In this article, which is a sequel to Part 1 and Part 2, we explore the systemic causes leading to physician suicide. We have previously explored the individual risk factors and barriers to doctors getting help. In so doing we hope to prevent suicide in doctors by addressing the key physician suicide root causes.
The toxic systemic causes cannot be blamed on one person or institution, or even the government of the day. I argue that they are chronic, entrenched, and are protected by vested interests keeping the status quo. And yet the longer this continues, the sicker our doctors will become, and the more we will lose to dropping out, illness, addiction or suicide.
As Hartzband and Groopman have said so cogently, “Currently proposed solutions do not address the underlying problem: a profound lack of alignment between caregivers’ values and the reconfigured health care system.”
As I have argued elsewhere, resilience classes and free pizza are not the answer to systemic problems.
Below, I have broken down the root causes of physician suicide into autonomy, regulatory, economic, cultural, litigation, and administrative. I then proffer a number of solutions.
Trigger warning: This article discusses suicide in physicians. Resources are given at the end of this article.
Currently proposed solutions do not address the underlying problem: a profound lack of alignment between caregivers’ values and the reconfigured health care system.
Autonomy, according to Gagné and Deci, means having the right to act with a sense of volition and having the experience of choice.
Not too many decades ago, physicians had enormous power and choice. Not just over life and death, but over clinical decision-making. In the intervening years, for reasons we could spend weeks debating, that power has been eroded by legislation, economic drivers, and cultural shifts. Increasing oversight and regulation has diminished physicians’ autonomy, which has been linked to decreased job satisfaction and burnout.
Physicians now endure a profound lack of choice and control over their time, clinical practice, and even time off at home (see Administrative, below). The amount of time we spend with a patient, what is discussed (even to the point of uniform scripts), and how a visit is documented are all frequently mandated. We are further controlled by surveillance in the form of time and motion studies and timing of our use of the EHR.
Solution:
Regulatory issues, specifically, complaints and/or referrals to doctors’ licencing regulators have seriously deleterious effects on doctors’ mental state. The ‘multiple jeopardy’, where a doctor could spend many years defending themselves at different parts of the medical, legal, and regulatory systems, must also be addressed.
Doctors who had recently received a complaint of any kind were found to be 77% more likely to suffer from moderate to severe depression than those who had never had a complaint. Those without complaints had suicidal an ideation rate around 2.5 percent, but this increased to 9.3 percent for those with a current or recent complaint and 13.4 percent for those with a past complaint.
Doctors’ suspension from work, being under investigation, licensing issues, and job loss are more common than ever before, and are specific risk factors for physician suicide. In the UK, between 2005 and 2013, 28 doctors died through suicide or suspected suicide while undergoing GMC investigation (the UK physicians’ licensing body).
Furthermore, by asking about mental illness treatment in their paperwork, credentialling, and licensing processes, regulators create barriers stopping ill physicians from getting help.
Solutions:
Doctors in the US and many other countries graduate from medical school with enormous student debt. The US average is $215,000; in the UK the average is £82,000 ($100,000). These are termed “golden handcuffs”.
Starting as a junior doctor/resident we are the most vulnerable economically and in our careers. Residency is seen as a make-or-break period. Moreover, the junior doctor pay per hour is derisory, but we push on through it because of the “promise” of economic security once we complete our residency/specialist training.
Using a monetary reward as a central motivation strategy seems practical and appealing. However, in a recent survey of more than 15,000 doctors in 29 specialties (Medscape National Physician Burnout and Suicide Report 2020), half the doctors said they would give up at least $20,000 in annual income in order to reduce their work hours; these doctors included millennials, who are among the lowest earners.
Solutions:
Suing doctors is on the increase worldwide, but the US is the dubious world leader in malpractice litigation. Litigation is a risk factor for suicide.
Medical education encourages stoicism. From medical school on, doctors are taught there is no room for error and are expected to perform to demanding standards – or else they may fail or get sued.
Furthermore, physicians are trained to put patients first—often to our own detriment – as we have discussed in Part 2: Overcoming barriers.
Trainees and even qualified doctors may believe they will be criticized for showing vulnerability and thus steer clear of asking for help. This self-imposed isolation increases the risks of burnout, but also means it does not get addressed. If the stress continues, the risk of burnout progressing to become a mental illness, addiction, or suicidal thinking is highly concerning.
Doctors, quite accurately, fear discrimination in medical licensing, hospital privileges, and professional advancement. As a result, although physicians are typically better resourced than the general population, there remain significant barriers to seeking help.
Because the culture of medicine accords low priority to physician mental health despite evidence of untreated mood disorders and an increased burden of suicide, it is crucial to identify these barriers which include may be punitive and discriminator.
Solutions:
Suing doctors is on the increase worldwide, but the US is the dubious world leader in malpractice litigation. Litigation leads to over-investigation and treatment defensive medicine; over-documentation; giving demanding patients what they want rather than what they need clinically; excessive insurance bills; and enormous stress upon doctors.
Litigation is a risk factor for physician suicide. While litigation is a right and cannot be prevented, the obscene volumes of litigation and “promise” of huge payouts can be addressed.
Solutions:
Electronic health records were supposed to do a lot: make medicine safer, bring higher-quality care, empower patients, and save money. Modern physicians are increasingly burdened by cumbersome electronic health records systems and stringent documentation requirements, which now frequently occupy more of their work hours than direct patient care.
Disturbingly, US physicians now routinely spend hours every day at home on their laptops completing EHR “paperwork”. This consumes so much time because the systems are generally poorly designed, and the level of detail required of doctors is high in order to reduce litigation risk and optimize billing to insurers.
Needless to say, in single-insurer systems like the UK NHS the EHR burden is a fraction of that in the US; and burnout rates are lower.
Solutions:
“Given the trauma and the burnout they have experienced, this is like sending the entire workforce off to war for 18 months and then refusing to support them when they return” – J. Corey Feist, Brother-in-law of Dr Lorna Breen.
Prevention of suicide in doctors requires a range of strategies, including improved management of psychiatric disorder, measures to reduce occupational stress and restriction of access to means of suicide when doctors are depressed.
Stehman et al. propose that system-based approaches are likely to be more successful in combating suicidal behavior and ideation. Such system-based causes include limitations of the electronic health record, long work hours and substantial financial debts within a highly litigious culture.
If we break a leg, there is no way we would avoid seeing an orthopedic surgeon and try and fix it ourselves. Why do so many of us refuse to get help from the right professionals?
No matter how fearful we may be of career consequences, we cannot expect to make ourselves get better by willpower, working harder, or working smarter. If we are mentally ill or addicted or burned out, we need to get help. We owe it to ourselves, our loved ones, and our patients.
As we’ve discussed above, we cannot pour from an empty cup.
Physician Support Line (US only)
Psychiatrists Supporting Physicians
Click here or call:
1 (888) 409-0141
Free & Confidential. No appointment necessary. Available 7 days a week.
If you are having thoughts of wanting to end your life,
please first call the National Suicide Prevention Lifeline.
1-800-273-8255 or call 911 if in imminent danger.
