#129 Depression and Suicide: Occupational Hazards of Practicing Medicine

December 10, 2018 | By Nora Taranto

Physician suicide is a problem. There, we said it. We all have that story; Many of us have experienced the symptoms of depression or suicidal ideation ourselves, or have the colleague, mentor, friend, teacher, sibling, parent, or significant other who has experienced these signs and symptoms. Some of us (probably more than you’d think) have lost someone meaningful to suicide. And yet, we don’t talk about suicide and mental health in medicine–or at least, not enough. So, today, we at the Curbsiders are trying to change that.

The problem of depression and suicide is a particularly real one in medicine, a profession that is, by its very nature traumatic and emotionally draining (both in terms of work demands and also the sick and dying patients we treat). In this episode, we talk with expert Dr. Elisabeth Poorman about the natural history of depression in residency and beyond. We share some of our own personal stories, and discuss how we can support one another and reach out for help, how to take care of our mental health in an emotionally demanding career, how to deal with licensing questions and worry about stigma, and what systemic changes may be coming (read: we think need to be coming) down the line.

N.b. This is a sensitive topic. If this is triggering for anyone listening, the national suicide hotline number 1-800-273-8255. Moreover, if anyone needs or wants guidance on available resources, Dr. Elisabeth Poorman has made herself available either via email, private msg on FB or twitter (@DrPoorman), or any of us on twitter. We are happy to talk and see that you get support you need.

Full show notes available at http://thecurbsiders.com/podcast. Join our mailing list and receive a PDF copy of our show notes every Monday. Rate us on iTunes, recommend a guest or topic and give feedback at thecurbsiders@gmail.com.

Credits

Written and produced by: Nora Taranto MS4, Shreya Trivedi MD

Hosts: Stuart Brigham MD, Shreya Trivedi MD, Matthew Watto MD

Edited by: Matthew Watto MD

Guest: Elisabeth Poorman, MD

Time Stamps

• 00:00 Disclaimer, Intro, Guest Bio
• 3:25 Wellness Recommendations: Find a Therapist
• 6:12 How to find a therapist in training
• 6:39 Licensing and Mental Health
• 12:14 Disclaimer and Trigger Warning: Stories are Sensitive. National suicide hotline info
• Next, Dr Poorman and each of The Curbsiders share their personal experiences with mental health (see below).
• 12:05 Shreya story
• 21:40 Stuart’s story
• 31:19 Elisabeth’s story
• 36:17 Watto’s story
• 37:41 Passive suicidal ideaiton, a definition  
• 41:10 Suicide and Depression: Do they always coexist? (No)
• 42:20 Life Cycle of Depression and Suicide in the Medical Profession
• 47:15 Depression and Suicide in Primary Care
• 47:59 Mini-Cases
• 54:00 Noticing signs in a colleague: how to help
• 58:00 Specific programs doing things well
• 1:03:08: Questions from Social Media
• 1:03:10: Burnout vs. Depression
• 1:04:27: Will getting treatment affect your board applications
• 1:06:14 Take home points
• 1:08:00 Outro

Mental Health in Medicine: Pearls

1. Medicine is, by nature, a traumatic profession in which to train and practice.
2. You are not alone in struggling. Depression and suicide are problems that will affect almost all of us, either directly or indirectly. Be proactive about taking care of yourselves, and keep an eye out for your colleagues.
3. Rates of depression rise dramatically at the beginning of training, and these higher rates of depression and suicide persist above general population levels throughout life.
4. Ask (in a non-hospital environment, if possible) when you are concerned about a colleague.
5. Therapy is a great thing for medical professionals, with or without a diagnosable mental illness. It is very important to seek therapy or counseling out before you’re depressed when you may not have the energy to do it.
6. We need to be open in discussing and addressing suicide when it happens in our community. We also need to be more open about seeking help for mental health, and talking about it.
7. If we are telling our patients that mental health is an important thing to take care of for them, then we should be similarly compassionate towards our physician colleagues and ourselves.
8. We need to discuss more openly, as a medical community, how to improve mental health access and support of medical students, residents, attendings, and other medical professionals.

Physician Depression and Suicide Show Notes

Medicine is, by its nature, a traumatic profession.

Physicians take care of people who are sick, dying, and in the midst of difficult life circumstances.  On top of that, we have a robust culture that encourages putting work before everything. Therefore, by the time we notice colleagues are struggling because of a drop in work performance, they’ve typically been struggling for a while (and substance use problems also abound in medicine, which only compounds the problem). Depressed medical professionals can perform exceptionally well as trainees and physicians, in spite of their mental health struggles. We have a remarkable drive to put work first, above all else, and to delay and sacrifice time and time again in the name of our profession. This is an incredibly dangerous skill.   

Sleep deprivation (which is pervasive in medicine, in case you didn’t know) is also an independent risk factor for suicidal thoughts (Bernert Neuropsychiatr Dis Treat 2007).  

Depression in Medicine: The stats are worrisome

Medical students are smart, driven and, most often, healthy. Medical students, most often, have better-than-average support systems, and have not experienced major illness (including mental illness). Going in to training, medical students have lower than average rates of mental illness. Then comes the training.  The rates of mental illness–and depression specifically–peak in clinical years, when medical students experience stress and death firsthand in a very real way. Things improve again in 4th year. But then, in intern year, we have a huge increase (from 4% to approximately 42% who report having had time during the year when they met the criteria for clinical depression (Mata JAMA 2015).

After training, early career physicians have a particularly high rate of burnout (perhaps due to loneliness, a loss of external drive from training, or a loss of sense of self in a community…a la military personnel returning from war zones). There seems also to be a spike in depression and suicide in early career physicians who are practicing on their own for the first time, especially (anecdotally, at least, according to Dr. Poorman) in primary care physicians.  And then suicide rates plateau (at a higher than average population rate, especially for women (Dobson BMJ 2007) for the rest of one’s career.

And, by the way, depression and suicidal thoughts do not always coexist. But often they do.

Find a therapist. (But How?)

We need to acknowledge this traumatic environment in order to understand how best to support physician wellness.  One of the best ways, says Dr. Poorman, is to find a therapist–and to find one early (see Dr. Poorman’s 2017 Article, Congrats medical student, now it’s time to find a therapist). You will face traumatic situations in medicine, and you will have to process them somehow. It would be great if the resources for this were explicitly and regularly encouraged within training programs. This is not the case everywhere, but many programs are improving their emphasis on mental health access.

Models of mental health support in residency

Some programs have all residents go to therapy.

To Dr. Poorman, this seems like the best of all possible outcomes, since there is such an increase in rates of depression in residency, and since the medical profession is intrinsically traumatic. Psychiatry programs are traditionally better at folks providing resources and telling residents that they are expected to attend therapy. It’s time for Internal Medicine to catch up.

Stanford

The Stanford General Surgery program has been innovative, following the suicide of one of its residents. The program responded by creating debriefing sessions for residents. These are run by mental health professionals who don’t have other evaluatory roles in residency. These professionals facilitate and also serve as liaisons for people who need more help outside of those debriefing sessions. They stock healthy foods in fridges, but so importantly, they have the residents iteratively evaluate the helpfulness of the program.

Boston Medical Center

Boston Medical Center is attempting to reduce paperwork for residents.

Cambridge Health Alliance

At Cambridge Health Alliance (where Dr. Poorman trained), two psychiatrists help connect people to therapy and psychiatric services either within or outside the hospital system. For residents, they don’t keep notes or electronic records that might be stumbled upon.

Protecting privacy.  Program Directors and chief residents often inadvertently put up barriers to accessing mental health by telling residents to talk to them first for permission if they need to go to therapy.  Some people will not access care who need it solely because they do not want to disclose their mental health status to their bosses. If you are not twisting yourself into knots thinking about how to protect their healthcare, you’re NOT protecting privacy. –Dr. Poorman

We are talking more, at the residency level, about how to create healthier clinical and learning environments, how to address burnout, how to move way from expectations of perfection to reality. But we struggle with acknowledging that there is a certain amount of work that is unreasonable to ask people to do. And we aren’t all the way there yet. –Dr Poorman

What about the stigma of seeking help?

It’s real. We’re not going to lie. There is real discrimination against physicians who do seek therapy. There is the potential for legal discrimination against physicians, at present.  In the medical licensing process, 28 states (currently) ask if you have ever been treated for a mental health disorder. The existence of those questions discourages a lot of people from seeking treatment, and is stigmatizing. The AMA has recently came out against this practice and suggested different language that’s less stigmatizing (AMA Adopts Policy to Improve Physician Access to Mental Health Care, 2018).  (This is also likely a violation of Americans with Disabilities Act (Schroeder Acad Med 2009)).

So, these licensing questions are a real problem. But, says Dr. Poorman, it is unlikely that you would have licensing denied if you say yes to this question. Generally, you have to just provide additional documentation. Moreover, it is commonplace to worry about how supervisors or colleagues will react when you tell them you are seeking mental health treatment.  What about the stigma? What will people say?

Telling my story meant that no one else could tell it for me. People will come at you with misconceptions about different things, but if you can confidently think through this and say that as a physician, trauma and mental health are real issues, it’s very clear we should be connected to mental health resources. –Dr. Poorman

Suicide by another (or no) name

This is a common story. Many (if not all) of us have experienced the suicides of colleagues, friends, or family members in the medical profession, which have never been called suicides by the program or institution in which they resided.

We don’t want to admit that this is a problem to ourselves, and so we hesitate to acknowledge–publicly or within our community–and whisper about it behind closed doors. This is counterproductive and hurtful–to our profession, to the families of the victims, to colleagues who may be struggling. This attitude reflects the same stigma in society we have about not talking about mental illness, even when it ends with a suicide.  Dr. Poorman had her own experiences with this, when she faced her own struggles with depression. Many of her colleagues were willing to discuss their own struggles in confidence but no one talked about it in public, or on a broader stage. Then she received a letter, some years ago, from someone whose brother had committed suicide while in residency; the residency program had declined to talk about it even though he had explicitly asked them to (For more of this narrative, see her 2018 article What I wish my family had known about residency).  This is all too common.

The American Foundation for Suicide Prevention has a toolkit called “After a Suicide: A Toolkit for Physician Residency/Fellowship Programs.” One of the first things it says is to call it a suicide if you have permission from the family.

It seemed like this [the unwillingness to talk] was the true sickness. I knew it was a story we needed to share with one another. –Dr. Poorman

How to talk to a struggling colleague

Don’t do this at the hospital. Make time outside the hospital to check in with them. There is not one script for this. You can open by saying something like “I just wanted to check in. How are you doing?” or “It seemed like you might be struggling, and I wanted to check in.”  It ought to be habit to openly talk about our own vulnerabilities and going to therapy. Having this conversation as the status quo makes it much easier to broach the topic and to connect individuals to care when we notice them struggling.

If you have experienced struggles in your own training, it can be extremely meaningful to say “I wanted to share with you that I’ve also struggled and experienced this.” That said, at the same time as we want to normalize that many of us struggle, it is essential to ask whether there is any thoughts of self-harm or suicide. This question, while awkward with a friend or colleague, needs to be asked.

A few cases:

We have all heard those supervisors who say “we worked 100 hours a week, would wake up after 4 hours of nap and not complain or be depressed. Medical students and residents are just weaker”

This attitude is damaging, but likely comes from a self-protective place. The individuals who say this likely do not want to confront how big this problem is. In addition, a lot of these physicians were likely in programs where their own humanity was also denied. When they were struggling and needed help, the response was to suck it up. And so, they think, “When I was struggling, nobody cared. So you guys need to pull it together.” No one had kindness or empathy for me, and now I don’t have it for you.

Being patient and physician centered in medicine:

Most people have acknowledged that the clinical environment has gotten a lot worse, especially for residents, in terms of the amount of work, the pace, the documentation that they are responsible for.  Duty hours were important, but they’re not enough and they don’t deal with the problem of work compression, or what are safe limits for what physicians should be handling. Recent studies revealed that residents spent less than 8 minutes of facetime with each patient (Block J Gen Intern Med 2013), and that on average they had to provide 2 hours of documentation for every hour clinical care (Sinsky Ann Intern Med 2016).

Say you are an intern, and your co-intern is signing out to you and just seems emotionally exhausted, you keep catching mistakes that he or she made during the past week or so which are unusual for him or her. You are getting worried about him or her. How do you navigate that situation?

By the time people are making mistakes and visibly struggling, they have likely been struggling for a while. Physicians prioritize work, so it’s the last thing to go. It’s important to talk to this person, and ask what’s going on (see above, how to talk to a struggling colleague).  Suicide is common in our professions, and suicidal thoughts are even more common. This can be difficult to handle. Medical trainees are often told to go to the Emergency Department at the hospital where they work and where they may run into myriad colleagues. The problem is amplified working in a rural setting since there are even more limited options for mental health resources. Telehealth may help with this, but it remains a problem.

Questions from Social Media:

Burned out on “Burnout”?

As physicians we understand what depression means, its severity, and the need to get treatment. Sometimes we see people who are clearly depressed calling themselves burned out. In those cases it is a dangerous euphemism. It also gives the administration some cover to think about this as a less serious problem than it is. –Dr Poorman

Mental Health Treatment and Licensure:

There are states that specifically ask about mental health disorders and mental health treatment. Don’t lie. But second, only disclose what you have to. In Massachusetts, the question reads “Do you have a condition that would impair your ability to practice medicine?” If you have depression, and are being treated appropriately, the answer is typically that you can practice medicine safely. And states very rarely deny applications based on this question. But if you are concerned, consider getting a lawyer to help get you through this licensure process.  

Goals and Learning Objectives

Goal

Listeners will learn about the risk factors for depression and suicide in medical training, and be empowered to advocate for themselves and their colleagues to be safe.

Learning objectives

After listening to this episode listeners will

1. Learn about the life cycle of depression in training and its prevalence at different stages in our careers.
2. Analyze the risk factors that lead to depression and why depression is becoming more prevalent in doctors over time.
3. Evaluate barriers to effective care for physicians and the impact of stigma on those experiencing depression or suicidal thoughts.
4. Assess effective strategies for supporting physicians and physicians-in-training facing depression at different stages in their career.

Disclosures

Dr. Poorman reports no relevant financial disclosures. The Curbsiders report no relevant financial disclosures.

Links from the show

Links are included in the show notes above.