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Mar 26

Physician Suicide and Identity

 Physician suicide and identity

 

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.

 

Processing

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.

 

Time

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:

 

  1. Either the self-selecting physician population is somehow fundamentally psychologically different from the general population or
  2. 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

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.

 

Life calling

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?

 

Failure

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.

26 comments

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  1. Wealthy Doc

    What an important topic. We need more of this kind of reflection, thought and discussion. Thanks for what you do!

    1. TheHappyPhilosopher

      Thank you Wealthy Doc.

  2. VagabondMD

    I think that you have nailed it…or have at least provided an excellent construct for healing and redemption. Every MD should read this. It could safe a life or two.

    Through trial and error, and with some guidance from others, I have stumbled upon the solution that works for me. I no longer identify with being a Physician (capital P). In fact, I recoil when someone from work (a nurse or a tech) calls me Dr. XYZ outside the Hospital setting.

    In my own mind, I am a Vagabond, one who is temporarily facing some geographic and lifestyle restrictions. My day job is currently to be a physician (lower case p) and I do my best to leave the day job back at the Hospital, like the ER receptionist or one who works in the accounting department.

    When I finally untether from the day job in a few years (or maybe sooner), I will be able to assume the identity I prefer, and no one will ever know that I was once a Physician.

    1. TheHappyPhilosopher

      I would be delighted if every doc read this, trying my best to spread the word 🙂

      I can completely relate to your thoughts. For some strange reason I feel much more comfortable when I’m around people who have no idea what I do for a living.

  3. MrsWow

    “The emotional toll of seeing sickness and death day in and day out can overwhelm our emotional ability to process”

    Being a occupational therapist working with really young children, this hits really close to home. Constant exposure to death and disease definitely takes a toll on my emotional and mental well-being. It blurs the line between my professional identity and my personal identity, making it impossible not to think about it while I’m “off the clock”. Thank you for opening the discussion about such an important and much overlooked topic.

    1. TheHappyPhilosopher

      Although I voice this topic from my perspective as a physician, everyone who works in health care experiences this to some extent. It is a highly emotional environment and difficult to maintain a balance all the time. I would love to hear more abut your experience. If you ever write about it give me a shout.

  4. Lara

    The section on identity and ego is a really beautiful and eloquent description of a concept I’ve been thinking about and struggling with since the start of medical school. Thank you.

    1. TheHappyPhilosopher

      Thank you for your comment Lara. These thoughts have been swimming in my head for years now and I’m just beginning to articulate them. I would love to hear more of your experiences with this. Feel free to leave a comment here or contact page for privacy.

      http://thehappyphilosopher.com/contact/

      1. Lara

        There’s a quote I heard from some TV show years ago that’s stuck with me. “First day of medical school, they give you a stack of books and a dead human being. That, I’m afraid, will change you.” My training definitely hardened me to suffering and dying (in very necessary ways- you can’t be crying while running a code). Even now that I’m working outpatient primary care, I think those experiences irreparably changed something in me. I’ve struggled a lot with if that’s a good thing or a bad thing.

  5. Hatton1

    Great thought provoking post. One of the reasons I quit ob was that I found telling patients that their baby was dead so horrific. No way you don’t take that conversation home with you. One of my coresidents and good friend committed suicide a few months after he finished residency. He was in the closet and the first black resident at my program I suspect these life factors weighed in to his decision. You never really get to ask. It bothered me for years. I have a non-physician friend at 76 who is contemplating it because he has aml. I find this to be understandable.

    1. TheHappyPhilosopher

      That is a terrible thing to have to face. I think I would struggle with maintaining the emotional connection and empathy required for a situation like that without becoming overwhelmed by it.

      I would be surprised if there was a doc out there not touched by suicide in some way. It stays with you for a long time.

  6. Mrs. Picky Pincher

    I’m very sorry to hear about the loss of your friend. I wish more people were aware of the physician suicide rate and how demanding the profession is. People think doctors have it made with high salaries and flashy lives, but the reality is anything but.

    Again, I’m so sorry for your loss and for your friend’s family’s loss.

    1. TheHappyPhilosopher

      Thank you. My friends suicide felt like losing a family member. As you can probably tell from my writing, it still affects me today.

      I’ve found society has little sympathy for doctors. We are well paid and should just suck it up. I can understand this attitude. Everyone thinks they have it rough and the grass is always greener on the other side.

      I think the best thing non-physicians can do it just to understand that a lot of docs are suffering.

      The main problem is not from society at large though. We do not take care of our own. We allow our colleagues to suffer and offer little support for those in need. I think this is a problem we have to fix from within.

  7. Ten Factorial Rocks

    Sorry to hear your friend’s case. Until I read about this in POF and other physician blogs, I never would’ve even guessed this as an issue. Live-savers cannot be Life-takers – this was my prevailing thought until recently. There is stress in every job, including senior management role that I am in, but it must take months of severe stress and untreated depression to eventually lose the will to live. Don’t physicians get psychiatric counseling? I would guess the right treatment may be awaiting them at the very hospital they are working. Why don’t suicidal physicians get help?

    1. TheHappyPhilosopher

      Thank you TFR. The answers to your questions are very complicated and probably deserve a whole blog post each.

      Physicians often avoid seeking help for mental illness or substance abuse because it can lead to negative consequences by an employer or the state medical board. Without a medical license you can not practice. Medical boards have enormous power and from what I can tell very little oversight.

      There is a huge stigma against mental illness. I’ve heard stories of docs going out of town for treatment and paying cash so they don’t have to use their real name for fear of negative consequences. Who knows to what extent this actually happens, just rumors.

      There is also this attitude that develops doing residency that we are superhuman and don’t need to seek help. We should be able to fix ourselves.

      But even the ones that do get help are still living the extremely stressful life of a physician and dealing with ego, shame, etc. that I discuss above. My friend was getting help, but his illness was too much for him. It is impossible to know what roll his life as a physician played in his death.

  8. Fishbird

    As a physician who very recently was experiencing extreme burnout and feelings of being a failure, I think you hit the nail on the head. I believe that there is something to the notion of identity becoming a toxic construct in which it becomes nearly impossible to disentangle from at the end of the day. Compound that with sleep deprivation and rabid and constant multitasking, and it isn’t surprising that it sometimes leads to suicide.

    Your topics have been very useful to me in my recovery from burnout. Like you, part time work seems to be the middle path that best satisfies my need to take care of myself (maybe even become reacquainted with myself) as well as pay the bills. It is truly good to know that I am not alone in feeling the way that I did. I believe that there is extreme shame in our profession in even considering the notion of leaving the profession or feeling that you have nothing left to give or that there’s too much on your plate in a given day. I have commented to friends outside of medicine that, in many respects, medicine is the most MACHO of professions: one can never admit to being overwhelmed, dumbfounded or depleted.

    Keep up these important posts. They really do make a difference.

    1. TheHappyPhilosopher

      Thanks for the comment and your observations Fishbird. I write these posts for this very reason, to let people know they are not alone. I will keep writing until I have nothing left to say 🙂

  9. saveinvestbecomefree

    Wow. Very insightful observations. I’m really sorry about your friend. It seems doctors sometimes feel there is no way out when being a doctor isn’t working. It’s their whole life. I work in a demanding job but it’s nothing like what doctors do. The most unhappy time in my life was grad school where the culture was long-hours and completely focused on academic science. The lack of balance really bothered me. This is a small glimpse of what a doctor does (and without the life/death stress level) and I’m glad I didn’t choose that path.

    The system of brutal hours in residency is baffling to me. Lack of sleep is a huge negative influence that is now better understood. You would think things would start changing, even if it’s just for the benefit of patients. Unfortunately, I suspect too many people benefit financially from the way it is.

    It’s wrong that doctors can’t have more balance in their lives. It seems the best option is finding a way to work part-time or at least fewer hours. Those that have done this seem very happy. I would guess the rates of suicide of this cohort are drastically lower. Assuming that is true, it would give the medical community something to reflect on.

    1. TheHappyPhilosopher

      Thank you. There are embedded norms and structure to medical training that will be difficult to change, and to be honest it is not all bad. There are some benefits to working long intense hours, it’s just many times the line is crossed. I actually thought my residency did a great job of staying on the line and not crossing over into insanity.

      Balance is a difficult thing to find in medicine for a host of reasons. I love part time, but it’s not feasible for everyone. It would be interesting to look at suicide rates for full time vs. part time docs, but it would be tough to know what the results meant. Part time docs are a self selecting cohort and are probably very different than full time docs.

  10. Biglaw Investor

    Wow, this is a great post covering a very difficult topic. I hope a lot of doctors find it. Until I read this post, I was under the impressions that doctors didn’t discuss suicide (which I find a little odd since doctors talk about life and death all the time) since my limited experience of doctors who committed suicide involved sweeping the manner of death under the rug.

    I think a lot of professionals struggle with these issues and the only way out are for more professionals to get together and discuss the pressures of being a type A-personality in hyper competitive job market.

    Good work Happy Philosopher.

    1. TheHappyPhilosopher

      Thank you! There is no incentive for anyone to have a meaningful discussion about this topic (except for the eventual victims of suicide). Often there is much shame involved. Hospitals have nothing to gain other than negative press, etc. My hope is that this article finds at least a few people that are close to the edge and nudges them in a positive direction.

      Interestingly the job market dynamics are much different for physicians than many other professional careers. Once you jump through all the hoops you are not really competing all that much. The job market cycles of course, but few competent doctors have trouble finding as job. The perfectionist type-A personality probably contributes to increased suicide. We are not used to failing, so when we do the mind breaks down.

  11. snowcanyon

    Disappointing. I was hoping for a “how to” guide.

  12. TwinDadMD

    When I was in residency, one of my friends and co-residents killed themselves during one of the more difficult rotations. He had a wife, one small child, and another on the way. It was until after his death, that we found out he also had a substance abuse problem. He had a lifelong chronic illness that he was also dealing with. This illness was probably also a catalyst for him becoming a physician. Problems with substance abuse and mental health issues are far too taboo in both society and the medical profession. Speaking for myself, I fear that if I had a serious mental illness, and sought successful treatment for it, my medical career would still suffer. Instead of punishing those who need help for mental illness in our community, we need to celebrate those with the courage to seek help and welcome them back to work. The negative stigma associated with mental health problems prevents people from seeking help. I think we are doing a better job at changing this as a society, but the physician community needs to take care of each other. I’ll stop now, as I feel I could go on forever. Thanks for your post, and keep up the good work.

    1. TheHappyPhilosopher

      Thanks for sharing. The inability for people to seek help in a safe environment is a real problem. Physicians do a terrible job of helping our own. I think the first step is a healthy discussion.

  13. b

    Wow. Another great post. Here is all the ways physicians are set up to be failures:
    1. Your research didn’t get a grant
    2. You don’t want to do academics, so you are a sell out
    3. You only went to a mid tier college/medical school/residency/fellowship so you’ll never ever make dean or managing partner
    4. You aren’t “nice” enough
    5. You don’t see enough patients
    6. You RVUs are barely at the median
    7. You don’t spend enough time teaching the students/residents/fellows
    8. The students/residents/fellows gave you bad reviews on your 360 eval
    If you don’t ace all of the above, you are a failure at part of someone else’s expectations. I love your idea about this being a “single person” ride. I also read recently that when you need someone else’s approval, you make yourself their slave. Imagine having to check off the approval list as a doc: 1. wife 2. kids 3. dean 4. 25 y/o MBA office administrator 5. Nurses 6. Research staff 7. Procedure area staff 8. ER 9. ICU nurses 10. The other docs 11. Patients 12. Patient’s families (even if calling over the phone states away that haven’t even seen said patient in years,…) 13. Insurance companies 14. Private contractors for insurance companies,…

    Oiy. We enslave ourselves to too many people,…
    b

    1. TheHappyPhilosopher

      The more we do things for ourselves and use internal metrics, the happier we become. We have to learn to say no and enough so we can say yes to what really matters.

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