Today's post is what those last few posts were building up to- the big, bad topic we have to get past. The one we have to talk about before we can move on to ideas of how we can start making things right, if that's even a possibility in this crazy medical climate. I have to believe there's hope, so I'm going on that assumption... but before we get to that, we have to acknowledge that some of our sisters and brothers, the people who trained us, or who we trained with, or who we've trained, have been lost to suicide.
We've known for over a century that, despite the fact that physicians have about the same prevalence of depression as the general population, the rate of suicide in physicians is about twice that of non-physicians, about 4%. I'm talking about completed suicides- and this may be partly because physicians know how to successfully complete a suicide. As in the general population, men are more likely to complete a suicide. But the risk for women physicians is also high.
Physicians reading this probably already know everything I've written here. Perhaps non-physicians do, too. It's been all over the medical websites and the medical newsletters, but it's also just been all over the news- there have been articles in the New York Times, The Atlantic....I can't even remember where else I've seen them. Dr. Pamela Wible, a Family Practitioner in Oregon, has devoted much of her time to helping suicidal physicians and to getting the word out, collaborating with filmmaker Robyn Symon to make the film 'Do No Harm', a documentary about physician suicide, out recently, and calling attention to the greatly increased rates of depression and suicide in medical trainees.
Some doctors are lucky- this information is theoretical for them. Others, like me, have lost colleagues and friends in medicine to suicide. Maybe, again like me, you are a physician who can also understand all too well how it happens. Hopefully, you haven't planned or attempted your own suicide, or even come close, and you haven't lost a parent, or sibling, or spouse, or child who is in the medical field to suicide.
Sadly, my friend (I'm going to call her Marge), did lose her adult child this way. It's been almost a year, so she is coming up on the first anniversary of his death. As painful as it is for her, she was willing to talk to me about it in detail. I wanted to understand what happened. She is still trying to make sense of the senseless. I'm going to change some details of the story, but basically, this is what I know.
Marge's son, Dan (not his real name) was a shining star in his field, a pediatric subspecialty. He practiced in an academic center, where he was the chair of his department and headed up a multidisciplinary team, caring for children with sometimes devastating illness and disability. The work he did had the capacity to significantly improve the quality of the lives of these children and their families. When it did, it was miraculous. But sometimes, these kids died or deteriorated, not as a result of his actions, but from their underlying ailments. So in the course of a day, Dan's work might be exciting and elating in the morning and shockingly full of grief in the afternoon.
Dan was naturally a giver. Not only did he devote himself to the children under his care, but he also volunteered time for a foundation to raise money to help them. And he gave not just of his time, but of himself. He wanted to make these kids smile, to see them laugh, to see them have some happiness in their lives; he worked hard at that. He gave more of his time and also his money so advances in his field might happen. In addition, he gave of himself academically, hoping that those he trained might practice the way he did, and that the research he did and lectures he gave might impart knowledge that others could use to help kids. As we all know, often the only compensation for our academic work is that, in theory, it's going to make a difference to the patients.
Aside from being a healer and a scholar, Dan was also a husband, a son, a brother and a friend- to many. I didn't know him, but I imagine him as the kind of guy who led. He led his medical team, he led in research, he led in so many ways. The type of guy who listened to other people. So often, maybe, that nobody really noticed that everyone leaned on him but he didn't lean on others. The kind of guy who always had a smile for everyone. But Dan also had a history of depression, and things were often hard for him.
Between his pre-existing depression, the pressure of his work, the fatigue of his many roles, and some contract issues, Dan got into a dispute with administration at his institution about his responsibilities, and got labeled as a 'disruptive physician.' This could mean so many things. I've seen doctors called to the carpet as 'disruptive' for yelling at trainees and nurses, for throwing instruments in the OR, for truly egregious misconduct. But I've also seen administrators use the 'disruptive physician' label to punish physicians for speaking their minds or for blowing the whistle on dangerous practices.
Dan was, at that point, quite depressed, and needed treatment. Choosing his own treatment, in consultation with his close family, would have been the best case scenario. But the health system decided to send him to their program for impaired physicians. This program was in another state, far from his wife, friends, and other family. In addition, the program had been tailored for substance abusers, not physicians with mood disorders, and the therapy and psychiatric interventions were inappropriate for his problems. To make matters worse, he was told that he was expected to stay there for 3 months. And if he didn't comply, he was at risk of losing not only his job, but his medical license.
As I discussed in the previous blog post, these programs vary quite a bit from state to state and from program to program. The issue of a program being inappropriate to his diagnosis is not unique to Dan's circumstances. I have seen this before; it is a known deficiency of many Physician Health Programs.
I don't think I need to go much further with this story. Imagine being in despair, feeling like your world is crashing in . Then imagine that you are told that to salvage the little you have left, the work you love, you must spend months in confinement, far from your social supports, being treated as a substance abuser, drug tested and going to 12-step meetings, while you become increasingly hopeless, and nobody addresses your hopelessness. By the time he returned home, Dan was a different person, and not in the way you'd hope. It is not a surprise to me that when he got home, he carefully planned and carried out his suicide, leaving a note asking his loved ones to 'look into what happened to me, so that this does not happen to someone else.'
Marge, her daughters, and Dan's wife all know that Dan had an underlying depression. But none of them believe that he ever would have arrived at this point if not for the brutal and unforgiving health system that treated a man who embodied humanity so inhumanely.
I didn't know Dan. But I believe he suffered from many of the things that I have written about in previous posts. I think he had secondary trauma, and likely either didn't have, or didn't give himself, the opportunity to talk about all the pain he absorbed through his work. He may have also had great joy, but the trauma lived in him. I believe he was bullied by an administration that didn't want to find a way to help him live a balanced life so that he could go on practicing his profession at a high level. And I believe he was mistreated by a Physician Assistance Program that was ill-equipped to diagnose and treat him appropriately, thus worsening the mental health problems he was already experiencing.
This is a loss that should have been prevented. Marge lives every day with a hole torn in her heart.
Dan's patients have lost a true healer. His wife and sisters and friends and colleagues have all lost someone dear. The world has lost his ideas and his energy. When are we going to make this stop?
We all want to do better than this for our patients. And we certainly should want to treat our colleagues with the utmost of care. Cutting corners and pushing doctors into programs as though every physician struggling emotionally can be treated in the same cookie-cutter model, with the goal of rushing him back to work, is making a ridiculous assumption. We would never assume that every patient with palpitations needed the same drug or the same procedure, nor would we deny them the right to choose their own cardiologist, or force them back into work before they were ready. Are we really going to let the shoemaker's child go barefoot? The end result is clearly not acceptable.
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I'm busy working on my blog posts. Watch this space!