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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
352;24
www.nejm.org june
16, 2005
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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
2475
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
... HCPs are pressured with dealing with public health crisis in real time, in which difficult moral decision-making is associated with significant stress, lack of control, and feelings of fear [46]. Troublingly, the prevalence of burnout, depression, and suicide is high for this group [47][48][49]. Compromised wellbeing among HCPs leads to medical errors, reduced patient safety, high rates of staff turnover, increased absence due to sickness, and diminished patient care [12,14,50,51]. Thus, health care organizations have a responsibility to support and protect staff well-being for both patient and staff safety [52] and the well-being thermometer has shown it can be a useful tool in supporting this objective. ...
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Background Advancements in medical science have focused largely on patient care, often overlooking the well-being of health care professionals (HCPs). This oversight has consequences; not only are HCPs prone to mental and physical health challenges, but the quality of patient care may also endure as a result. Such concerns are also exacerbated by unprecedented crises like the COVID-19 pandemic. Compared to other sectors, HCPs report high incidence of stress, depression, and suicide, among other challenging factors that have a significant negative impact on their well-being. Objective Given these substantial concerns, the development of a tool specifically designed to be used in clinical settings to measure the well-being of HCPs is essential. Methods A United Kingdom–based cross-sectional pilot study was carried out to measure self-reported well-being in a cohort of 148 physicians, using the newly developed well-being thermometer. The aim of the tool is to allow respondents to develop an individual sense of “well-being intelligence” thus supporting HCPs to have better insight and control over their well-being and allow insights into how to manage it. The tool consists of 5 well-being domains—health, thoughts, emotions, spiritual, and social. Each domain can be measured individually or combined to produce an overall well-being score. Results The tool demonstrated good internal consistency; the Cronbach α in this study was 0.84 for the total scale. Conclusions Results from this cohort demonstrated that the well-being thermometer can be used to gather intelligence of staff well-being. This is a promising new tool that will assist HCPs to recognize their own well-being needs and allow health care organizations to facilitate change in policies and practices to reflect a better understanding of staff well-being.
... Burnout in medical doctors has serious consequences for both individuals and institutions. Physician suicide rates are up to six times higher than among the general population [9,14]. Physicians suffering from burnout, particularly medical students and residents, are also more likely to develop depression, substance dependence [15,16], or cardiovascular disease [9]. ...
... Implementing interventions to enhance the learning environment in the medical, dental, and pharmacy fields is imperative to mitigate stress and feelings of hopelessness among students. Recognition of symptoms of loneliness, hopelessness, and stress is critical in identifying students at higher risk of suicidal thoughts (33,(38)(39)(40)(41)(42)(43)(44)(45)(46)(47)(48)(49)(50)(51)(52)(53)(54). ...
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Suicide is a multifaceted public health problem that, unfortunately, remains the leading cause of death worldwide. Studies show that the rate of mental illness, particularly suicide, is higher among doctors than among the public, and the risk of depression and suicide among doctors has also increased. Interventions such as resilience and mindfulness programs can reduce suicidal thoughts among medical students. Suicide prevention programs should target high-risk groups, such as physicians. Studies have shown that medical students and physicians are at higher risk of suicide than the general population. The prevalence of mental health issues and suicidal thoughts increases during medical school. Psychological factors, such as burnout, depression, anxiety, and hopelessness, can lead to suicidal thoughts. Considering the worldwide significance of this issue and the recent increase in mortality among youthful Iranian physicians, we conducted and investigated the prevalence and possible causes of suicidal ideation among Iranian medical students and graduates in this study. The problem of suicides among Iranian doctors and the sudden increase in the deaths of doctors, especially young people, is dangerous. Suicides among Iranian medical, dental, and pharmacy students have increased in recent years. It may be beneficial to support populations at high risk for suicidal ideation and provide screening for early intervention, as well as raise awareness of the prevalence and impact of suicidal thoughts among male students, school officials, and teachers. Screening should include individuals with a family history of mental health issues and those who are separated from their parents, as these individuals are at increased risk for suicidal thoughts. Reducing the prevalence of suicidal ideation may benefit from smoking cessation interventions and stress-reducing curricula. In addition, studies show that work stress among Iranian doctors and dentists can affect their work and treatment. Controlling and managing occupational stress is vital to prevent future problems, as it can have physical and psychological consequences. High levels of occupational stress among these doctors can also pose a danger to their patients. Identifying the causes of physician suicide can help to control and manage it.
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... This would provide long-term benefits as physicians face increased risk of burnout and suicide. 17,18 Specific approaches that many students reported that they plan to use included meditation and massage therapy Meditation in particular, is increasingly popular, evidence supported, and accessible to help students grow self-awareness and improve their emotional and psychological health. 19 We dedicated almost a full day of curriculum on mindfulness and awareness practices. ...
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This paper continues a previous report (Litman, 1984) in exploring the use of psychological autopsies to clarify intention in suicide; clinical experience is compared with courtroom experience. The certification of suicide requires a judgment that the deceased intended to use his or her own death to resolve his or her problems of living, as demonstrated by a preponderance of the evidence. Now that suicide has been decriminalized, the issue of "sane or insane" in insurance contracts has probably become irrelevant. Mental disorders are important as part of the suicide constellation, as one element of many interacting factors. The capacity to have the intent to commit suicide--that is, to understand the physical nature of one's own death--is lost due to mental disorders only under special and unique circumstances.
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The authors surveyed all U.S. medical schools to ascertain the frequency with which medical students attempt suicide, complete suicide, and seek psychiatric treatment. In the classes of 1974-1981 the annual suicide rate for male students was 15.6 per 100,000, which is comparable to their agemates in the national population. The rate for female students equaled that of the male students but was three to four times that of their agemates. Seventy-six percent of the suicides were committed by sophomore and junior students, and 50% were committed in November, December, or January. The authors discuss four steps schools can take in suicidal prevention.