Caring for Our Caregivers: Physician Suicide Awareness and Prevention

The conclusion of September brings the end to National Suicide Awareness month, a topic often shunned by public discussion. Awareness regarding this issue should not be limited to just one month, rather year-round conversations are necessary to examine systemic issues and barriers regarding suicide prevention with additional emphasis on high-risk groups. Physicians are one such high-risk group who on average face a higher death-by-suicide rate than other professions, with studies estimating the suicide of 300-400 practicing physicians yearly (Yaghmour et al., 2017, p. 976). It is estimated that “The suicide rate among male physicians is 1.41 times higher than the general male population. And among female physicians, the relative risk is…2.27 times greater than the general female population” (American Foundation for Suicide Prevention, 2022). A fundamental problem exists that perpetuates the crisis seen in medical professionals. 

Not often viewed as the byproduct of an individual event, suicide is commonly the aggregated result of multiple risk factors, with the highest occurrence being mismanaged mental health conditions (American Foundation for Suicide Prevention, 2022). Following the completion of medical school, physicians enter a formative period of residency training for three to seven years to become specialized in their respective fields. Residency training is labor intensive and highly demanding of a physician's time, as individuals may work between 60-80 hours per week depending on their specialty and rotation by standardized working conditions. In 2003, The Accreditation Council for Graduate Medical Education (ACGME) imposed an 80-hour weekly work limit, averaged over four weeks, and 24-hour shift limit guidelines for residents (Accreditation Council for Graduate Medical Education, 2004). Though these regulations were created to combat overwork and sleep deprivation for residents, studies have shown it is a common occurrence to underreport or falsify one’s hours worked to comply with ACGME. Through an anonymous survey completed by 6202 residents at ACGME-accredited medical programs, “Nearly half of residents (42.9%) responded that they falsely reported their duty hours at some time, including 18.6% who reported falsely at least once or twice per month” (Drolet et al., 2013). Although legal limitations are established for resident working conditions, physician training generally applauds a visible dedication and commitment to maturing in one’s field. This may encourage residents to stay longer to observe more patients, take on more cases, and commit to more educational or academic tasks at home or in the hospital (on their own time). Thus, to fit national compliance, trainees might be more flexible in logging false hours. Long hours translate to fewer hours for oneself, whether it be doing leisure activities or spending time with loved ones.  

Amongst long hours and competitive, high-stress training environments, “... trainees often learn to ignore signs and symptoms of burnout, depression, and suicidality” (Kalmoe et al., 2019). A meta-analytic review of multiple studies examining suicide amongst physicians and healthcare workers found “... between 20.9% and 43.2% of trainees screened positive for depression or depressive symptoms during residency” (Mata et al., 2015). It is important to note that a significant increase in the onset of depressive symptoms lies at the start of residency, which supports the finding that training experience across all specialties is commonly distressing to the individual’s mental health  (Mata et al., 2015). In a study cohort of 740 first-year U.S. residents across 13 institutions and multiple specialties, it was examined that suicidal ideation escalated by 370% over the first several months of their training year (Guille et al., 2015). 

While physician training applauds fortitude and passivity from its residents, it is no doubt that the profession demands for its trainees to forgo themselves to be more devoted to their training. Though physicians routinely check for their patient's mental health concerns, medical culture routinely stigmatizes mental health treatment and support for its own. Lacking an adequate support network can further amplify the dehumanizing experience faced by medical trainees leading them to isolation in combating their mental health issues. Similar to the barriers faced by many others, resident physicians may also come across financial and social barriers in seeking mental health treatment. With medical educational debt having an average of $200,000-$300,000 and resident salaries being around $50,000-$60,000, residents may struggle to obtain affordable care or therapy combined with their other living expenses and continuing medical education. With finances not being a concern, even finding adequate time to schedule appointments may be difficult with the long shifts and on-call hours. 

While it is advised for physicians, particularly residents, to address their mental health conditions through treatment, it is vital to recognize this issue not as a personal conflict, but as a systemic crisis. Individual actions may fall short of the larger issue at hand, which is a large burden placed on physicians during their training to constantly be more and do more. It is crucial for medical training to become humanized to combat depressive symptoms faced by physicians and remind them they are not alone. 

References

Accreditation Council for Graduate Medical Education. (2004). The ACGME’s Approach to Limit Resident Duty Hours 12 Months After Implementation: A Summary of Achievements. ACGME Home. https://www.acgme.org/globalassets/PFAssets/PublicationsPapers/dh_dutyhoursummary2003-04.pdf

American Foundation for Suicide Prevention. (2022). Facts about Mental Health and Suicide Among Physicians. https://www.datocms-assets.com/12810/1578319045-physician-mental-health-suicide-one-pager.pdf

Drolet, B. C., Schwede, M., Bishop, K. D., & Fischer, S. A. (2013). Compliance and falsification of duty hours: Reports from residents and program directors. Journal of Graduate Medical Education, 5(3), 368-373. https://doi.org/10.4300/jgme-d-12-00375.1

Guille, C., Zhao, Z., Krystal, J., Nichols, B., Brady, K., & Sen, S. (2015). Web-Based Cognitive Behavioral Therapy Intervention for the Prevention of Suicidal Ideation in Medical Interns: A Randomized Clinical Trial. JAMA psychiatry, 72(12), 1192–1198. https://doi.org/10.1001/jamapsychiatry.2015.1880

Kalmoe, M. C., Chapman, M. B., Gold, J. A., & Giedinghagen, A. M. (2019). Physician Suicide: A Call to Action. Missouri medicine, 116(3), 211–216.

Mata, D. A., Ramos, M. A., Bansal, N., Khan, R., Guille, C., Di Angelantonio, E., & Sen, S. (2015). Prevalence of depression and depressive symptoms among resident physicians. JAMA, 314(22), 2373. https://doi.org/10.1001/jama.2015.15845

Yaghmour, N. A., Brigham, T. P., Richter, T., Miller, R. S., Philibert, I., Baldwin, D. C., & Nasca, T. J. (2017). Causes of death of residents in ACGME-accredited programs 2000 through 2014. Academic Medicine, 92(7), 976-983. https://doi.org/10.1097/acm.0000000000001736