COMMENTARY

Why Three MDs From One Hospital Died by Suicide Within 8 Months: Can We Stop This?

Pamela Wible, MD

Disclosures

July 19, 2021

Lincoln Medical Center, New York City

Why did three young doctors die from suicide within months of each other — all working at one internal medicine residency?

Dr Pamela Wible

They came with hopes and dreams. Dreams of helping the most vulnerable with the best training in the world. They left behind their families. From India, China, and Jordan, they arrived for the first time in the United States to start their lives in New York City, in search of the American dream.

Dr Adhiraj Satija died in August 2020; Dr Bo Yu died in February 2021; Dr Waleed Saleh Abuhishmeh, MD, died in May 2021.

Young and naive, most foreign medical graduates (FMGs) have never lived on their own, never shopped or paid bills. Thrust into a new culture and a new language, they must learn to practice medicine in a complex and disjointed system — alone with no social support, their loved ones now thousands of miles away.

Then came the pandemic. Thrown into the front lines, working 120-hour weeks for less than minimum wage, they ran intensive care units and saved New Yorkers' lives. Yet who helped them?

Struggling, their only way out was suicide and an "accidental" drowning.

Sent back home in coffins, they were never draped with American flags, never honored for their service like Dr Lorna Breen, who died by suicide and was hailed a hero by the media, as she should have been. No media celebrated them as heroes. No media reported their deaths — until I broke their story on Instagram. Why?

Without well-connected families in the United States, they had no advocates. No physician father to ensure they were praised as heroes. No attorney sibling to celebrate them on television, launch a Heroes' Foundation in their name.

When will Dr Stija, Dr Yu, and Dr Abuhishmeh be honored as heroes? Two still have no online obituaries. None have been celebrated by The New York Times or The Today Show. They have no foundations in their names, no US senators rallying around them in Washington, DC.

For nearly a decade, I've run a free doctor suicide helpline. Friends and family have submitted more than 1600 suicided doctors to a registry I maintain. I've led eulogies and candlelight vigils for our forgotten physicians, many FMGs. I can't recall any other suicided physicians celebrated as heroes. Most are shunned.

What US hospital wants to celebrate doctors who step off their rooftops? What grieving family in China has the energy to speak to the US media? How can a mother in Jordan amass the legal force to take on a US hospital system?

Yet these beautiful souls — Dr Adhiraj Satija, Dr Bo Yu, and Dr Waleed Saleh Abuhishmeh — were sons, brothers, uncles, friends — and all are physician heroes.

Dr Adhiraj Satija, from India, was "a true gem of a person, a brilliant doctor and a sincere friend. He was in his second year in an internal medicine residency at Lincoln Medical Center, in New York City, when he texted a co-resident: 'I'm sorry,' then killed himself."

"He worked hard for his goals and dreams and helped his friends achieve theirs," according to a Facebook post. "He was always available to help any of us in need. He did his best and put his all in everything he did. He cared dearly for his friends and was always ready to celebrate all of their achievements. He believed in birthday cakes and made sure his closest friends always had one on their birthdays. He was one of the best among us and he will never be forgotten and will be forever missed."

Dr Bo Yu, from China, graduated from Shanghai Jiaotong University School of Medicine. He was also in his second year of internal medicine residency at Lincoln when he posted farewell photos on social media, then died by "accidental" drowning in a pool. He was still processing his grief from the suicide of his friend, Dr Adhiraj Satija, at the time of his own death. He was down to earth with a quirky sense of humor, super intelligent, and extremely compassionate. (Note: Some still dispute that his death was a suicide).

Dr Waleed Saleh Abuhishmeh, from Jordan, was a first-year resident in internal medicine at Lincoln when he died by suicide just a few months after Dr Bo Yu died. Reserved and soft-spoken, he was always respectful of his superiors (even when bullied). He had few friends and grew more withdrawn while in residency. Waleed told his family of his emotional struggles. They flew to New York. By the time they arrived, he was dead. "He was one of the kindest and nicest guys out there ever," per his friends, all heartbroken by his suicide.

Although FMGs research residencies, they have no idea what their lives will really be like so far from home. With visas now sponsored by their employer, their lives and future are beholden to the leadership of their residency program.

These three deaths were shielded from the world until June 29, 2021, when I began getting anonymous emails from Lincoln residents: "Lincoln Medical Center has had 3 resident suicide deaths in the past 1 year...please save us."

More residents reached out on social media: "Saw the post on Facebook concerning Lincoln. As a resident there, I can say that this is 100% true. We work under horrible conditions with little support from administration. I'm glad somebody is speaking up. Several of my co-residents including myself have felt suicidal at some point working here."

Since then, I've spoken with nearly 20 Lincoln doctors and their relatives. Like me, they want to prevent the next resident suicide. They want to create a culture of wellness at Lincoln. Fearing retaliation, they've requested anonymity in this article.

Harmful Environments for Doctors

I first learned of the hazardous conditions in some NYC hospitals in 2018 when I was called in by physicians to investigate a suicide cluster at Mount Sinai:

"I'm a physician. I have a career ahead of me, which I'm too scared to speak out against. I came home again to another suicide. Another doctor dead from Mt. Sinai in NY. I think NY is a horrible place to work. Conditions are deplorable for doctors and you should investigate. Both suicides were horrible — jumped from our high rise. I'm convinced it's the exhaustion, the demands to perform at 100% 24/7 to meet ridiculous administrative and financial demands. We have to do every job AND document and be nice 100% of the time. I love what I do, but I have grown to hate this system. I have lived in a culture of shame for too long. Would you please expose these Manhattan hospitals? Don't let another doctor's life go unspoken for."

I flew to NYC to eulogize Dr Deelshad Joomun, led a candlelight vigil and 10-hour memorial where I heard first hand about working conditions for NYC residents, particularly FMGs. Dr Joomun and Dr Esha Baichoo both were internal medicine residents at Mount Sinai, both from Mauritius, both stepped off the same Mount Sinai building. Dr Joomun's suicide is now the opening scene in a documentary exposing the suicide crisis among doctors in training.

In 2017, despite public protest, the Accreditation Council for Graduate Medical Education (ACGME) nearly doubled new doctors' work hours to 28-hour shifts and 80-hour weeks. Yet with chronic understaffing in NYC hospitals, doctors in training report working 120 hours per week. Amid the pandemic, residents contracted COVID and were forced to work nonstop while sick.

A student doctor in the Army Reserve told me she was less stressed in Afghanistan under active sniper fire than during US medical training because "I had their back and they had mine. In an unsafe country and a future filled with uncertainty, I felt secure because we supported each other."

Physician Backstabbing, Bullying and Betrayal

Lack of camaraderie and trust may endanger physicians' lives. Backstabbing and bullying so common in US residency training are reinforced by a rigid hierarchy intolerant of critical inquiry.

Some Lincoln residents complained: "The program director has his favorite residents. He yells at everyone else, slams things. Attendings bark orders: 'This is what I said! Do it! Why haven't you done it already?' If you do not know something, you get harassed like an FBI investigation. Residents are scared. Attendings have a rite-of-passage attitude — like a boot camp mentality where people may die of dehydration because they are afraid to ask for a drink of water. It's sink-or-swim." ― Lincoln IM graduate

"Attendings will makes you cry in front of everyone and will move toward you so that you are against the wall. This one was a female attending FMG from Lincoln. Once you are in the 'bad resident' box, you can't get out of it. Environment is not about teaching. It is about blaming and judgment. If you present a case with any mistake, you will be nailed and co-residents will laugh at you. No mentorship. No support beyond rounds. Rest of the day attendings are MIA. No connection. Very dark." ― Lincoln IM graduate

"Residents say things like, 'I wish I were dead. I feel like I'm in prison. I'm going to serve my time and get out.' There's a palpable hopelessness among residents." ― Lincoln IM graduate

"We just had orientation and our program director told us two residents died by suicide. Cold and callous, he told us we'd better reach out if need help. Next day I find out a third resident died. I'm very, very afraid. I've sacrificed a lot to come here. I was so excited to be here. Now I've never been more depressed in my life. His response to the suicides is chilling. Suicide victims are blamed. He took us into the wellness room and said, 'Let me be clear we are not here to entertain you; we are here to train you.' Soldier-like. Very traumatic." ― Lincoln IM resident

"Well, this is the third celebration of life this year. They know all the right steps and it doesn't mean anything and they do not know what to do to make anything better. What concerns me most is we are waiting for the next suicide. There is no sense that we should be doing something about the toxic culture. Everyone just shrugs their shoulders. They tend not to do anything unless in the public eye, in the press." ― Lincoln attending

Doctors Felt Despair

Lincoln Hospital is in a violent and dangerous area of the South Bronx with one of the busiest emergency departments in NYC serving the most impoverished, yet I heard nothing but positive feedback about the quality of teaching in the emergency medicine residency. What I kept hearing was how many doctors feared the internal medicine department.

Although vicarious trauma and overwork are taxing to physicians in training, what drives physicians to insurmountable despair is chronic disrespect and emotional violence from their own peers.

The solution to physician suicides is obviously not to shut down the hospital or residency, not to punish residents or attendings. Rather, we must create a nonviolent culture that allows physicians to feel safe with one another. With simple interventions we can improve this teaching hospital and make it a model for the country.

To remediate what is not working, it's important to understand how current advocacy efforts have failed to protect residents, particularly FMGs.

"Accreditation Council for Graduate Medical Education (ACGME) and NYC Health & Hospitals system did not really help these Lincoln residents, except giving us a huge resident lounge with ping pong table. Hope the death of these three colleagues can bring to public attention about how foreign doctor-in-training struggling, suffering in this chaotic system. Majority of us came to United States for American dream, but unfortunately match at Lincoln." ― Lincoln IM resident

ACGME and US teaching hospitals are supposed to ensure a safe environment for trainees, yet both failed to protect Lincoln residents: "ACGME sends us a yearly survey but the program director asked the chief residents to monitor those surveys with us often completing them under their supervision. The PD would then summon us for a meeting so that he would review our answers with him, and he would often show surprise or frustration with some of the answers. I felt coerced to answer questions like he wanted me to so I would not face repercussions." ― Lincoln IM graduate

The reality is that residents are terrified of reporting to ACGME because their program may be shut down or placed on probation, which might jeopardize their entire career. FMGs would then be deported.

Is It a Simple Staffing Solution?

With understaffing, residents are chronically overworked and say they are coerced to lie about work hours on ACGME surveys. The solution to overwork is to hire more staff. For every FMG matched into a US residency, there are hundreds, possibly thousands, awaiting a spot. Unmatched medical graduates from the US and abroad would gladly work even a part-time position.

Yet how can we hire more staff when we have Medicaid dollars siphoned from poor hospitals to more prestigious NY hospitals? Why defund safety-net hospitals full of FMGs who risked their lives during the pandemic to save New Yorkers?

Understaffing clearly exacerbates the toxic culture plaguing NYC residents.

Unsure if there is a better program, FMGs feel lucky to match and remain compliant with whatever their program says. When leadership instills fear, residents "keep their heads down, graduate, and never look back" — behavior that only perpetuates the cycle of abuse.

I've spoken to Lincoln alums who would love to mentor current residents, and current residents want to nurture new interns. Peer-to-peer support with nonviolent communication could be offered while onboarding new residents, yet leadership has perpetuated a culture that does not allow for such "soft" activities.

What prevents physicians in leadership from embracing empathy?

Repetition compulsion is a psychological phenomenon in which a person unconsciously and habitually repeats an event over and over again. An FMG attending — once a survivor of teaching by terror, public humiliation, and intimidation — now uses the same violent teaching tactics on FMG residents, often choosing to fill their program with FMGs most similar to himself. Same religion, same country of origin.

Unconsciously employing a psychological strategy to protect the attending from anxiety arising from his own buried feelings, he now reenacts abuse on others who then graduate to become attendings that repeat the compulsion on their trainees. An entire program may be filled with victim-turned-perpetrator graduates who abuse FMGs just like themselves to avoid facing their own wounds — acting out a form of self-hatred on others.

I asked Lincoln doctors, "How can we prevent a fourth suicide this year?"

"I think we need to remove the current internal medicine director and program director," explained a Lincoln physician. "Or stage an AA [Alcoholics Anonymous]–style intervention to help them understand how to teach."

To admit we need help as doctors requires vulnerability.

Losing three kind, caring, bright doctors from one residency means we need help.

Let's help Lincoln.

Pamela Wible, MD, runs IdealMedicalCare.org, which teaches how to run community-designed medical clinics. She also maintains a physician suicide hotline in Eugene, Oregon.

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