Preventing and Responding to Physician Suicide

When Buffalo Bills football player Damar Hamlin had cardiac arrest during the team's game on January 2, 2023, the emergency medical response and the decision to cancel the game showed crisis preparedness and sensitivity to the athletes' emotions. 1Weiter T. ESPN report: Bengals, Bills led the charge to cancel Monday Night Football game — not the NFL. WCPO Cincinnati website. https: //www. wcpo. com/sports/football/bengals/espn-report-bengals-bills-led-the-charge-to-cancel-monday-night-football-game-not-the-nflDate accessed: April 10, 2023Google Scholar Like sports teams, health care teams must be prepared to respond to unexpected critical events. Injury and even untimely death are risks incurred by virtually any worker or professional, including physicians, and one well-documented and concerning risk for physicians is suicide. According to findings from a survey by The Physicians Foundation, 55% of US physicians know a physician who has considered, attempted, or died by suicide in their career, and 20% of physicians reported knowing a physician who considered, attempted, or died by suicide during the COVID-19 pandemic. 2The Physicians FoundationSurvey of America's physicians: COVID-19 impact edition; a year later. The Physicians Foundation website, 2021https: //physiciansfoundation. org/wp-content/uploads/2021/08/2021-Survey-Of-Americas-Physicians-Covid-19-Impact-Edition-A-Year-Later. pdfDate accessed: April 10, 2023Google Scholar A 2021 article in the Journal of Psychiatric Research reported a male to female physician suicide ratio of approximately 2: 1. 3Ye G. Y. Davidson J. E. Kim K. Zisook S. Physician death by suicide in the United States: 2012-2016. J Psychiatr Res. 2021; 134: 158-165Crossref PubMed Scopus (32) Google Scholar This finding is consistent with a 2020 meta-analysis comparing male and female age-standardized suicide mortality ratios among physicians vs in the general population. 4Duarte D. El-Hagrassy M. M. Couto T. C. E. Gurgel W. Fregni F. Correa H. Male and female physician suicidality: a systematic review and meta-analysis. JAMA Psychiatry. 2020; 77: 587-597Crossref PubMed Scopus (101) Google Scholar From this meta-analysis, physician suicide rates may not seem to differ from those in the general population on a macroscopic level, but some anomalies become apparent when we analyze the data. For example, the National Violent Death Reporting System for 2012 through 2016 found that, although male physicians had a suicide rate on par with men in the general population, female physicians had higher age-adjusted rates of suicide than their counterparts in the general population. 3Ye G. Y. Davidson J. E. Kim K. Zisook S. Physician death by suicide in the United States: 2012-2016. J Psychiatr Res. 2021; 134: 158-165Crossref PubMed Scopus (32) Google Scholar In addition to a physician's sex, a red flag for whether a physician might be at elevated risk for suicide may be the state in which they practice medicine. Physicians may be less likely to seek psychiatric help in states where they must report mental health diagnoses to the medical review board. 5Dyrbye L. N. West C. P. Sinsky C. A. Goeders L. E. Satele D. V. Shanafelt T. D. Medical licensure questions and physician reluctance to seek care for mental health conditions. Mayo Clin Proc. 2017; 92: 1486-1493Abstract Full Text Full Text PDF PubMed Scopus (139) Google Scholar Additionally, the authors of the article in Mayo Clinic Proceedings reported that nearly 40% of physicians do not report mental illness because they fear it might harm their careers. 5Dyrbye L. N. West C. P. Sinsky C. A. Goeders L. E. Satele D. V. Shanafelt T. D. Medical licensure questions and physician reluctance to seek care for mental health conditions. Mayo Clin Proc. 2017; 92: 1486-1493Abstract Full Text Full Text PDF PubMed Scopus (139) Google Scholar Of 1 in 16 surgeons surveyed by the American College of Surgeons who reported suicidal thoughts in the past year, more than 60% stated that they hesitated to seek help, fearing it would affect their license. 6Shanafelt T. D. Balch C. M. Dyrbye L. et al. Special report: suicidal ideation among American surgeons. Arch Surg. 2011; 146: 54-62Crossref PubMed Scopus (610) Google Scholar The Federation of State Medical Boards has taken up the issue of mental health disclosure requirements, stating that these requirements may violate the Americans with Disabilities Act. 7Saddawi-Konefka D. Brown A. Eisenhart I. Hicks K. Barrett E. Gold J. A. Consistency between state medical license applications and recommendations regarding physician mental health. JAMA. 2021; 325: 2017-2018Crossref PubMed Scopus (18) Google Scholar Minnesota provides an excellent example of how health disclosure policies incentivize or disincentivize physicians on whether to seek mental health treatment. Until 2021, the Minnesota Board of Medical Practice's physicians license application asked, "Have you within the past five years been advised by your treating physician that you have a mental, physical, or emotional condition, which, if untreated, would be likely to impair your ability to practice medicine with reasonable skill and safety? "8University of MinnesotaStudents seek change in mental illness disclosure requirements. University of Minnesota website, 2020https: //twin-cities. umn. edu/news-events/students-seek-change-mental-illness-disclosure-requirementsDate accessed: April 10, 2023Google Scholar To the credit of the Minnesota Board of Medical Practice, this language was amended in 2021 to "Do you currently have any condition that is not being appropriately treated which is likely to impair or adversely affect your ability to practice medicine with reasonable skill and safety in a competent, ethical, and professional manner? "9Minnesota Board of Medical PracticeMinnesota Board of Medical Practice physician application packet. Minnesota Board of Medical Practice website. https: //mn. gov/boards/assets/PY%20Application%20Packet%208-2023ₜcm21-36587. pdfDate accessed: April 10, 2023Google Scholar In the first case, physicians are incentivized to avoid formal diagnosis of their condition, and in the second, they are incentivized to seek formal treatment of their condition. Perhaps this example will encourage our readers to review the mental health disclosures required by the licensing body in their state and, if appropriate, to engage with stakeholders in making changes that support physicians' well-being. A preventive measure that health care administrators and teams can take is to conduct a forensic psychiatric assessment that, with full consent from all involved parties, could potentially identify key personal, familial, professional, and workplace-related factors that could be amenable to an early intervention. 10Glancy G. D. Ash P. Bath E. P. et al. AAPL practice guideline for the forensic assessment. J Am Acad Psychiatry Law. 2015; 43: S3-S53PubMed Google Scholar The findings from a forensic assessment could lead to implementing safeguards in the workplace and at home that may help mitigate the risk of physician suicide. Health care leaders should consider engaging the organization's well-being work group or creating a wellness group to improve health behaviors, reduce workers' stress, and build resilience. Profound distress may stem from employment and insurance concerns, financial stressors, childcare problems, children's distance-learning management, and physical or emotional disconnection from families, friends, and colleagues. Remote work may create a feeling of disconnection. 11Osibanjo R. How leaders and employees can close the connection gap in the post-pandemic workplace. Forbes website. https: //www. forbes. com/sites/richardosibanjo/2022/07/28/how-leaders-and-employees-can-close-the-connection-gap-in-the-post-pandemic-office/? sh=1aca8258597bDate accessed: April 10, 2023Google Scholar Iterative bidirectional engagement of well-being teams will help ensure that appropriate resources are shared with the health care team to address burnout, job satisfaction, and other wellness topics proactively and that employee assistance resources are disseminated during emotional turmoil. Building trust with those around us is imperative because interpersonal mistrust has been associated with increased odds of suicidal ideation. 12Yu Z. Xu L. Sun L. et al. Association between interpersonal trust and suicidal ideation in older adults: a cross-sectional analysis of 7070 subjects in Shandong, China. BMC Psychiatry. 2019; 19: 206Crossref PubMed Scopus (16) Google Scholar Improving communication among health care team members may help to enhance connections with colleagues and patients and to encourage supportive conversations necessary to prevent suicide. Better communication may require moving from what the Co-Active Training Institute terms self-focused listening to more active listening, focused on others. 13The People Piece3 Levels of listening: when to think, when to focus, when to step back. The People Piece website. https: //www. peoplepiece. com/our-insights/levels-of-listeningDate accessed: April 10, 2023Google Scholar Despite efforts to identify warning signs, health care teams may find themselves responding to the suicide of a physician. Responding with empathy to the decedent's family and colleagues while managing the needs of scheduled patients and organizational interests is daunting and requires preparation. The American Medical Association has published a comprehensive toolkit that guides the administrative response to a physician's suicide. 14Dyrbye L. Jin J. Moutier C. Y. Bucks C. After a physician suicide: responding as an organization toolkit. American Medical Association website. https: //www. ama-assn. org/practice-management/ama-steps-forward/after-physician-suicide-responding-organization-toolkitDate accessed: April 10, 2023Google Scholar Steps recommended in the toolkit are activating a crisis response team, contacting the physician's emergency contact person, informing close colleagues and then others in the organization, providing staffing and other logistical support for the affected work unit or practice, honoring and remembering the deceased physician, and carrying out needed organizational change to prevent other suicides. A crisis response team typically includes pastoral care, behavioral health, and crisis management specialists. This team should be empowered to respond to tragedies such as physician suicide in collaboration with health care team leaders. The affected health care team should be notified of their colleague's suicide in person if possible, with an opportunity for the crisis response team to provide immediate support and grief counseling. Because grief may affect the health care team's ability to deliver competent and compassionate patient care, 15Crowe S. Sullivant S. Miller-Smith L. Lantos J. D. Grief and burnout in the PICU. Pediatrics. 2017; 139e20164041Crossref PubMed Scopus (19) Google Scholar assistance should be recruited from unaffected health care workers or if such assistance is not available, elective clinical encounters should be rescheduled or canceled. Reminders from the well-being work group of relevant crisis resources also may be helpful at this time. Physician suicide is alarming and a tragedy that affects many people. Although suicide prevention is of utmost importance, crisis preparedness may allow the best possible decisions to be made for health care team members, families, organizations, and patients.