Saving the doctors

To prevent physician suicides, we must look beyond depression to other factors

July 07, 2008|By Claire Panosian Dunavan

He was a slim, twitchy guy with red hair and rage - and as I recall, he worked as hard or harder than any of us rookie docs back when a best-seller called House of God had just blown the cover on the grueling days and nights, raunchy jokes and general misery of U.S. medical trainees.

In those days, high-tech hospitals were just a gleam in some muckety-muck's eye. In other words, at our vaunted citadel, there were no fancy scans, no computerized labs, and certainly no one but the lowest grunt on the totem pole to hang blood or push meds or run EKGs between taking histories and probing organs and orifices of the seemingly endless stream of new arrivals on the ward.

When patients called "train wrecks" rolled in, hacking and blue, we still hunted for tiny evildoers in their phlegm using ancient stains and scopes - and when they stopped breathing altogether, we performed mouth-to-mouth resuscitation, even if they had just vomited or bled.

So why were we so shocked, I wonder now, when our red-haired friend went home one night, tied a tourniquet around his arm, and then plunged a syringe of potassium chloride into a vein, forever stopping his heart as only a medical insider knew how? "I never saw it coming - did you?" we whispered back and forth. Which, in some ways, was a lie. It didn't take an M.D. degree to figure out he was depressed. But since many of us were depressed, we took his pain for granted.

Two days later, we attended his memorial service and wept. Then we returned to the life our comrade-in-arms had so violently and irrevocably rejected.

Thirty years ago, a fellow resident committed suicide, and my world rocked. Yes, I had witnessed death, but like most twentysomethings, I pictured myself (and my peers) as immune to its icy clutch.

Today, I see my friend's suicide in a different light. For one thing, it shocks me less. It also angers me. Why? Even in 2008, I'm not sure it could have been prevented.

The truth is, medical doctors are more likely to commit suicide than any other professional group. But facing this fact remains largely taboo. Fear of stigma is one reason broken healers often hide or self-treat their pain (with substances legal and not). Fear of repercussion from hospitals and licensing boards is another.

Why certain physicians kill themselves is harder to parse. Are they melancholy from the get-go - or does work push them over the edge? Although research suggests that many doctors are emotionally muted, experts also believe they start life with no greater risk of depression than anyone else. Yet once a day, on average, an American physician takes his or her life.

Struggling in Silence, a recent PBS special on doctor suicide, interweaves stories of doctors who died by their own hand with happier endings. A medical student once gripped with anxiety now counseling peers. A researcher channeling bipolar disease into writing. A surgeon retraining in end-of-life care.

Sponsored by the American Psychiatric Association and a pharmaceutical company, the program lauds the growth in mental health programs now offered in medical schools and hospitals. All well and good. My institution launched its 24-7 service more than two decades ago. Today, it sees roughly 10 percent of all students and trainees (whether they represent the 10 percent at highest risk of suicide is another question).

One stark omission from the PBS show, however, is the contribution of external stressors to modern-day medical despair. Yes, brain biochemistry fuels major depression, but what about burnout from day-in, day-out exposure to death and suffering - or paperwork and bureaucracy - or waste and maldistribution in American health care - or sheer exhaustion?

Actually, it's no surprise that many brilliant (and typically stoic) medical leaders downplay these vague unmeasureables. But there is one outcome they track: boots on the ground. "Where have all the doctors gone?" wrote the former dean of Harvard Medical School in a recent editorial in The Boston Globe in which he decried the flow of newly minted doctors into lucrative, lifestyle-oriented specialties as opposed to hard-core essentials - for example, family medicine and general surgery.

Today, evidence of physician dissatisfaction runs the gamut from severe depression to strategic expediency in choosing a specialty, practicing "concierge medicine" or refusing health insurance altogether. Perhaps these latter trends - which hurt the public far more than 300 to 400 doctor suicides a year - will finally focus attention on new ways of restoring health to a struggling profession. Mood elevators and talk therapy may help, but they are not the only answer.

Dr. Claire Panosian Dunavan is a professor of medicine at the David Geffen School of Medicine at UCLA. Her e-mail is cpanosian@mednet.ucla.edu.

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