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Physician Suicide Prevention: The Ethics and Role of the Physician Colleague and the Healing Community

Case History

Dr. Ware is an internist who cares for patients in a large, tertiary care hospital as part of a 12-member group practice.  Weekly “all team” meetings are one of the rare times all 12 of her colleagues are together, along with the team’s social worker and nurse specialist.  Dr. Ware enjoys the educational content, discussions of practice support innovations, and review of cases, but also considers them a way to build camaraderie over patient care responsibilities amid the increasing pressures and complexity of practicing medicine.

Typically, these meetings are rather lively. They include a mixture of catching up on a personal level, followed by addressing important issues related to professional practice and planning.  For example, during the last meeting, the team discussed a new care pathway that included improved discharge instructions and case management resources for avoiding unnecessary hospital readmissions.

Lately, Dr. Ware notices that one of her colleagues, Dr. Cleary, has been less involved than usual in the group’s discussions.  While not usually the most vocal in the group, she seems even more reserved of late.  Dr. Ware’s concerns grow when she realizes Dr. Cleary has missed several meetings, and when she hears through the hospital grapevine that Dr. Cleary had seemed more irritable, down, and angry of late. Admittedly, though, she otherwise interacts with Dr. Cleary infrequently; they tend to work different hours, and don’t often interact socially.

In the back of Dr. Ware’s mind is a traumatizing experience from residency when a fellow resident died by suicide. Although she was not close to the physician she did not have a way to process the event and was deeply affected.  She vowed to be more aware of colleagues who could be showing early warning signs.

Dr. Ware struggles with how to respond. She doesn’t want to overreact, and she hasn’t heard any concerns about Dr. Cleary or her practice.  Should she talk to Dr. Cleary – and if so, what should she say?  Or should she bring it up to other members of their group (e.g., their Director), or perhaps someone outside the hospital altogether?

Commentary

In this case, foundational ethical and professional values and principles can guide Dr. Ware. The American College of Physicians has recently re-emphasized how medicine is a unique moral community, characterized by a commitment to the effacement of self-interest in service to patients, each other, and society.  The medical community and its members’ ethical and professional commitments must inform the response to concern for the well-being of a colleague [1]. The medical community has a responsibility to foster a culture that supports education, screening, and access to mental health care for physicians and physicians-in-training [1].

Within that community, individual physicians have a duty to care for the sick.  This includes identifying and assisting colleagues who may be experiencing mental illness or even suicidal thoughts [1]. Reducing stigmatization of depression, mental illness, and suicide—and the culture of silence—can also create an environment that better acknowledges the grief of those, like Dr. Ware, who struggle to respond to an individual suicide.

Suicide remains a major global health problem. In recent years, there has been increasing recognition of physician suicide [2].   Dr. Ware is right to be concerned about her colleague, bearing in mind the ethical and professional values of respect for autonomy, beneficence, non-maleficence, and justice, as well as those of respecting privacy and confidentiality, having honest and transparent communication, and avoiding harm [3]. These ethical and professional values can guide how physicians, hospitals, health systems, and others should act in preventing and responding to physician suicide.

Assessing Risk

The tension Dr. Ware experiences in deciding whether to act regarding Dr. Cleary and if so, how, perhaps reflects her intuition that determining who is at risk for suicide is a complex phenomenon. In most cases, no single causal factor is determinant.  Physicians experience many of the same major risk factors as other individuals (e.g., depression and substance use). Although limited data suggest an increased risk of suicide among female physicians, and that physicians who die by suicide are less likely to have experienced the death of a friend or family member and more likely to have experienced a work-related problem, generalizing across suicides and attributing causation would be inappropriate [4]. Suicide can occur in the absence of any work-related issues.   It would also be erroneous to assume risk only at the level of the individual physician. Toolkits for preventing suicide emphasize that both risk factors and protective factors exist at the interpersonal, community, and broader societal levels.  This underscores the unique and important role of the medical community and its members in trying to prevent physician suicide [5].

The Interpersonal Psychological Theory (IPT) of suicide, for instance, posits that suicidal ideation arises from three factors: a belief that one is a burden to others, a sense of loneliness, and the acquired capability to actually complete suicide [6]. Today’s time-pressured practice environment may result in less time with patients and less time with each other.

It is critical to clearly differentiate between physician impairment (the inability to care for patients safely and effectively) from the diagnosis and treatment of mental illness [7].  Similarly, today’s focus on “burnout” must acknowledge that burnout and suicidality are not the same; there is at present no causal link between burnout and suicide, which means programs addressing physician well-being could be helpful but are not enough to address suicide fully.

It is an obligation of the community to create a culture that is supportive and responsive.  Importantly, education, screening and access to mental health treatment are essential for reversing longstanding stigmatization of mental health in the medical profession. As shown by suicide prevention programs in other special communities, such as the United States Air Force, leadership commitment is a critical part of building this culture.

Physicians benefit from societal-level programs aimed at suicide prevention and should engage with and support them.  But there is a need to develop evidence regarding programs unique to physicians. Some universities and the American Medical Association have developed programs to help prevent suicide [8-10]. For example, the University of California, Davis Health System, Sacramento, Calif., identified medical staff at risk for depression and suicide using a confidential online survey, referring 11% of respondents for further evaluation or mental health treatment.

Respect, Privacy, and Responding to a Suicide

Dr. Ware remembers clearly a past experience of a death by suicide.  Principles of ethics and professionalism can similarly inform the “postvention” response (i.e., the organized response to a suicide).  A primary goal following a physician suicide, drawing upon obligations of beneficence and respect, is creating a supportive environment for grieving family members, peers, and colleagues.  The principle of respect requires respecting the deceased individual and the privacy and confidentiality of family members and close friends.  Although disclosure of information can help reduce suicide stigma and contribute to knowledge regarding physician suicide, this ethical obligation is bounded by the need to respect the privacy and confidentiality of those involved and protect their well-being in times of grief, recognizing that not all individuals grieve in the same way.

Requests of others to participate in interviews or participate in data collection about a suicide “must be appropriately timed (i.e., in respect to those grieving), avoid placing burdens or pressure on loved ones, and fully respect the choices of those asked, emphasizing voluntariness” [1]. Legally, the Health Insurance Portability and Accountability Act (HIPAA) privacy rule protects individually identifiable health information for 50 years following the date of death; when data collection efforts involve the attempt to create generalizable knowledge, human subjects research protections may also apply.

If information is shared and discussed, how this is done has important implications.  The timing and content of information must be carefully considered; sharing the method of suicide, for instance, is thought to contribute to future suicides (a phenomenon known as suicide “clusters” or “contagion”).  In addition, recognizing the many complex causes of suicide means not communicating information in a way that blames the victim and inadvertently reinforces stigma, hindering suicide prevention efforts.

Dr. Ware’s tragic experience in residency highlights another important aspect of physician suicide. Suicide is the number one cause of death of male residents, and medical students and residents experience depression and suicidality more frequently than other graduate trainees.  Physician suicide sometimes comes to the forefront of people’s minds because of media coverage of suicide in medical trainees [11].

Part of the medical community’s ethical obligation is to ensure efforts at changing culture start at the earliest stages of medical training. Recognizing the unique stressors and environment that medical trainees experience is crucial. There is a need to create not only formal educational programs that promote awareness of mental health but also to make certain that less formalized aspects, such as role modeling by mentors and teachers as well as institutional structures support a positive culture. A toolkit created by experts in graduate medical education, resident distress and wellbeing and endorsed by the American Foundation for Suicide Prevention (AFSP) can help residency/fellowship training programs in the aftermath of a resident death by suicide. The toolkit contains formal procedures, such as a must-have list for proactively developing a suicide prevention response team and daily and weekly checklists for after suicide meetings, debriefings, wellness planning, and more [12].   

Conclusion

Physicians’ obligations to each other require reinvigorating collegiality and community within the profession.  In being sensitive to what Dr. Ware doesn’t know about Dr. Cleary, it could be reasonable to apply the same knowledge and skills she has in approaching patients who may be suicidal and ask simple questions, such as “Sometimes, it can help to talk to someone when times are tough. Do you want to talk?” [1].  

Dr. Ware should not shoulder the entire responsibility of addressing a colleague in distress. While reaching out to the physician is the first option in a stepwise approach, it may be necessary to report a physician whose struggles risk imminent harm to that physician or that physician’s patients [7]. The AFSP-endorsed toolkit advises taking that step: “If you see something say something (speak with the resident, call the PD), e.g., if you notice changes in a resident’s behavior, irritability, etc.”

If, after speaking to Dr. Cleary, Dr. Ware still has concerns, seeking help early may be indicated. In this case, it may very well be acting as part of a healing community.

If you are depressed or contemplating suicide, please reach out to a friend, the National Suicide Prevention Lifeline (1-800-273-TALK (8255) or text HOME to 741741), a therapist, or an employee assistance program. If you are concerned that a colleague is suffering from depression or contemplating suicide, please reach out, ask, listen, and assist the individual in finding help. For international support, find a 24/7 hotline at:  https://www.iasp.info/resources/Crisis_Centres/.

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References

  1. DeCamp M, Levine M, for the American College of Physicians Ethics, Professionalism and Human Rights Committee. Physician suicide prevention and the ethics and role of a healing community: an American College of Physicians Policy Paper. J Gen Intern Med. 2021. Accessed at:  https://doi.org/10.1007/s11606-021-06852-z on 25 August 2021.
  2. Center C, Davis M, Detre T, Ford DE, Hansbrough W, Hendin H, et al. Confronting depression and suicide in physicians: a consensus statement. JAMA. 2003;289:3161–6.
  3. Sulmasy LS, Bledsoe TA, for the American College of Physicians Ethics, Professionalism and Human Rights Committee. American College of Physicians Ethics Manual: Seventh Edition. Ann Intern Med. 2019;170:S1-S32.
  4. Ye GY, Davidson JE, Kim K, Zisook S. Physician death by suicide in the United States: 2012–2016. J Psychiatric Res. 2021;134:158-165.
  5. Gold KJ, Schwenk TL. Physician Suicide—A Personal and Community Tragedy. JAMA Psych. 2020;77:559-560.
  6. Fink-Miller EL. An examination of the interpersonal psychological theory of suicidal behavior in physicians. Suicide Life Threat Behav. 2015;45:488–94.
  7. Candilis PJ, Kim DT, Sulmasy LS, for the American College of Physicians Ethics, Professionalism and Human Rights Committee. Physician impairment and rehabilitation: reintegration into medical practice while ensuring patient safety: a position paper from the American College of Physicians. Ann Intern Med. 2019;170:871-9.
  8. American Medical Association. Physician Suicide and Support. Identify At-Risk Physicians and Facilitate Access to Appropriate Care. Accessed at: https://edhub.ama-assn.org/steps-forward/module/2702599 on 25 August 2021.
  9. Moutier C, Norcross W, Jong P, Norman M, Kirby B, McGuire T, et al. The suicide prevention and depression awareness program at the University of California, San Diego School of Medicine. Acad Med. 2012;87:320–6.
  10. Haskins J, Carson JG, Chang CH, Kirshnit C, Link DP, Navarra L, et al. The suicide prevention, depression awareness, and clinical engagement program for faculty and residents at the University of California, Davis Health System. Acad Psychiatry. 2016;40:23–9.
  11. Sinha P. “Why do doctors commit suicide?” New York Times, 4 September 2014.
  12. After a Suicide: A Toolkit for Physician Residency/Fellowship Programs. American Foundation for Suicide Prevention. 2018. Accessed at: http://www.acgme.org/portals/0/pdfs/13287_afsp_after_suicide_clinician_toolkit_final_2.pdf on 25 August 2021.

Ethics case studies are developed by the American College of Physicians Ethics, Professionalism and Human Rights Committee and the ACP Center for Ethics and Professionalism. The series uses hypothetical examples to elaborate on controversial or subtle aspects of issues in the College's Ethics Manual or other College position statements. The current edition of the ACP Ethics Manual and additional case studies and College policy on ethics, professionalism, and human rights issues are available at https://www.acponline.org/clinical-information/ethics-and-professionalism or by contacting the Center for Ethics and Professionalism at 215/351-2839.