'If you seek help, you risk your career': Physician suicide needs solutions, not silence

Key takeaways:

• More than 50% of physicians know of a colleague who has considered, attempted or died by suicide.
• There are strategies that have already been implemented and seem to help improve physicians’ well-being.

High rates of physician suicide are a devastating reality that require multiple solutions, according to experts.

September is National Suicide Prevention Month, and Sep. 17 was National Physician Suicide Awareness Day. The Physicians Foundation, a nonprofit organization, marked the occasion by releasing a new report — the 2023 Survey of America’s Current and Future Physicians — that offered troubling insights into the current state of mental health among medical providers and students.

“We know that physicians have one of the highest suicide rates of any profession,” Gary Price, MD, president of The Physicians Foundation, told Healio. “For too long, there has been an assumption that physicians just need to be more resilient, and well-being strategies have focused on this approach. Our current and future physicians need and deserve better.”

The survey, which was conducted from June 8, 2023, to June 28, 2023, included responses from 2,114 physicians, residents and medical students. The responses revealed that more than 50% of physicians know of a colleague who has either died by suicide, attempted to do so or considered doing so — more than in 2021 and 2022. When asked about the past year, 20% of physicians said they knew someone who had considered, attempted or died by suicide. This number was also higher than those in 2021 and 2022.

Also, 38% of residents and 45% of medical students knew a peer or colleague who at one point considered suicide.

Sarah C. Nosal, MD, FAAFP, a member of the American Academy of Family Physicians board of directors, recalled her residency, which was bookended by tragedies. In the early years of her training, one colleague jumped from the balcony of their hospital building in New York City. At the end of her residency, a resident in another program did the same.

“Residency is a wonderful blur of exhaustion and learning, but it is highly isolating, at times demeaning — a den of imposter syndrome, and a competition to maintain that external highly competent and capable facade,” Nosal said. “At the time I was training, you would have never taken a day off for ‘mental health.’ You would not have even taken a few hours off to see a therapist or psychiatrist.”

Nosal said that, after the deaths of her peers, she had “a vague recollection that support and services were offered,” but the message “was known and clear: if you seek help, you risk your career.”

Stigma

Around eight in 10 medical students (76%), residents (79%) and physicians (78%) agree that, among physicians, there is a stigma surrounding mental health care, and about half of each group (55% of students, 48% of residents and physicians) said they know someone who would not seek mental health care.

“What we found most concerning is that there is still rampant stigma surrounding seeking mental health care and that underlying system barriers are preventing physicians from accessing this care,” Price said. “A culture, reinforced by licensing boards, hospital and insurance credentialing has developed viewing seeking mental health care as a potentially career-ending sign of weakness.”

Four in 10 physicians and half of medical students and residents said either they themselves were afraid or they knew a colleague afraid of seeking mental health care because of questions asked in medical licensure, credentialing and insurance applications.

“Hospital credentialing needs to change,” Nosal said. “The questions that are asked and the way they are asked — to make having sought or received treatment for mental health a reason for exclusion — is unreasonable, harmful and dangerous to physicians and physicians in training.”

Although the specific questions depend on the state, they generally ask if the applicant has ever received treatment of any kind, like medication or therapy, for a diagnosed mental illness or substance use-related diagnosis. These questions, Nosal said, “stigmatize any care and make it seem like you might not be allowed to be credentialed if you had or are receiving such care.”

Nosal said the fear of seeking help was prevalent early in her career. She described the effects of premedical students being “weeded out quickly for any perceived weakness.”

“My fellow premed classmate who was struggling with an eating disorder during undergrad felt she had to avoid treatment and seek it only in secret, paying cash so it would not be on her insurance record and discoverable in the future,” Nosal said. “I recall a classmate with anxiety disorder having panic attacks explicitly avoiding engaging mental health clinicians for fear they would one day have to declare treatment or diagnosis on hospital credentialing forms.”

Every so often, Nosal said, a classmate who had been struggling “would disappear.” Once they left, “they rarely returned.”

“It was a poorly kept secret that if you showed weakness, you would be asked to take a leave,” Nosal said. “Seeking care meant your career ended. Medical students pushed on, self-medicating through risky behaviors, drinking and occasional substance use — walking a fine line of ‘letting off steam’ and abuse.”

It was not until she took a leadership role at the student-run free clinic that Nosal said she “felt protected from some of the very common feelings of inadequacy and depression that touched the lives of more than a third of medical students by being involved in activities and valuing work and contribution outside of the academic setting solely.”

“Yet, just a few years ago, one of our student leaders of that same free clinic, which I now help supervise as an attending, took her life, to the shock of her classmates, clinical leaders and her medical school,” Nosal said. “She had maintained a nearly perfect facade of competency and accomplishment — a deadly demand of medical school and a medical career.”

Burnout

Another major factor in poor mental health among physicians is burnout.

“Physician burnout has long been a crisis, but the COVID-19 pandemic certainly exacerbated the issues that physicians face,” Price said. “For the third year in a row, approximately six in 10 physicians often have feelings of burnout. This proportion of physicians is significantly higher than what was reported during pre-pandemic times (40% in 2018).”

Price said it is possible that, during the pandemic, there was a lack of resources and time “to concentrate on improving the environment in which physicians work,” which may have “allowed physician well-being to deteriorate.”

“This may well be compounded by the growing physician shortage, consolidation in health care with a larger proportion of physicians switching to employed vs. independent models, multiple strains on health care reimbursement, a lack of reform of preapproval policies, electronic records systems which actually decrease productivity instead of promoting it and a failure to reign in bureaucratic burdens to providing care,” Price said. “All of these compete for time spent actually caring for patients — a source of tremendous frustration for physicians on a daily basis.”

In addition to other challenges during the pandemic, like patients being unwilling to get vaccinated and the “respect of physicians crashing to new lows of harassment and disdain,” Nosal also acknowledged that understaffing and “poor payment for primary care and preventive services” are drivers of burnout.

“Many individuals retired or left medicine during the pandemic,” Nosal said. “Pre-pandemic salaries are no longer competitive to recruit or retain staff, which contributes to understaffing — particularly at safety net and nonprofit health organizations. This chronic understaffing is a repetitive cycle of those who stay taking on more responsibilities than possible to maintain, feeling overwhelmed and [then] leaving, with the rate of new staff entering the system unable to keep up.”

The next generation

Despite the troubling findings, Price said the survey also indicates that “there is a generational shift happening where medical students are seeking mental health care and are engaging more openly with these topics.”

About half of medical students — 47% — have sought help for a mental health problem, according to the survey. This number is significantly higher than the proportions of physicians (19%) and residents (29%).

Additionally, about 70% of medical students report having checked in with a peer they thought was facing mental health issues, compared with 65% of residents and 35% of physicians. About 60% of students also said physician well-being should be a topic of conversation in medical school classes.

“The next generation of doctors are really different. They are coming out of medical school and residency demanding much more acknowledgement as humans with human medical and behavioral health needs,” Nosal said. “In medicine, we are not necessarily ready to meet these needs. Systems will need to be broken down and rebuilt so that we can continue to provide excellent care to our patients and communities while also meeting the needs of those who make that care possible.”

Strategies at work

“The future of medicine is dependent on change to offer the right resources and eliminate barriers that impact physicians’ well-being,” Price said. “The solutions to improve physician well-being and prevent suicide are not a secret — physicians, residents and medical students have identified the solutions they need.”

Some of those solutions are already making an impact. More specifically:

• Administrative burden reduction was helpful for 80% of physicians and 85% of residents.
• Confidential therapy, counseling or support phone lines were helpful for 64% of physicians and 80% of residents.
• Changes to or removal of credentialing application questions were helpful for 59% of physicians and 64% of residents.
• Peer-to-peer support groups were helpful for 57% of physicians and 72% of residents.

According to Price, The Physicians Foundation recently launched Dear FutureDoc, a new initiative from the Vital Signs campaign.

“The goals of Dear FutureDoc are to encourage future physicians to reflect on their own mental health and well-being, to support each other and to share their hopes for the future of physician well-being,” he said.

Price said the initiative includes three simple resources:

• Selfie Sign, which physicians, residents and medical students can use as a background when they post on social media about physician well-being;
• Note to Self, a card that can be used to write encouraging messages to their future selves; and
• Note to Others, a card that can be used to write encouraging messages to peers and colleagues.

Click here to learn more about Dear FutureDoc.

Anyone in crisis can contact the 988 Suicide & Crisis Lifeline by texting or calling 988 or reaching out online at 988lifeline.org.

References:

• 2023 Survey of America’s Current and Future Physicians. https://physiciansfoundation.org/research/amplifying-physician-resident-and-student-voices-to-drive-wellbeing-and-care-delivery-solutions/. Published Sept. 14, 2023. Accessed Sept. 18, 2023.
• Dear FutureDoc. https://npsaday.org/wp-content/uploads/2023/08/PF23_DearFutureDoc_EncourageMentalHealthReflection_V1h.pdf. Accessed Sept. 20, 2023.
• Vital Signs: The campaign to prevent physician suicide. https://npsaday.org/. Accessed Sept. 20, 2023.