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Taking Their Own Lives — The High Rate of Physician Suicide

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n engl j med
352;24
www.nejm.org june
16, 2005
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PERSPECTIVE
tianity. This long-standing religious presence has
made atheists, agnostics, and members of minority
religions view themselves as oppressed, but recent
efforts to purge the public square of religion have
left conservative Christians also feeling subjugated
and suppressed. In this culture war, both sides claim
the mantle of victimhood — which is why health
care professionals can claim the right of conscience
as necessary to the nondiscriminatory practice of
their religion, even as frustrated patients view con-
science clauses as legalizing discrimination against
them when they practice their own religion.
For health care professionals, the question be-
comes: What does it mean to be a professional in
the United States? Does professionalism include
the rather old-fashioned notion of putting others
before oneself ? Should professionals avoid ex-
ploiting their positions to pursue an agenda sepa-
rate from that of their profession? And perhaps
most crucial, to what extent do professionals have
a collective duty to ensure that their profession pro-
vides nondiscriminatory access to all professional
services?
Some health care providers would counter that
they distinguish between medical care and nonmed-
ical care that uses medical services. In this way, they
justify their willingness to bind the wounds of the
criminal before sending him back to the street or to
set the bones of a battering husband that were bro-
ken when he struck his wife. Birth control, abortion,
and in vitro fertilization, they say, are lifestyle choic-
es, not treatments for diseases.
And it is here that licensing systems complicate
the equation: such a claim would be easier to make
if the states did not give these professionals the ex-
clusive right to offer such services. By granting a
monopoly, they turn the profession into a kind of
public utility, obligated to provide service to all who
seek it. Claiming an unfettered right to personal
autonomy while holding monopolistic control over
a public good constitutes an abuse of the public
trust — all the worse if it is not in fact a personal act
of conscience but, rather, an attempt at cultural
conquest.
Accepting a collective obligation does not mean
that all members of the profession are forced to vi-
olate their own consciences. It does, however, ne-
cessitate ensuring that a genuine system for coun-
seling and referring patients is in place, so that every
patient can act according to his or her own con-
science just as readily as the professional can. This
goal is not simple to achieve, but it does represent
the best effort to accommodate everyone and is the
approach taken by virtually all the major medical,
nursing, and pharmacy societies. It is also the ap-
proach taken by the governor of Illinois, who is im-
posing an obligation on pharmacies, rather than on
individual pharmacists, to ensure access to services
for all patients.
Conscience is a tricky business. Some interpret
its personal beacon as the guide to universal truth.
But the assumption that one’s own conscience is the
conscience of the world is fraught with dangers. As
C.S. Lewis wrote, “Of all tyrannies, a tyranny sin-
cerely exercised for the good of its victims may be
the most oppressive. It would be better to live under
robber barons than under omnipotent moral busy-
bodies. The robber baron’s cruelty may sometimes
sleep, his cupidity may at some point be satiated; but
those who torment us for our own good will torment
us without end for they do so with the approval of
their own conscience.”
When I was an oncology fellow in Vienna, a col-
league who had attended rounds with me on the
ward went home afterward and strangled herself.
Only later was it learned that she had suffered from
depression. In the course of that same year, three
more physicians in my immediate circle — two res-
idents and a department head — took their own
lives. This stunning series was my first encounter
with physician suicide, and it left many of us doc-
tors with an important message: we must care not
only for our patients but also for ourselves. In an ef-
fort to prevent further such tragedies, a program
Taking Their Own Lives — The High Rate of Physician Suicide
Eva Schernhammer, M.D., Dr.P.H.
The Celestial Fire of Conscience — Refusing to Deliver Medical Care
Dr. Schernhammer is an instructor in medicine at Har-
vard Medical School and Brigham and Women’s Hospi-
tal, both in Boston.
n engl j med
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www.nejm.org june
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PERSPECTIVE
was launched at the hospital to help physicians and
nurses grapple with the emotional effects of caring
for the chronically ill. But the suicides that had al-
ready occurred were never discussed openly, no one
undertook a publicly acknowledged serious analysis
of the causes, and no other clear safeguards were
put into place. The deaths were simply accepted as
a fact of medical life.
Although physicians tend to have healthier life-
styles than those of the general public and thus to
live longer, it has been known for some time that
suicide rates among doctors are higher than those
in the general population (see graphs). And when
these tragic events make it into the headlines, as did
the recent suicide of gifted heart surgeon Jonathan
Drummond-Webb, we begin to wonder why these
healers apparently cannot heal the hurt in their
own lives.
The gap in suicide rates evidently begins as early
as medical school, where overall suicide rates are
higher than in the age-matched population. This
increased rate of suicide is driven largely by higher
rates among women: female medical students com-
mit suicide at the same rate as male medical stu-
dents,
2
whereas in the United States in general, sui-
cide rates are much higher among men. Evidence
from a large study of physician suicide indicates that
female doctors, in particular, are much more likely
than other women to take their own lives. The com-
bined results of 25 studies suggest that the suicide
rate among male doctors is 40 percent higher than
that among men in general, whereas the rate among
female doctors is 130 percent higher than that
among women in general.
1
Several factors that may contribute to the suicide
of physicians, especially female physicians, deserve
closer examination. Physicians may have a higher
prevalence of depression than nonphysicians, and
depression is clearly an important risk factor for
suicide; among female physicians, the risk may be
exacerbated by sexual harassment; and when they
become suicidal, physicians generally choose effec-
tive suicide methods.
A prevalent view is that both biologic and psy-
chosocial factors play a role —and interact — in
the decision to commit suicide. There is a higher
prevalence of psychiatric disorders among physi-
cians than in the general population. Some 30 to 70
percent of all persons who attempt suicide appar-
ently have an affective disorder (generally depres-
sion), a substance-use–related disorder, or schizo-
phrenia.
3
Evidence further suggests that drug abuse
and alcoholism, possibly under circumstances of
heightened stress or depression, are often associ-
ated with the suicides of physicians. Female phy-
sicians, in particular, have been shown to have a
higher frequency of alcoholism than women in the
general population. Drug abuse is also related to
specialty, being particularly prevalent among psy-
chiatrists, anesthesiologists, and emergency physi-
cians. Recent reports emphasize that the exposure
that anesthesiologists have to drugs as they work
represents a risk factor for drug addiction and pos-
sibly suicide, indicating that access to drugs may
support higher suicide rates among physicians by a
variety of pathways. In the general population, ac-
cording to autopsy studies and other evidence, as
many as 25 percent of all persons who commit sui-
cide are drunk at the time of their deaths.
Another way to view the problem is that the pro-
fessional burden carried by doctors leads to social
isolation and an increased probability of undergo-
ing phases of disturbances in their social networks.
It has also been noted that physicians tend to ne-
glect their own need for psychiatric, emotional, or
medical help and are more critical than most peo-
ple of both others and themselves. They are more
likely to blame themselves for their own illnesses.
And they are apparently more susceptible to depres-
sion caused by adverse life events, such as the death
of a relative, divorce, or the loss of a job.
4
Being single and not having children have also
been linked to an increased risk of suicide, and more
female than male physicians are single or childless.
Some studies of coping have emphasized that wom-
en in general are subject to a double burden — being
vulnerable to pressures of both family life and work
life. Stress and burnout may be added risk factors for
all physicians, and female doctors may feel more
stress than their male counterparts because of the
difficulty of succeeding in a male-dominated pro-
fession.
They may also be the targets of sex-based or sex-
ual harassment, which may, in turn, lead to depres-
sion and suicidality. In a study by Frank et al., 48
percent of female physicians reported having expe-
rienced sex-based (“gender-based,” per study ques-
tionnaire) harassment at least once, and 37 percent
reported sexual harassment.
5
Moreover, the study
established a link between higher rates of harass-
ment and a history of depression or suicide at-
tempts, showing an association between the sever-
Taking Their Own Lives — The High Rate of Physician Suicide
n engl j med
352;24
www.nejm.org june
16, 2005
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PERSPECTIVE
ity of harassment and the likelihood of depression.
Sex-based harassment and sexual harassment are
more common in historically male-dominated spe-
cialties, such as surgery and emergency medicine.
According to unpublished data from a recent U.S.
study by Straehley and Longo of the difficulties
women face when entering the field of medicine,
more than 75 percent of interviewed female sur-
geons said that they had been harassed. Moreover,
according to Frank et al., whose study results con-
curred with these findings, harassment rates are not
declining.
5
It has been argued that the reinforcing
of sex stereotypes through the promulgation of the
belief that women are innately inferior to men in
science may well contribute to the ongoing harass-
ment of female physicians.
Finally, physicians who make suicide attempts
are much more likely than nonphysicians to suc-
ceed. Among physicians in this country, in fact,
there are fewer unsuccessful suicide attempts than
completed suicides — a stark contrast to the data
for U.S. women in general, for instance, among
whom the ratio of unsuccessful attempts to com-
pleted suicides is between 10:1 and 15:1.
Not surprisingly, the method chosen predicts
the likelihood of success. Women in the general
population make more unsuccessful suicide at-
tempts than men, in large part because they prefer
Suicide Rates among Male Physicians (Panel A) and Female Physicians (Panel B) in Relation to the Rates in the General Population
of the Same Sex.
The size of each box represents the relative size of the study sample, and the horizontal line that intersects the box indicates the 95 percent
confidence interval. The dashed red line in each panel indicates the combined estimate. The diamond-shaped box represents the confidence
interval. The data are from a meta-analysis by Schernhammer and Colditz.
1
0.23 1.00 1.41 26.40
Individual Studies of Physician Suicide
Ratio of Suicide Rate among Male Physicians
to Rate among Men in General Population
0.23 1.00 2.27 26.40
Individual Studies of Physician Suicide
Ratio of Suicide Rate among Female Physicians
to Rate among Women in General Population
BA
Taking Their Own Lives — The High Rate of Physician Suicide
n engl j med
352;24
www.nejm.org june
16, 2005
2476
PERSPECTIVE
methods that are typically less deadly than those —
such as the use of firearms — favored by men. It is
possible, therefore, that the higher suicide rate
among female physicians simply reflects a combi-
nation of the sex difference in the rate of suicide at-
tempts and a higher rate of completion inside the
medical profession than outside it.
According to a recent study, doctors most com-
monly take their own lives by poisoning themselves,
often with drugs taken from their offices or labora-
tories. The fact that greater access to drugs leads to
higher suicide rates has long been known — for ex-
ample, in Australia, an increase in suicides among
women coincided with the implementation of a law
that made it easier to obtain barbiturates. It seems
likely that the higher suicide rate among physicians
is related to both their relatively free access to drugs
and their medical knowledge, which enhances their
ability to use such methods successfully.
There are few interventions in place to help pre-
vent suicide among physicians. Such safeguards
might include the provision of discreet and confi-
dential access to psychotherapy and open discussion
of the stress encountered in a medical career. The
barriers that may prevent physicians from seeking
help for mental disorders (such as the threat of los-
ing their medical licenses) must also be addressed.
Part of the solution for female doctors must ulti-
mately be to equalize professional conditions in or-
der to reduce stress. In time, perhaps these and oth-
er measures will help doctors to do what they do
best: save lives, beginning with their own.
1.
Schernhammer ES, Colditz GA. Suicide rates among physi-
cians: a quantitative and gender assessment (meta-analysis).
Am J Psychiatry 2004;161:2295-302.
2.
Pepitone-Arreola-Rockwell F, Rockwell D, Core N. Fifty-two
medical student suicides. Am J Psychiatry 1981;138:198-201.
3.
Litman RE. Mental disorders and suicidal intention. Suicide
Life Threat Behav 1987;17:85-92.
4.
Kirsling RA, Kochar MS. Suicide and the stress of residency
training: a case report and review of the literature. Psychol Rep
1989;64:951-9.
5.
Frank E, Brogan D, Schiffman M. Prevalence and correlates
of harassment among US women physicians. Arch Intern Med
1998;158:352-8.
Taking Their Own Lives — The High Rate of Physician Suicide
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