The Painful Truth: Physicians Are Not Invincible

Merry N. Miller, MD, K. Ramsey Mcgowen, PhD, Department of Psychiatry and Behavioral Sciences, James H. Quillen College of Medicine, East Tennessee State University, Johnson City.

South Med J. 2000;93(10) 

In This Article

Rates of Psychosocial Problems Among Physicians

Limited information is available that describes rates of suicide, depression, substance abuse, marital problems, and other emotional problems among physicians. Most of the research done to evaluate physician suicide rates is at least 10 years old. In addition, many findings are contradictory, making interpretations difficult. Methodologic problems, such as the use of only American Medical Association (AMA) data in early research on physician suicide, have also limited conclusions that can be drawn.

Suicide

The overall physician suicide rate cited by most studies has been between 28 and 40 per 100,000, compared with the overall rate in the general population of 12.3 per 100,000.[1] Overall, then, physicians are more than twice as likely as the general population to kill themselves. Each year, it would take the equivalent of 1 to 2 average-sized graduating classes of medical school to replace the number of physicians who kill themselves. This rate appears higher than among other professionals.[2]

This phenomenon has been explored since the 1960s. Blachly et al[3] gathered data on 249 physicians listed in JAMA obituary columns and made extrapolations to determine which specialties had the highest risk. They interpreted their data to show that psychiatrists had the highest suicide rate and pediatricians had the lowest rate. Further support for the notion that psychiatrists might be at higher risk is found in the work of Rich and Pitts,[4] who found that psychiatrists committed suicide at twice the expected rate.

Later studies have reported contradictory findings regarding specialty risks, however. Rose and Rosow[5] took another look at the evidence gathered by Blachly et al,[3] as well as their own review of death certificates in California, and found that differences among specialties were not statistically significant. Craig and Pitts[6] studied more than 8,000 physician deaths reported to the AMA and also found no clear differences between specialties. In 1975, Everson and Fraumeni[7] determined that one leading cause of death for medical students and young physicians was suicide. More recent data are provided by Samkoff et al,[8] who studied mortality among young physicians by examining death certificates for actual causes of death. They determined that suicide was the most common cause of death for young physicians (26% of deaths). Although contradictory evidence exists about differences in suicide rates among specialties, the fact that physicians complete suicide at a higher rate that the general population seems clear. The fact that overall mortality from other causes of death is lower for physicians (than the general population) while the suicide rate is doubled raises serious concern.8

Female physicians appear to be especially vulnerable. Suicide rates for women physicians are approximately four times that of women in the general population.[1,9] The rates for male and female physicians are roughly equal, whereas women in the general population are much less likely than men to complete suicide.

Many of the risk factors for suicide in physicians correspond to risk factors in the general population. Suicide rates have been found to be higher among physicians who are divorced, widowed, or never married.[5] The high-risk physician has been described as driven, competitive, compulsive, individualistic, ambitious, and often a graduate of a high-prestige school. He often has mood swings, a problem with alcohol or other drugs, and sometimes a non- life-threatening but annoying physical illness.[10]

An attempt to identify clinical predictors of physician suicide was conducted by Epstein et al.[11] They retrospectively studied results of psychologic testing administered during medical school for possible predictors of later suicide, since nine of the tested students later killed themselves. A psychiatrist blinded to the later outcome was able to identify all nine suicides correctly. Students who later committed suicide were rated significantly higher than controls on many personality factors, including self-destructive tendency, depression, and guilty self-concept.

The AMA and American Psychiatric Association in the 1980s conducted an extensive study of physician suicide.[1] In retrospective interviews with family and friends of 142 physicians who died by suicide and 101 physicians who died of other causes, they found little difference across specialties. Physicians who committed suicide were found to have had slightly more difficult or emotionally draining patients than other physicians, both throughout their careers and in the final 2 years of their lives. They also were reported to have fewer friends and acquaintances than controls and to receive and to give less emotional support to others.

In the same study,[1] physicians who killed themselves also had more chronic physical or mental disorders at the time of death. More than one third of the physicians who committed suicide were believed to have had a drug problem at some time in their lives, as opposed to 14% of controls. Another difference was in personality styles. Those in the suicide group were perceived as more likely to be critical of others and of themselves. They also were perceived as more likely to blame themselves for their own illnesses. Of the physicians who committed suicide, 42% had been seeing a mental health professional at the time of death, whereas 7% of controls had. One third of the physicians who committed suicide had a history of at least one psychiatric hospitalization. The physicians who committed suicide were more likely to have made previous attempts on their lives and to have talked about killing themselves before the actual suicide. They had a slightly higher incidence of suicide among their own parents than controls. They also reported more emotional problems before age 18 than controls.

Depression

Depression has been noted to be a common occurrence during medical training.[12] Rates of clinical depression among interns have been reported to be 27%[13] and 30%,[14] and 25% of interns have been reported to have suicidal ideation.[14] A review of the literature on stress during residencies documented that depression and increased anger were important problems during training.[15] Among practicing physicians, depression has been studied more in female physicians than in male physicians. Welner et al[16] published a study in which female professionals were interviewed and evaluated for a lifetime history of depression according to the Feighner criteria. They found that 51% of female physicians and 32% of female PhDs they selected from the general community had a history of depression. Among physicians, psychiatrists had the highest rates, with 73% reporting a history of depression compared with 46% of other female physicians. A more recent study assessed the lifetime prevalence of self-identified depression and suicide attempts among 4,501 US women physicians who responded to the Women Physicians' Health Study, a nationally distributed questionnaire.[17] In this study, 19.5% of female physicians reported a history of depression, and 1.5% reported a history of suicide attempts. The latter study suggests that prevalence rates of depression among female physicians may be similar to those in the general population. The contradiction in these findings suggests the need for further study of depression in female physicians. Depression among male physicians also warrants further study.

Substance Abuse

Substance abuse probably has received more attention than suicide or depression as a problem within medicine, and reported prevalence rates vary widely. Recent data suggest that the prevalence of alcoholism and illicit drug abuse by physicians is similar to that among the general population, but physicians may be at increased risk for prescription drug abuse.[18] Special substance abuse programs for physicians, such as those of the Talbott-Marsh Clinic in Atlanta and Caduceus Clubs, have been developed all over the United States and Canada.

The availability of addictive agents may play a role in the increased rates of drug addiction among physicians. Physicians also have the opportunity to self-medicate and otherwise treat themselves rather than entrust their care to others, and this may have terrible consequences. Also, physicians are more knowledgeable about the lethal doses of various medications, so this may play a role in the increased rates of successful suicide.

As mentioned earlier, there is a strong link between suicide and both substance abuse and depression. It has been estimated that 40% of physician suicides are associated with alcoholism, and 20% with drug abuse.[10] An association between mood disorders, substance abuse, and suicide among physicians has been described.[19]

Divorce

Divorce rates among physicians have been reported to be 10% to 20% higher than those in the general population.[20] Furthermore, those couples that include a physician who remain married reported marriages that are more unhappy. Much has been written about the "medical marriage," and some problems have been reported as widespread among physicians' marriages. For many years in pre-med college, medical school, and residency, physicians focus on getting through the next hurdle. They may postpone the pleasures of life that others enjoy. It has been hypothesized that this psychology of postponement may be related to compulsive traits. In particular, the compulsive personality traits that are widely heralded as being key ingredients in professional success may have the unwanted consequence of leading to more distant relationships. Many physicians place work above all else, and it has been speculated that this may serve the purpose for them of helping to avoid intimacy, thus placing strain on intimate relationships.[21]

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