Physician suicide and identity
I was out of town, working for several days at a remote hospital. It was about an hour after I finished work. The day was typical, busy but manageable. I was in a very good place in my life. I was about 6 months into my part-time experiment, and well through my recovery from burnout. My cellphone rang and after a moment or two I realized this would be a call that changed my life forever.
My wife was on the other end of the call and she was clearly upset. Through the sobs, I learned our close friend just died from suicide. Unknown to us, he had been struggling with severe depression for months, and this day was the day that his will to live was finally broken.
Like many men, I’m not particularly good at dealing with uncomfortable emotional situations, and this event hit my psyche hard. When I first learned of the suicide I felt almost nothing but numbness. I assume this was my mind’s defense mechanism against a terrible reality it wasn’t yet ready to process.
My friend was a physician. We went to medical school together. We were similar in age and at similar stages of our careers. I went through a period of severe burnout several years before this and came out the other side healthier and more focused. My friend went through a severe bout of depression and it cost him his life. My only memories of him were happy ones, and it was hard to even imagine him depressed. I don’t know how much of his depression was induced by the stress of his career as a physician, and I don’t know what triggered this change in him. We will never have these answers, but why did we take so similar a path and have such different outcomes? The answer to this question still haunts me.
That night I went out for a quiet dinner alone and scoured the internet for answers about suicide, specifically physician suicide. What I found was not comforting. I learned that the suicide rate was shockingly high amongst physicians; and it seemed there were few people studying the problem or looking for solutions. The loudest voice seemed to be a random family practice doctor who was blogging, writing articles and running a rogue suicide prevention hotline in her spare time between seeing patients.
This didn’t seem quite right. Where was the outrage? Who was doing the studies, and starting the intervention programs? Over the next several weeks, then months I continued to read and research. I learned a lot, but I could not shake this feeling that there was some deeper truth waiting to be discovered.
It took a year or more before I was able to really feel the amalgam of emotions; deep sadness, anger and disappointment that should have been there from day one. It took me several months longer to develop the emotional strength to have a conversation with my friend’s widow, a truly wonderful person although someone I knew less well than my friend.
We all learn in different ways, and one way I synthesize information is to actually have a conversation and hear myself talk, working out ideas that have been simmering in my head since the suicide. My conversation with her was part of my healing and understanding, but it brought me no closer to my real question.
Why is the suicide rate so high?
The suicide rate for physicians is about twice as high as the general population. Some researchers think it may actually be even higher, as some physician suicide deaths are incorrectly classified as accidents. These are only estimates as good data is difficult to obtain, but in any event the rate is unnaturally high.
There are two basic possibilities I see for this massive increase in suicide among physicians:
- Either the self-selecting physician population is somehow fundamentally psychologically different from the general population or
- There is something about becoming or being a physician that predisposes to suicide.
I can’t accept that the physician population is so different that it would account for such an increase based on self-selection alone. There is simply no good evidence for this that I have been able to find. There must be something about becoming or being a physician that causes suicide.
Burnout rates for physicians are incredibly high, greater than 50% by most estimates. From my boots-on-the-ground observations I think it is probably closer to 80-90%. Many recover, a few permanently burn-out, and some drift in and out. Burnout and depression are not the same, but they are closely linked. They are comorbidities.
Most people feel that burnout and/or depression are responsible for this increase suicide rate, and this is probably true. It is also likely that physicians self-treat or choose not to treat for fear of adverse reaction from their employer or their state medical board. I think some of this fear is justified. But it just doesn’t seem like this should double the suicide rate. Burnout is high in many professions without a huge increase in suicide. I don’t buy it. There is something else going on.
Suicide is a complex topic. I’m not sure we fully understand what happens to the mind in suicide, but at the end of the day it results from all of our protective coping mechanisms failing. We seek to survive above all else. This is the root code of our operating system. It is embedded in our DNA and in our spirit. When the pain and hopelessness is too great for a person to bear we are vulnerable. Something breaks within our mind and suicide becomes a possible outcome. Why do physicians break?
Identity and ego
Being a physician is unique in many ways. Every profession has its own challenges of course, but I think physicians are in a perfect storm for becoming suicidal. Our work is stressful. We are often sleep deprived. Our training programs can be malignant and abusive. Treatment for mental health is stigmatized in our society. The emotional toll of seeing sickness and death day in and day out can overwhelm our emotional ability to process. We have higher rates of burnout and depression than average.
These are well known and much discussed, but what I seldom see discussed is the issue of identity. We are not simply a person who practices medicine, we actually become a doctor. It never leaves us. Instead of doing something we are something. This is underappreciated by many who discuss the causes for burnout and physician suicide.
Medical school and residency are at least 7 years of post-college training, and more likely 10 or more years for those that specialize or do additional fellowships. This is not 40 hours per week of easy shift work training. It is a life which consumes you. Days, nights, weekends, you are always thinking about it. It saturates your being.
The primary stress of medical school is the intense pressure to learn an impossible amount of information. In residency it is about working an insane amount of hours that would probably be classified as torture by most human rights groups. You must somehow function in this state of chronic sleep deprivation, and you are responsible for thousands of human lives over these years. Life and death decisions become routine. The only rational way to deal with this is to develop some sort of emotional detachment as a defense mechanism.
Ironically though, as your mind fights to stay alive and detach, being a physician becomes your identity. It becomes a part of your psyche in a way that being an accountant or office manager usually does not. As you slog through the trenches with a fire hose of information to assimilate and call shifts that cause perception of time to melt away, you become a physician. It is like a symbiotic being living in your body that will always be there.
Acting the part of a doctor day in and day out changes how you perceive and interact with the world in a way that I doubt is as intense as most professions. I have had many jobs including grocery bagger, busboy, waiter, door-to-door salesman and lab technician. Never did any of these jobs become my identity. As soon as my shift was over I became myself with no thoughts as to what I did to trade my time for money. As soon as my workday was over I was just me again.
Becoming a physician changed that. The lines between me and the physician me were blurred. Eventually I reached a point where I could never really fully detach.
It is always assumed that people become physicians because it is their life calling. They want to be a healer. There is this almost mystical narrative that somehow the universe just calls to you and you step forward to fight the battle against sickness and disease.
It is assumed that this situation is permanent. It is assumed that no one ever makes a mistake selecting this career. This is a calling and your destiny and it is not questioned. The narrative has an almost religious feel to it at times.
What happens when docs start hitting maximum burnout a decade into their careers?
What happens when the subconscious looks for a way out when they realize they may have made a mistake.
What happens when they don’t want to be a doctor anymore?
What happens when what was exciting and new 10 years ago is now tedious and draining?
What happens when you realize it is not your life calling but just a career that you may or may not be suited to?
What happens when you realize that at best you are not happy and outright miserable at worst?
We all fail at many things in life. Some are big things, some are little things. It is natural to fail. It is healthy to fail. But there is a big difference between failing at something and being a failure. This may seem like a small distinction, but it is the difference between feeling a little disappointed and the wholesale destruction of our ego. When we are a failure we introduce shame into the equation, and this is one of the most destructive emotions there is.
When we fail at something we can quit and do something else. When we are the failure the only path to redemption is to succeed at it. But sometimes success is not possible, and when this is true we are creating a scenario where we literally cannot win. The mind does not do well in this situation.
I think that for some, this deep sense of shame and assault on the ego results in the destruction of that firewall that protects us. As our last defense falls we are vulnerable. The unthinkable becomes the rational. We point to an external event that seems to be the breaking point, but this internal shame is often invisible. We can’t diagnose what is unseen.
Disengaging our ego from our job may be the most important thing we can do for our well-being. If you are struggling with these issues take a deep look within yourself and ask the honest question: Do you believe you are a failure?
If the answer to this question is yes, you need to reframe your thinking. This is a hair on fire emergency. You are not a failure. There is no such thing. You can and will fail, but you are not a failure. You can feel disappointment or even guilt. These things may be healthy at times, but shame is never healthy. Becoming the failure is always toxic. When we feel intense shame we cannot heal.
I will have more to say on this topic in the future, but for now ponder these issues. Please share any of your personal observations with career, identity and ego even if you are not a physician.