Content warning: This article contains discussions of suicide and suicidal ideation.
In early 2020, Justin Bullock, MD, MPH, did what few, if any, resident physicians have done: He published an honest account in The New England Journal of Medicine (NEJM) of a would-be suicide attempt during medical training.
In the article, Bullock matter-of-factly lays out how in 2019, intern-year night shifts contributed to a depressive episode. For Bullock, who has a bipolar disorder, sleep dysregulation can be deadly. He had a plan for completing suicide, and this wouldn't have been his first attempt. Thanks to his history and openness about his condition, Bullock had an experienced care team that helped him get to a psychiatric hospital before anything happened. While there for around 5 days, he wrote the bulk of the NEJM article.
The article took Bullock's impact nationwide. In the medical world, where mental illness is a serious problem but still deeply stigmatized, Bullock's unblinking honesty on the issue is still radical to many. On Twitter and in interviews, Bullock is an unapologetic advocate for accommodations for people in medicine with mental illness. "One of the things that inspired me to speak out early on is that I feel I stand in a place of so much privilege," Bullock told Medscape Medical News. "I often feel this sense of…'You have to speak up, Justin; no one else can.'"
Bullock's activism is especially noteworthy, given that he is still establishing his career. In August, while an internal medicine resident at the University of California, San Francisco (UCSF), he received a lifetime teaching award from the UCSF School of Medicine because he had received three prior teaching awards; a recognition like this is considered rare someone so early in their career. Now in his final year of residency, he actively researches medical education, advocates for mental health support, and is working to become a leading voice on related issues.
"It seems to be working," his older sister, Jacquis Mahoney, RN, says during a visit to the UCSF campus. Instead of any awkwardness, everyone is thrilled to learn that she is Justin's sister. "There's a lot of pride and excitement," she says.
Suicide Attempts During Medical Training
Now 28, Bullock grew up in Detroit, Michigan, with his mom and two older sisters. His father was incarcerated for much of Bullock's childhood, in part because of his own bipolar disorder not being well controlled, Bullock says. When he was younger, Bullock was the peacekeeper in the house between his two sisters, says Mahoney: "Justin was always very delicate and kind."
He played soccer and ran track but also loved math and science. While outwardly accumulating an impressive resume, Bullock was internally struggling. In high school, he made what he now calls an "immature" attempt at suicide after coming out as gay to his family. While Bullock says he doesn't necessarily dwell on the discrimination he has faced as a gay, Black man, his awareness of how others perceive and treat him because of his identity increases the background stress present in his daily life.
After high school, Bullock went to MIT in Boston, where he continued running and studied chemical-biological engineering. During college, Bullock thought he was going to have to withdraw from MIT because of his depression. Thankfully, he received counseling from student services and advice from a track coach who sat him down and talked about pragmatic solutions, like medication. "That was life-changing," says Bullock.
When trying to decide between engineering and medicine, Bullock realized he preferred contemplating medical problems to engineering ones. So he applied to medical school. Bullock eventually ended up at UCSF, where he was selected to participate in the Program in Medical Education for the Urban Underserved, a 5-year track at the college for students committed to working with underserved communities.
By the time Bullock got to medical school, he was feeling good. In consultation with his psychiatrist, he thought it worthwhile to take a break from his medications. At that time, his diagnosis was major depressive disorder and he had only had one serious depressive episode, which didn't necessarily indicate that he would need medication long-term, he says.
Bullock loved everything about medical school. "One day when I was in my first year of med school, I called my mom and said, 'It's like science summer camp but every day!'" he recalled.
Despite his enthusiasm, though, he began feeling something troubling. Recognizing the symptoms of early depression, Bullock restarted his medication. But this time, the same selective serotonin uptake inhibitor only made things worse. He went from sleeping 8 hours to 90 minutes a night. He felt angry. One day, he went on a furious 22-mile run. Plus, within the first 6 months of moving to San Francisco, Bullock was stopped by the police three different times while riding his bike. He attributes this to his race, which has only further added to his stress. In September 2015, during his second year of medical school, Bullock attempted suicide again. This time, he was intubated in the emergency department and rushed to the intensive care unit.
He was given a new diagnosis: bipolar disorder. He changed medications and lived for a time with Mahoney and his other sister, who moved from Chicago to California to be with him. "My family has helped me a lot," he says.
Bullock was initially not sure whether he would be able to return to school after his attempted suicide. Overall, UCSF was extremely supportive, he says. That came as a relief. Medical school was a grounding force in his life, not a destabilizing one: "If I had been pushed out, it would have been really harmful to me."
Then Bullock started residency. The sleep disruption that comes with the night shift — the resident rite of passage — triggered another episode. At first, Bullock was overly productive; his mind was active and alert after staying up all night. He worked on new research during the day instead of sleeping.
Sleep disturbance is a hallmark symptom of bipolar disorder. "Justin should never be on a 24-hour call," says Lisa Meeks, PhD, associate professor of psychiatry and family medicine at the University of Colorado Anschutz and a leading scholar on disability advocacy for medical trainees. When he started residency, Bullock was open with his program director about his diagnosis and sought accommodations to go to therapy each week. But he didn't try to get out of night shifts or 24-hour calls, despite his care team urging him to do so. "I have this sense of wanting to tough it out," he says. He also felt guilty making his peers take on his share of those challenging shifts.
In December 2019, Bullock was voluntarily hospitalized for a few days and started writing the article that would later appear in NEJM. In January, a friend and UCSF medical student completed suicide. In March, the same month his NEJM article came out, Bullock attempted suicide again. This time, he quickly recognized that he was making a mistake and called an ambulance. "For me, as far as suicide attempts go, it's the most positive one."
Advocating for Changes in Medical Training
Throughout his medical training, Bullock was always open about his struggles with his peers and with the administration. He shared his suicidal thoughts at a Mental Illness Among Us event during medical school. His story resonated with peers who were surprised that Bullock, who was thriving academically, could be struggling emotionally.
During residency, he led small group discussions and gave lectures at the medical school, including a talk about his attempts to create institutional change at UCSF, such as his public fight against the college's Fitness for Duty (FFD) assessment process. That discussion earned him an Outstanding Lecturer award. Because it was the third award he had received from the medical school, Bullock also automatically earned a lifetime teaching award. When he told his mom, a teacher herself, about the award, she joked: "Are you old enough for 'lifetime' anything?"
Bullock has also spoken out and actively fought against the processes within the medical community that prevent people from coming forward until it is too late. Physicians and trainees often fear that if they seek mental health treatment, they will have to disclose that treatment to a potential employer or licensing board and then be barred from practicing medicine. Because he has been open about his mental health for so long, Bullock feels that he is in a position to push back against these norms. For example, in June he co-authored another article, this time for the Journal of Hospital Medicine (JHM), describing the traumatizing FFD assessment that followed his March 2020 suicide attempt.
In that article, Bullock wrote how no mental health professional served on the UCSF Physician Well Being Committee — comprising physicians and lawyers who evaluate physician impairment or potential physician impairment — that evaluated him. Bullock was referred to an outside psychiatrist. He also describes how he was forced to release all of his psychiatric records and undergo extensive drug testing, despite having no history of substance abuse. To return to work, he had to sign a contract, agreeing to be monitored and to attend a specific kind of therapy.
While steps like these can, in the right circumstances, protect both the public and doctors-in-training in important ways, they can also "be very punitive and isolating for someone going through a mental health crisis," says Meeks. There were also no Black physicians or lawyers on the committee evaluating Bullock, she says. "That was really egregious, when you look back." Meeks is a co-author on Bullock's JHM article and a mentor and previous student disability officer at UCSF.
Bullock raised objections to UCSF administrators about how he felt that the committee was discriminating against him because of his mental illness despite assurances from the director of his program that there have never been any performance or professionalism concerns with him. He says the administrators told him he was the first person to question the FFD process. This isn't surprising, given that all the power in such situations usually lies with the hospital and the administrators, whereas the resident or physician is worried about losing their job and their license, says Meeks.
Bullock contends that he's in a unique position to speak out, considering his stellar academic and work records, openness about his mental illness before a crisis, access to quality mental health care, and extensive personal network among the UCSF administration. "I know that I hold power within my institution; I spoke out because I could," Bullock says. In addition to writing an article about his experience, Bullock shared his story with a task force appointed by the medical staff president to review the Physician Well Being Committee and the overall FFD process. Even before Bullock shared his story with the public, the task force had already been appointed as a result of the increased concern about physician mental health during the ongoing COVID-19 pandemic, Michelle Guy, MD, clinical professor of medicine at UCSF, wrote in an email to Medscape.
Elizabeth Fernandez, a UCSF senior public information representative, declined to comment on Bullock's specific experience as reported in the JHM. "As with every hospital accredited by The Joint Commission, UCSF Medical Center has a Physician Well Being Committee that provides resources for physicians who may need help with chemical dependency or mental illness," Fernandez told Medscape via email.
"Our goal through this program is always, first, to provide the compassion and assistance our physicians need to address the issues they face and continue to pursue their careers. This program is entirely voluntary and is bound by federal and state laws and regulations to protect the confidentiality of its participants, while ensuring that – first and foremost – no one is harmed by the situation, including the participant."
Overcoming Stigma to Change the System
All of the attention — from national media outlets such as Vox to struggling peers and others — is fulfilling, Bullock says. But it can also be overwhelming. "I have definitely been praised as 'Black excellence,' and that definitely has added to the pressure to keep going…to keep pushing at times," he says. Mahoney adds, "He's willing to sacrifice himself in order to make a difference. He would be a sacrificial lamb" for the Black community, the gay community, or any minority community.
Despite these concerns and his past suicide attempts, colleagues feel that Bullock is in a strong place to make decisions. "I trust Justin to put the boundaries up when they are needed and to engage in a way that feels comfortable for him," says Meeks. "He is someone who has incredible self-awareness."
Bullock's history isn't just something he overcame: It's something that makes him a better, more empathetic doctor, says Mahoney. He knows what it's like to be hospitalized, to deal with the frustration of insurance, to navigate the complexity of the healthcare system as a patient, or to be facing a deep internal darkness. He "can genuinely hold that person's hand and say, 'I know what you're going through and we're going to work through this day by day,'" she says. "That is something he can bring that no other physician can bring."
In his advocacy on Twitter, in lectures, and in conversations with UCSF administrators, Bullock is pushing for board licensing questions to be reformed so physicians are no longer penalized for seeking mental health treatment. He would also like residency programs to make it easier and less stigmatizing for trainees to receive accommodations for a disability or mental illness.
"They say one person can't change a system," says Meeks, "but I do think Justin is calling an awful lot of attention to the system and I do think there will be changes because of his advocacy."
If you or someone you know is having thoughts of suicide, call the National Suicide Prevention Lifeline at 1-800-273-8255 (TALK). If it's an emergency, call 9-1-1. Resources for the LGBTQ community and more can be found here: https://www.speakingofsuicide.com/resources/ .
Jillian Mock is a freelance science journalist based in New York City. She writes about healthcare, climate change, and the environment. Her work has appeared in many publications, including the New York Times, Audubon Magazine, and Scientific American.
Lead image: Justin Bullock
Image 1: Justin Bullock
Image 2: Lisa Meeks
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Cite this: Resident Doctor Who Attempted Suicide Three Times Fights for Change - Medscape - Nov 01, 2021.