Physician, Heal a Colleague

The ozone of the physician blog-o-sphere was recently pierced by a commentary on why doctor’s kill themselves.¹ The author is a family physician who herself faced the ultimate decision: to continue on while risking her emotional life and soul every day or to end that everyday life. Fortunately Pamela Wible, MD, was able to discern the thin gray line that stretched between those black and white options and has reclaimed her life and medicine as her passion-on her own terms. You can read her story, here.²

Like many who, once healed from a malady, take up the cause to help others, Dr Wible now dedicates part of her time to physician healing. She recently led a 4-day retreat³ in the mountains of Oregon attended by a group of health care professionals each deep in the throes of his or her own burn outhell.⁴ When she asked how many in the group had considered suicide, every hand went up. Some acknowledged having a plan. Perhaps it was the perceived anonymity associated with such a gathering that allowed these members of a profession both prized and maligned for its stoicism and selfless dedication to divulge their desperation-and human nature-to one another. Here, certainly, was refuge from the omnipresent and paralyzing fear of professional reprisal. Here, they might find help. But why here? 

The typical physician suicide victim differs in important ways from the non-physician victim.Analysis of datafrom the National Violent Death Reporting System (NVDRS) published this year in General Hospital Psychiatry⁵ found that having a known mental health disorder or a significant job-related problem prior to death significantly predicted being a physician. Personal tragedy, on the other hand, such as death of a family member or close friend within the 2 weeks preceding death, was far more highly predictive of being a non-physician. 

Analysis of toxicology results found that the greater likelihood of having mental illness among physicians did not match the presence of antidepressant medication. Physicians who had committed suicide were significantly more likely than non-physicians to have ingested lethal doses of antipsychotics, benzodiazepines, and barbiturates. Despite limitations in interpreting the NVDRS, it does offer “critical and heretofore rarely available” data on psychosocial, psychiatric, mental health care, medical comorbidity, and substance abuse variables associated with suicide. The study documents, perhaps for the first time, work place–associated stress and mental health issues as factors contributing to physician suicide. Successful interventions can be mounted for both issues-when the issues are recognized.

Going it alone
The reluctance to seek professional help is legion in the medical profession. A 2009 survey in the UK⁶-the first of its kind of this scale to look at non-psychiatric physicians’ preferences for disclosure and treatment in the event of becoming mentally ill-found that 73% of the 3500 doctors surveyed would be most likely to discuss mental health problems with family or non-physician friends rather than seek formal or informal advice. The reasons affecting that decision are familiar: career implications (33%); professional integrity (30%); and fear of stigma (20%). Key among study findings was that only 13% of respondents would choose to disclose a mental health problem to a primary care physician or another health professional. Approximately 40% of the physicians would seek informal advice for outpatient treatment, but 8% would either self-prescribe or opt out of treatment altogether.

A widely cited studyof the presence of suicidal ideation (SI) among American surgeons⁷ found that of the surgeons in the study who reported SI during the previous 12 months, only one-quarter (26%) had sought psychiatric or psychological help. Concern that seeking help would affect medical licensure was reported by 60% as the reason for going it alone. Antidepressant medication was rarely sought, and was obtained through a back door and via untraceable methods when it was. Among the 5.8% of surgeons who acknowledged antidepressant use in the previous 12 months, approximately 9% had self-prescribed, similar to the intent among the UK doctors, and 7.4% had received the prescription from a colleague who was not formally caring for them as a patient. 

Fear of consequences for self-disclosure⁷ is not completely unfounded. In fact, 80% of state medical boards do inquire about mental illness on initial licensure applications and 47% inquire on renewal applications. Many licensing boards these days, however, focus not on whether such a condition is present but rather on whether it poses an impairment to practice. Would that knowledge reudce the threat level? Fodder for another survey.

What might help?
Suggestions on how to temper physician burnout have been headline news and verge on the hyperurgent in advance of the remodeling of health care delivery outlined by the Affordable Care Act. But what about right now?

Another study,⁸ conducted at a prominent tertiary-care academic hospital, suggests a resource more accessible and immediate than the Oregon Cascades. When resident and attending physicians were asked how they would cope with the fallout of a traumatic, potentially job-threatening event (eg, medical error, legal action, substance abuse, mental health issues) physician colleagues were the most popular sources of potential support (88%), not surprisingly chosen over traditional routes, such as Employee Assistance Programs, (29%) and mental health professionals (48%). Horrendous and unimaginable events and the mental distress that follows are inherent in the medical profession. Conventional training, note study authors, just “does not address the potentially devastating emotional impact.” Coping mechanisms are left to the individual physician to devise, for better or worse.

The physicians surveyed at this institution, given the choice, would seek help from a peer; someone who on any given day might need the same and for similar reasons. The survey results are being used to redesign in-house physician support around confidential peer-to-peer consultation.

Which brings us back to the mountains in Oregon and a group of physicians who sought this venue to spend time with others who, on any given day, might feel the same way they do. A comment from Dr Wible on the power present when physicians help physicians:

Here, physicians, nurses, and medical students share their wounds and their wisdom-in community. We share . . . strategies to care for ourselves-so we can care for our patients. In 4 days, I witness more healing than in 4 years of med school. Once strangers, we’ve become family. . . . I didn’t know these doctors, but I know their despair. By speaking about my own pain, I validated their pain. By being vulnerable, I gave them the strength to be vulnerable too. But mostly we healed each other by not being afraid to say the word suicide out loud.References
1. Wible P. Why doctors kill themselves. www.Consultantlive.com. May 9, 2013. http://www.consultantlive.com/blog/display/article/10162/2141806
2. Ideal Medical Care.org. http://www.idealmedicalcare.org/
3. Wible P. Preventing physician suicide, depression, burnout. Ideal Medical Care. April 5, 2013. http://www.idealmedicalcare.org/blog/preventing-physician-suicide-depression-burnout/
4. Andrew LB, Brenner BE. Physician suicide. Medscape. March 8, 2012. http://emedicine.medscape.com/article/806779-overview
5. Gold KJ, Sen A, Schwenk TL. Details on suicide among US physicians: data from the National Violent Death Reporting System. Gen Hosp Psychiatry. 2013;35:45-49.
http://download.journals.elsevierhealth.com/pdfs/journals/0163-8343/PIIS016383431200268X.pdf
6. Fears about confidentiality put off doctors from accessing mental health services. Press release. Royal College of Physicians. August, 2009.http://www.rcplondon.ac.uk/press-releases/fears-about-confidentiality-put-doctors-accessing-mental-health-services
7. Shanafelt TD, Balch CM, Dyrbye L, et al. Special report: suicidal ideation among American surgeons. Arch Surg. 2011;146:54-62. doi: 10.1001/archsurg.2010.292. http://archsurg.jamanetwork.com/article.aspx?articleid=406577
8. Hu Y, Fix ML, Hevelone ND, et al. Physician’s needs in coping with emotional stressors: the case for peer support. Arch Surg. 2012;147:212-217. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3309062/pdf/nihms342255.pdf
9. Wible P. What I’ve learned from saving physicians from suicide. May 27, 2013. http://www.kevinmd.com/blog/2013/05/learned-saving-physicians-suicide.html