When I was a resident, I came home from a swing shift in May to the smell of gasoline wafting through the entryway of my home. I immediately knew something was wrong and anguish gripped me. I opened the door to the garage and turned on the light to find my fiancé dead on the floor. He had killed himself using the exhaust fumes of his motorcycle.

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My fiancé’s death occurred 20 years ago, but little has changed regarding the stigma and silence that surrounds suicide, especially among physicians. We have known since 1977 that, on average, the United States loses the equivalent of a large medical school class each year to suicide.¹

A study in 2000 showed that although physicians were less likely than non-physicians to die from heart disease or cancer, they are more likely to die of suicide. This study estimated that 400 physicians die each year due to suicide, and most feel this number is grossly underestimated.² Female physicians are at more risk than their male colleagues, with a 2.27 times higher rate of suicide compared to the general female population, but male physicians are also at risk, with a 1.41 higher rate than their non-physician counterparts.³

Suicide is frequently the result of untreated or undertreated depression or another mental illness that may be complicated by substance abuse and/or dependence, with the deadly combination of knowledge of and access to lethal means. Depression is at least as common in physicians as in the general population, where the prevalence is 7 to 8 percent, and a recent study suggests that the incidence in emergency physicians may be much higher, with 18.5 percent of attendings and 47.8 percent of residents reporting symptoms of depression.⁴ Prevalence of substance abuse disorders among physicians during the span of their careers is similar to that of the general population, with a rate of 10 to 12 percent.⁵ With regard to knowledge and access to lethal means, there is no doubt that physicians understand the physiology of death and have more access to lethal means than the general population, as evidenced by their higher success rate at committing suicide.3

Compounding the problem is that physicians are often unwilling to seek help for their mental health or substance abuse problems due to the stigma surrounding these issues. Fears regarding privacy, confidentiality, and how knowledge of their problem might affect their future career often dissuade physicians from seeking help. Physicians who successfully took their own lives were less likely to have received mental health treatment when compared to a similar cohort of non-physicians.⁶

The wall of silence is slowly coming down. The tragic deaths of two newly minted residents in New York City in 2014, both of whom jumped off of buildings within one week of each other, has brought attention from ACEP, the Accreditation Council for Graduate Medical Education (ACGME), the Society for Academic Emergency Medicine (SAEM), the Council of Emergency Medicine Residency Directors (CORD), and other national organizations to this problem. In 2015, ACGME held its first-ever symposium on physician wellness, and ACEP, SAEM, and CORD have also introduced wellness initiatives, including ACEP’s Emergency Medicine Wellness Week.

What will it really take to reduce the rate of physician suicide? Many suggest a three-pronged approach:

1. Destigmatize seeking help through education, with a change in culture and policies that makes it easier for physicians to access mental health care when it is needed.
2. Inform the medical community of how to recognize the signs of depression and burnout and the knowledge of how to refer colleagues who need help.
3. Research to understand and change the factors related to the practice of medicine that create higher rates of burnout and depression in physicians.

These are not easy tasks but are necessary to help avoid the loss of precious physician lives.

As the push continues on a global level, the question remains, is there more that we can do in our own shops to help our colleagues and friends? Keeping with the three-pronged approach, here are some suggestions:

1. Although it is not always possible to know when someone is contemplating suicide, some common warning signs include:

• Talking about their own death or being preoccupied with death/dying
• Obtaining the means to take their own life
• Withdrawing from social contact
• Feeling trapped or hopeless
• Increased use of drugs or alcohol
• Engaging in risky or self-destructive activities
• Giving away belongings or getting affairs in order without a logical reason
• Saying good-bye to people as if they will not see them again

2. If you suspect someone you know may be contemplating suicide, be willing to ask the difficult questions and to listen. You are not responsible for preventing someone from taking their life, but your intervention may help. Examples of questions to ask include:

• How are you coping with what is happening in your life?
• Do you ever feel like giving up?
• Have you thought about harming yourself?
• Have you ever attempted to harm yourself before?
• Do you have access to a means to harm yourself?

3. If someone shares with you that they are contemplating suicide:

• Encourage them to seek help; be aware of local resources including your institution’s well-being committee
• Provide them with the National Suicide Prevention Lifeline at 800-273-8255
• Offer to help them in seeking assistance and support
• Remind them that things will get better
• Encourage them to avoid alcohol and drug use
• Remove dangerous items from the person’s access, if possible

For more information about suicide and suicide prevention, go to www.suicidology.org, www.afsp.org, www.survivorsofsuicide.com, and www.acgme.org, which has developed a new set of resources particularly for physicians in training.

Dr. Weichenthal is assistant program director of emergency medicine, professor of clinical emergency medicine, and assistant dean of graduate medical education at the University of California, San Francisco in Fresno.

References

1. Sargent DA, Jensen VW, Petty TA, et al. Preventing physician suicide. The role of family, colleagues, and organized medicine. JAMA. 1977;237(2):143-145.
2. Frank E, Biola H, Burnett CA. Mortality rates and causes among U.S. physicians. Am J Prev Med. 2000;19(3):155-159.
3. Schernhammer ES, Colditz GA. Suicide rates among physicians: a quantitative and gender assessment (meta-analysis). Am J Psych. 2004;161(12):2295-2302.
4. Lu DW, Dresden S, McCloskey C, et al. Impact of burnout on self-reported patient care among emergency physicians. West J Emerg Med. 2015;16(7):996-1001.
5. Berge KH, Seppala MD, Schipper AM. Chemical dependency and the physician. Mayo Clin Proc. 2009;84(7):625-631.
6. 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(1):45-49.