and they complain far more than they should. He predicts people will soon ignore doctors' "cries of wolf." But to cry wolf is to complain about something when nothing is wrong. Yet studies have found that doctors suffer from depression, post-traumatic stress disorder and the highest suicide rate of any profession.
So what should we do?
Etiquette rule No. 1: Never ignore doctors' cries for help.
Bob Dohery, a senior vice president of the American College of Physicians, downplayed physician misery in a blog post on the ACP Web site this spring. His suggestion was classic: When doctors complain, quickly shift conversations from misery to money: their astronomical salaries. But when a doctor is distressed, how is an income graph by specialty helpful?
I run an informal physician suicide hotline. Never once have I reminded doctors of their salary potential while they're crying. Think doctors are crybabies? Read some of their stories at www.kevinmd.com/blog/2014/04/physician-suicide-letters.html before dismissing doctors as well-paid whiners.
Physician suicide etiquette rule No. 2: Avoid blaming and shaming.
After losing so many colleagues in my town, I sought professional advice from Candice Barr, the chief executive of our county's medical society. Here is her take:
"The usual response is to create a committee, research the issue, gather best practices, decide to have a conference, wordsmith the title of the conference, spend a lot of money on a site, food, honorariums, fly in experts, and have 'a conference.' When nobody registers for the conference, beg, cajole and even mandate that they attend. Some people attend and hear statistics about how pervasive the 'problem' is and how physicians need to have more balance in their lives and take better care of themselves. Everybody calls it good, goes home, and the suicides continue. Or, the people who say they care about physicians do something else."
So what works?
Our Lane County Medical Society established a physician wellness program with free 24/7 access to psychologists skilled in physician mental health. Since April 2012, physicians have been able to access services without fear of breach of privacy, loss of privileges or notification of licensing and credentialing bureaus. With 131 physician calls and no suicides in nearly two years, Barr says, the "program is working." Even doctors from outside the town are coming for support.
It's important to "do something meaningful, anything, keep people talking about it," Barr says. "The worst thing to do is nothing and go on to the next patient."
What's most important is for depressed doctors and those thinking about suicide to know they are not alone. Doctors need permission to cry, to open up, to be emotional. There is a way out of the pain. And it's not death.
Which brings me to physician suicide etiquette rule No. 3: Compassion and empathy work wonders. More than once, a doctor has disclosed that a kind gesture by a patient has made life worth living again. So give your doctor a card, a flower, a hug. The life you save may one day save you.