Suicide is a preventable tragedy, and all too often it’s the outcome of the stigma, shame, and silence associated with mental illness. In medicine, that stigma and silence comes at a high cost: physicians have the highest suicide rate of any profession, with a rate more than double that of the general population. According to the 2021 Medscape National Physician Burnout & Suicide Report, on average 13% of physicians have had thoughts of suicide. In some specialties, that number is even higher: 19% of OB/GYNs surveyed, for example, reported having suicidal thoughts. Other high-risk specialties include orthopedics (18%), general surgery (15%), family medicine (15%), and anesthesiology (15%), among others.
In light of this risk — which impacts physicians in every specialty to some degree — healthcare leaders have an obligation to understand and address the root causes of physician suicide. More importantly, they have a responsibility to make it possible for physicians to get help without fearing for their careers.
Unique risk factors in high-risk specialties
Some physician specialties come with unique stressors that can add to feelings of burnout and increase the risk of suicide. For instance, OB/GYNs already have stressful roles, but the COVID-19 pandemic heightened the pressures.
“Obstetrics didn’t stop, gynecology didn’t stop, women’s health issues didn’t stop. While the rest of the hospital was shutting down ‘elective’ procedures, OB providers were still delivering babies, they were still providing emergent surgeries for abnormal bleeding,” explains Dr. Mark Woodland, chair of the Department of Obstetrics & Gynecology at Tower Health Medical Group Gynecology and physician wellness chair for The American College of Obstetricians and Gynecologists. “Some people don’t realize what an urgent and immediate response team we are as a group of providers.”
The pandemic added crushing stressors for surgeons as well. First, surgeons faced the cancellation of elective surgeries, which greatly impacted their income. But once these procedures were able to resume, surgeons found themselves faced with a massive surgery backlog.
“Surgeons are now booked completely solid. A lot of them are in the operating room six or seven days a week to catch up on that backlog,” says Kathleen McCann, assistant director of member services for the American College of Surgeons. “Surgery and surgical procedures really carry the bottom line for a lot of health systems, so there’s an intense pressure right now to catch up. With limited resources and a punishing schedule, that really impacts burnout.”
Anesthesiologists generally work in isolation from the rest of the surgical team, and they can carry a heavy burden, explains Dr. Amy Vinson, assistant professor of anaesthesia at Boston Children’s Hospital and Harvard Medical School, and chair of the Committee on Physician Wellbeing for the American Society of Anesthesiologists. “Obviously, we want things to go perfectly for our patients all the time — every doctor does — but that’s just not going to happen. Bad things are going to happen, sometimes within our control and sometimes completely outside of our control,” she says. “But if anything goes wrong, we frequently carry the blame.”
Stigma and stereotypes
Physicians are expected to be immune to stress and mental health challenges, says Dr. Vinson. “But physicians — and other healthcare workers for that matter — are human. We can experience mental illness just as we can experience physical illness.”
“For physicians, there is an incredible stigma associated with seeking help for mental health and saying you’re not okay,” says Dr. Debra Williams, emergency medicine physician, founder of Dr. Deb Leads, and physician well-being committee chair for the American College of Emergency Physicians. “We are trained to be tough, resilient, superhuman, make no mistakes — so you don’t show emotion, you don’t cry, you don’t ask for help. We’ve all fallen into that trap.”
Dr. Williams says physicians tend to be high achievers and perfectionists. “So, we have those personality traits to begin with. And then when our mentors and attendings set that standard of, ‘you’re tough, you don’t cry, you don’t break down, you don’t ask for help, you just do it,’ that has all, over the years, contributed to where we are now.”
That ingrained culture of quiet stoicism makes it crucial for healthcare leaders to focus on physician suicide awareness and address mental health openly and with compassion.
Making wellness work
Wellness programs are one tool to help physicians manage stress and burnout. However, all too often those programs are merely Band-Aids that offer simplistic solutions in the form of diet and exercise advice. Furthermore, “most expect you to participate on your own time doing activities you may not find recharging or refreshing at the expense of personal or family time that was already being impacted by your work after clinic,” says Dr. Margot Savoy, senior vice president of education for the American Academy of Family Physicians.
“If organizations want their wellness programs to be successful, they can start by asking what physicians find rewarding and helping them access that better,” Dr. Savoy says. “For example, creating easy access to mental health services like counseling and coaching, or thinking outside the box to create a better sense of community can be successful strategies to engage your physician members.”
The American College of Surgeons has developed educational webinars that reframe wellbeing from a focus on yoga and meditation to “the concept of moral injury,” says McCann. “One of the systems-level projects we’re working on right now is the Caring for the Caregiver program, which systems can implement within their surgical department so that surgeons know there’s a safe space, safe people to talk to about their issues, to talk about adverse events, and get support.”
Systemic and local change
Over the past couple of decades, physicians have had to juggle greater and greater administrative burdens — and these tasks have become a major cause of burnout.
“In addition to the day-to-day emotional and cognitive burdens of delivering patient care, family doctors are often working second administrative jobs at night — entering data into the electronic medical record, completing prior authorization requests, returning patient calls/emails, and other paperwork related to practice,” Dr. Savoy says. Beyond feel-good recognition parties or after-hours wellness classes, physicians need “the practice support staff, tools, and resources to start and finish their work within reasonable working hours.”
Too often, physicians simply don’t feel supported in their workplace. Dr. Vinson routinely surveys her department about whether people feel supported and what they need to feel supported. “Then you can really tackle the microculture in your department by addressing those issues,” she says. “That’s really the most important question: ‘How supported do you feel in your work-life?’. We want to make sure that people feel supported in every aspect, in both their life and career.”
The career conundrum
The hard reality for physicians is that the simple act of seeking help could jeopardize their ability to practice. State licensing boards and credentialing applications generally require disclosure of mental health diagnoses or treatment.
“As long as you can lose your career by seeking mental health care, there will be physicians who will not seek care until they are forced to by crisis,” Dr. Savoy says. “If we want to support our physicians, we must begin by protecting them and allowing them safe spaces to receive care without retribution or punishment.”
Dr. Vinson suggests licensure and credentialing applications treat mental health the same way they treat physical health. “So instead of asking, ‘Have you ever had a mental healthcare condition or diagnosis?’ and ‘Do you currently have any physical conditions that impair your ability to care for patients?’ We get that parity, and we ask them, ‘Do you currently have any mental or physical conditions that impair your ability to care for patients?’” she explains.
If healthcare leaders truly want to begin addressing root causes of physician suicide, they need to ask themselves, “What is it about the culture of medicine that leaves such successful, bright people in such an unsupported state?” Dr. Vinson says. “As we rebuild after COVID, we can’t shrink away from asking the hard questions about what’s going on in our own house, even questioning some pretty central areas of medical culture.”
“We need to be talking about this more — opening a space where people can feel empowered to both seek help and talk about struggles,” Dr. Vinson adds. “But in order to do that we need to do the heavy lifting as leaders to support legislative changes that address the conditions that created those barriers in the first place.”
What needs to change in order to help prevent physician suicide? Share your thoughts and solutions in the comments below.