The Damaging Culture of Medicine and Physician Suicide

May 1, 2017

While admitting burnout isn't a problem for most doctors, many won't concede they need to see a mental health professional.

Michael Myers wrote a book about an incredibly morbid subject.

Dr. Myers, Professor of Clinical Psychiatry in the Department of Psychiatry & Behavioral Sciences at SUNY-Downstate Medical Center in Brooklyn, N.Y., explored physician suicide in his new book, "Why Physicians Die by Suicide."

Not surprisingly, Myers says burnout is a major cause of physicians taking their own life. However, admitting burnout, as many have done according to research done by the Mayo Clinic, is just one symptom of what could be a major problem. Unfortunately, he says, there is a stigma around doctors asking for mental health help from other medical professionals. If burnout is a "badge of courage," Myers says, physicians admitting they need to see someone for mental health issues is stigmatized.

Myers talked about physician suicide, the so-called shame of doctors' receiving mental healthcare, and much more in an exclusive Q&A with Physicians Practice.

Below are excerpts from this interview.

What kind of research backs up your belief that more and more physicians are dying by suicide?

I'm not sure if more and more are [dying by suicide], but the figure from the American Society for Suicide Prevention, estimates that somewhere between 300-400 die by suicide per year in the U.S., which translates into about one a day. We don't know how many medical students have taken their lives, so we don't know if this is an underestimate.

I've specialized in physician health my entire career. I've looked after a lot of suicidal [thinking] doctors. I've lost a few doctors in my practice to suicide. Two and half years ago, I started a qualitative interview project. I started interviewing family members of doctors who have died by suicide. Then I extended that to colleagues and friends of doctors, and I interview some patients of doctors who took their lives. I also interviewed some of their professors, students, and therapists. I also interviewed doctors who made near lethal suicide attempts, but lived and were able to talk about how awful that was for them, to be so sick. The book really is their stories…that forms the substance of the book.

What is causing these suicides to happen?

There is never one factor that drives a person to kill themselves. Those of us who specialize in suicide have always felt it's a whole number of factors coming together at one time. When it comes to physicians, what we look for is not just whether or not they are stressed by their patients or stressed by burnout, but we also look to see if they have a history in their families, for instance, of mental illness. If they've been previously depressed themselves and could be having a recurrence of that. Are they on particular medications that might be causing them to have suicidal thoughts? Do they have a head injury that could be making them depression prone or suicide prone?  Those are the so-called biological factors we look for. The other [factors] are psychological - is there something going on at work, in addition to a lot of work? Has there been a lawsuit recently? Are they in trouble with their employer? Are they going through a divorce? Have one of their children been kicked out of school or had a medical or psychiatric problem? Those are the psychological problems. Then we look for culture problems. Are they experiencing discrimination in the workplace because they are a racial or ethnic minority? Are they struggling with their gender or orientation? Do they have extreme financial difficulties? Even though they are physicians, they could have had a lot of things go wrong, and they could be struggling financially….Those are the socio-cultural factors that could be playing a part.

Why do you believe there is a stigma around doctors receiving mental health care?

First of all, we know it exists. Those of us in mental health, we've done a better job lowering this stigma in the general public than we have for those in medicine. It's still hard for physicians to admit to themselves, "I'm depressed, I'm going to see a psychiatrist."

Doctors will admit to burnout because it's not in the [Diagnostic and Statistical Manual of Mental Disorders] and burnout is almost seen as a badge of courage. They're working hard, they're working in a difficult medical system, so they'll say they're burned out. However, very few doctors will admit they've been diagnosed with major depression, they're seeing a psychiatrist, and are taking time off from work until they get well…The stigma makes them feel they're not holding up their end or they're ashamed of that. They're afraid they're going to be judged - and in some centers, they are being judged…There is a terrible sense of feeling different. Individuals feel frightened that if they go for help, this might affect their employment, they might have a problem when they try to renew their medical license. Some of the questions asked when you're going for your medical license application, in some states, not all, are very harsh. They're blanket statements and the doctor is made to feel like they're marked. They're stigmatized by the questions alone. That's troubling. Or they're worried [depression] will have an effect on their malpractice insurance, the rates will go up. Perhaps, they're afraid it will affect their overall health insurance.

As you probably know, we physicians tend to be perfectionists. You have to be to get into medical school, get into residency, and be successful in practice. There is kind of sense of having to be strong at all times in the medical culture. We prefer to be the healer than looking ourselves. It's not easy for us to change roles and to admit [when] it's [our] time to be the patient. Making the transition from physician to patient is hard for a lot of physicians. When they do it, they're usually so relieved. I've talked to physicians who said they've delayed and delayed in coming, and even at the end of the first visit, [are so glad they came].

What needs to change in the culture of medicine – especially around burnout?

We're all in this together. This is where changes are occurring, starting in medical school, there is much more effort to make sure students get through medical school safely. They look at what's built into the curriculum, they make sure there is access to good foods, gym, yoga, meditation, etc. Helping them from an early stage with balance. That's going on in residencies too.

After that, it's into the workforce. In some hospital settings, the CEOs and people who make major decisions, they have to make sure physician representatives are at the table. They need a say in what's expected of them and how hard they work, and what they have in the way of downtime. 

Those of us in the mental health field…we have to be on top of our game. We have to realize it's not easy for physicians to come see us. We have to make them feel comfortable and be patient with them. Because of the stigma...it's hard for them to accept being a patient.

What advice do you have to physicians who are feeling depressed about their current situation?

In the subways in New York, there are signs that say, "If you see something, say something." If you see something in yourself or a colleague, do something about it. If it is yourself, you know yourself. If you are out of sorts and it's not going away… find a primary-care doctor, someone who is at arm's length, not a friend or colleague - someone who will let you be a patient…Basically, let someone else look after you. If it's more serious, make sure you get in the hands of a psychiatrist. If it's a psychiatrist who only prescribes medication, make sure you also go to a social worker or psychologist/therapist to talk about those things that are troubling you, that might be generating some of your symptoms. The medication may help you feel better, so you're able to work effectively. But if there is stuff you've been sitting on and dealing with, it's good to work with someone who is a therapist in a trusting, confidential relationship.