In October 2012, Pamela Wible, MD, attended a memorial service in her town for a physician who had died by suicide. Sitting in the third row, she began to count all the colleagues she had lost to suicide, and the result shocked her: three in her small town alone, 10 if she expanded her scope to all the doctors she'd ever known.
And so she set out on a mission to document as many physician suicides as she could, in an attempt to understand why her fellow doctors were taking their lives. "I viewed this as a personal quest," she told Medscape. "I wanted to find out why my friends were dying." Over the course of 7 years, she documented more than 1300 physician suicides in the United States with the help of individuals who have lost colleagues and loved ones. She maintains a suicide prevention hotline for medical students and doctors.
On her website, Wible calls high physician suicide rates a "public health crisis." She states many conclusions from the stories she's collected, among them that anesthesiologists are at highest risk for suicide among physicians.
The claim that doctors have a high suicide rate is a common one beyond Wible's documentation project. Frequently cited papers claim that 300 physicians commit suicide per year, and that physicians' suicide rate is higher than the general population. Researchers presenting at the American Psychiatric Association (APA) meeting in 2018 said physicians have the highest suicide rate of any profession — double that of the general population, with one completed suicide every day — and Medscape's coverage of the talk has been widely referenced as supporting evidence.
A closer look at the data behind these claims, however, reveals the difficulty of establishing reliable statistics. Wible acknowledges her data are limited. "We do not have accurate numbers. These [statistics] have come to me organically," she said. Incorrectly coded death certificates are one reason it's hard to get solid information, she said. "When we're trying to figure out how many doctors do die by suicide, it's very hard to know."
Similar claims have been made at various times about dentists, construction workers, and farmers, perhaps in an effort to call attention to difficult working conditions and inadequate mental healthcare. Overall, the claims about physician suicide are "widely quoted as fact without any clear evidence," said Katherine Gold, MD, MSW, MS, an associate professor at the University of Michigan who researches physician wellness, mental health, and suicide. It's critical to know the accurate numbers, she said, "so we can know if we're making progress."
Scrutinizing a Statistic
The idea for the research presented at the APA meeting in 2018 came up a year earlier "when there were quite a number of physician deaths by suicide," lead author Omotola T'Sarumi, MD, psychiatrist and chief resident at Columbia University's Harlem Hospital at the time of the presentation, told Medscape Medical News. The poster describes the methodology as a systematic review of research articles published in the last 10 years. T'Sarumi and her colleagues concluded that the rate was 28 to 40 suicides per 100,000 doctors, compared with a rate of 12.3 per 100,000 for the general population. "That just stunned me," she said. "We should be doing better." A peer-reviewed article on the work has not been published.
The references on the poster show limited data to support the headline conclusion that physicians have the highest suicide rate of any profession: four papers and a book chapter. The poster itself does not describe the methodology used to arrive at the numbers stated, and T'Sarumi told Medscape Medical News that she was unable to gain access to her previous research since moving to a new institution. Gold, the first author on one of the papers the poster cites, said there are "huge issues" with the work. "In my paper that they're citing, I was not looking at rates of suicide," she told Medscape. "This is just picking a couple of studies and highlighting them."
Gold's paper uses data from the Centers for Disease Control and Prevention's (CDC) National Violent Death Reporting System (NVDRS) to identify differences in risk factors and suicide methods between physicians and others who committed suicide in 17 states. The researchers did not attempt to quantify a difference in overall rates, but found that physicians who die by suicide are more likely to have a known mental health disorder with lower rates of medication treatment than non-physicians. "Inadequate treatment and increased problems related to job stress may be potentially modifiable risk factors to reduce suicidal death among physicians," the authors conclude.
The second study referenced in the 2018 poster, "A History of Physician Suicide in America" by Rupinder Legha, MD, offers a narrative history of physician suicide, including a reference to an 1897 editorial in the Philadelphia Medical and Surgical Reporter that claims "our profession is more prone to suicide than any other." The study does not, however, attempt to quantify that risk.
The third study referenced does offer a quantitative analysis based on death and census data in 26 states and concludes that the suicide rate for white female physicians was about two times higher than the general population. For white male physicians and dentists, however, the study found that the overall rate of suicide was lower than in the general population, but higher in male physicians and dentists older than 55 years.
In Search of Reliable Data
With all of the popular but poorly substantiated claims about physician suicide, Gold argues that getting accurate numbers is critical. Without them, there is no way to know if rates are increasing or decreasing over time, or if attempts to help physicians in crisis are effective.
The most reliable data that exist, according to Gold, are found in the CDC's NVDRS database. The CDC just released its own updated analysis of NVDRS data by major occupational groups across 32 states in 2016. It shows that males and females in the construction and extraction industries had the highest suicide rates: 49.4 per 100,000 and 25.5 per 100,000 respectively. Males in the "healthcare practitioners and technical" occupation group had a lower than average rate, while females in the same group had a higher than average rate.
More data are found in the CDC's National Occupational Mortality Surveillance catalog, though it does not contain information from all states and is missing several years of records. Based on its data, the CDC provides a proportionate mortality ratio (PMR) that indicates whether the proportion of deaths due to a given cause for a given occupation appears high or low compared with all other occupations. But occupation data is often missing from the CDC's records, which could make the PMRs unreliable. "You're talking about relatively small numbers," said Gold. "Even if we're talking about 400 a year, the difference in one or two or five people being physicians could make a huge difference in the rate."
The PMR for physicians who have died by intentional self-harm suggests that they are 2.5 times as likely as other populations to die by suicide. Filtering the data by race and gender, it appears black female physicians are at highest risk, more than 5 times as likely to die by suicide as other populations, while white males are twice as likely. Overall, the professionals with highest suicide risk in the database are hunters and trappers, followed by podiatrists, dentists, veterans, and nuclear engineers. Physicians follow with the fifth highest rate.
The only way to get a true sense of physician suicide rates would be to collect all of the vital records data that states report to the federal government, according to Gold. "That would require 50 separate institutional review boards, so I doubt anyone is going to go to the effort to do that study," she said.
Even without a reliable, exact number, it's clear there are more physician suicides than there should be, Gold said. "This is a population that really should not be having a relatively high number of suicide deaths, whether it's highest or not."
As Legha writes in his "History of Physician Suicide," cited in the 2018 APA poster: "The problem of physician suicide is not solely a matter of whether or not it takes place at a rate higher than the general public. That a professional caregiver can fall ill and not receive adequate care and support, despite being surrounded by other caregivers, begs for a thoughtful assessment to determine why it happens at all."
If you or someone you know is in need of support, the National Suicide Prevention Lifeline's toll-free number is 1-800-273-TALK (8255).
Dana Najjar, MS, MA, is a freelance writer in New York City. She interned for Medscape in 2019.
Correction: This story originally stated that Gold considered the CDC's National Occupational Mortality Surveillance catalog the most reliable data available on physician suicide. She considers the CDC NVDRS data most reliable.
Medscape Medical News © 2020
Cite this: Dana Najjar. Are Doctors Really at Highest Risk for Suicide? - Medscape - Feb 05, 2020.