Occupational Hazard is a series about how different jobs affect workers' mental health.
In the early 2010s, John* showed up at the office of Michael Brog, a psychiatrist in private practice in St. Louis. John was a young physician nearing the end of his residency program and made a powerful first impression. He was brilliant, loved by his patients, committed to helping people, and downright charming.
“Oh, he could turn on the charm,” Brog tells me. “He wanted to impress, and be chummy. He was good at that. He had an absolutely winning smile that could be completely disarming.”
John had a great sense of humor. He loved the humanities, and Brog liked playing mental ping pong with him as they discussed music and literature. “He was able to engage with me around these dimensions of his personality in a way where he kept it fun and friendly,” Brog says. "But he was also keeping a distance from some of the deeper issues and desperation he was carrying, which were difficult to get him to bring into the room.”
There were few times when John was open, vulnerable. Overall, Brog says he held back. John often gave more of an intellectual description of why he was there, an almost-poetic description of inner pain, but without showing emotion.
John had come to therapy for a reason, not just to chat. He struggled with chronic depression, anxiety, and substance use issues. He was put under a physician monitoring program which helped him stay sober, but he resented its rigid requirements: regular drug testing and a 90-day residential treatment. He felt labeled, marked as an impaired physician. Brog says that John, like many doctors, held himself to extremely high standards, and could “hammer himself mercilessly” whenever he fell short of the mark.
"At some point, we ran into a vicious cycle of events that unfolded breathtakingly fast," Brog tells me. "And the result was suicide."
A significant minority of Brog’s patients are physicians—around 20 percent, he estimates. When a doctor enters therapy, they may be different than other patients. Physicians tend to minimize their mental health issues, Brog says. When they seek out psychiatric consultation, they can portray themselves as healthier or more stable than they really are.
Despite that facade, a crisis of physician and medical student mental health is emerging in the US. It’s estimated that 300 to 400 physicians die by suicide each year in this country. The suicide rate for male doctors is 1.4 times higher than the general male population, and among female doctors it's 2.27 times higher. Twenty-eight percent of residents experience a major depressive episode during their training, compared to 7 to 8 percent of similarly aged individuals in the general population.
Doctors who die by suicide are less likely to have been receiving mental health treatment than non-physicians. A recent survey of 2,000 physicians in the United States found that about half of them thought they met criteria for a mental health disorder, but didn’t seek treatment.
Michael Myers, a clinical psychiatrist at SUNY Downstate Medical Center and author of Why Physicians Die by Suicide: Lessons Learned from Their Families and Others Who Cared, tells me that while researching his book, he found about 10 to 15 percent of his sample of doctors who died by suicide had received no medical care at all before they died. They didn’t approach their primary care physician, an internist, a therapist, psychiatrist, clergy member—no one.
“They were well, they got sick, and then died by suicide,” Myers says. “It's unprecedented in other branches of medicine. I've asked my colleagues who are oncologists: ‘Have you ever heard of a doctor dying of cancer without going to an oncologist at least once?’ And they say no.”
Myers lost a roommate in medical school to suicide. He killed himself over Thanksgiving weekend in their first year. “I didn't really deal with it at the time,” he says. “That's kind of the way of it was in those days, you'd bury yourself in your studies; and it was so shocking and stigmatized. That was 1962.” As Meyers emerged into a career in psychology and psychiatry, he began to get referrals of medical students and physicians, and their families. Now he treats only physicians and their families.
You’d think that if a doctor began to feel bad, began to notice symptoms of depression or a mood disorder, that they’d be better equipped to seek help, given their training. “When I started to work in this area of physician suicide, my family, my siblings, my parents—they couldn't wrap their head around that at all,” Myers says. ”If you did recognize that you were ailing as a doctor, you've got a leg up because you might recognize it, you may have connections to get into a physician or a psychiatrist faster, or you've got the money to pay for it, all that sort of stuff.”
But unfortunately it doesn’t work like that. I ask Myers to explain some of these statistics to me: Why are our doctors dying? He says that while there are many factors to any suicide, for doctors, a few stand out, aside from untreated underlying mental health issues.
Doctors have a unique insight into toxicology and anatomy and “the knowledge of how to kill ourselves,” Myers tells me. “Most people don't have that, except say scientists or pharmacists or something like that. We can get access to lethal chemicals through our work. Physicians have lower rates of previous suicide attempts than people in general. When and if they are attempting suicide or planning suicide, they've usually researched it very carefully.”
Physician patients also have an intimate knowledge of the structure of psychiatric assessments. They know what questions will be asked. They know where to draw the line, and how much or little to reveal so as not to set off any alarm bells. “They can be quite skilled at masking their distress when they choose to be,” Brog says. “And I think that's part of what I bumped up against with my own patient.”
Brog says that many physicians fear the stigma of being admitted to a psychiatric hospital, so they might specifically minimize suicidal symptoms that would require hospitalization. They also shy away from psychiatric medication, even if they have no reservations about recommending them to their patients.
“I think physicians want to see themselves as strong and being able to fix things on their own, and not needing too much help,” Brog says.
Doctors are also notoriously busy. Brog tells me it was hard for John to get into therapy as regularly and as intensively as he really needed. “That's the paradox,” Brog says. “Physicians are much better caretakers for other people than they are themselves. And that is part of the culture of medicine, that we get used to prioritizing other people's well-being above and beyond our own, and it creates these sort of traps for people that can become quite dangerous."
After two years of working with Brog, John experienced a substance relapse. It triggered feelings of intense shame, and also worries and fears about how it might impact his professional life and what people would think of him. It was a serious enough relapse that Brog felt John needed to take time off and do some rehabilitation.
“He got in for a session, and we had what I thought was a more serious heart-to-heart conversation than we'd had before,” Brog tells me. “He opened up more about his fears. He showed more emotion. As we were talking, it gave me an opportunity to engage with his deep sense of shame, and affirm for him my own powerful belief in his goodness and his ability to find his way through this. He seemed to emote more than ever before, and I felt like I was getting through to him.”
At some point, it was as if the storm clouds parted, and John lightened considerably, Brog says. Right there in the office, John called the rehab center and arranged to be admitted later that day. “He left looking brighter, with our plan in hand to move forward with his life, and address this, and claim his bright future," he says. "And he walked out the door with that plan in hand. But within a day, he was gone.”
John never showed up at the rehab center, and his parents called Brog to ask if he knew anything. Someone was sent to John’s home to find out how he was, and they found him there, dead.
“After he left, something derailed the plan,” Brog says “I won’t go into the details, but he ended up going home, becoming heavily intoxicated, and dying by suicide. It was the worst telephone call of my life. It was horrifically crushing news. But at the same time, I was so devastated that I hadn't seen it coming. It set off a powerful mix of feelings with me. I of course experienced instantaneous, gut-wrenching heartbreak at the shock of losing this man, this fine physician, so gifted and talented, who had his whole life ahead of him, who was going to help so many people. And he was gone. At the same time, there were feelings of anger and betrayal at him. How could he have done this? Why didn't he reach out, and why didn't he call me? And I had a stinging sense of failure, that I had failed to see it coming, that I had failed to prevent it.”
When Dan Shapiro, a clinical psychologist and Vice Dean at Penn State College of Medicine, took his first faculty job, a doctor who had referred him patients came for therapy himself. Shapiro says this doctor was from a specialty we often stereotype as being cold and uncaring (“I won't say which one, ahem—surgery”) but found that this physician was very open and honest during his treatment. He referred some of his co-workers, and pretty soon almost half of Shapiro’s practice was physicians. "Over more than a decade, I've treated a lot of physicians and noticed some things along the way,” he says.
He says that while all doctors are afraid of being labeled as mentally unfit, there’s a larger issue at hand, one that goes all the way back to the early days of medical training. “The first thing we do, just about, is expose them to a dead body,” he says. “And about two-thirds of them are freaking out when they see it. But if you're there that first day of anatomy and you look around as they meet their cadavers—and we call it 'Meet Your Cadaver Day'— you can only tell that a couple of them are anxious. You know that because they throw up or run out of the room. The rest of them you have no idea if they're anxious and that's an important skill they learn.”
Physicians need to be able to hide their emotions, Shapiro says. It’s comforting to us as patients, and it helps them remain stoic in the face of terminal illness, bodily fluids, and watching people endure painful procedures. But Shapiro says in the process of teaching doctors to deny their emotions, they can also learn to deny themselves.
They become so used to performing that it can be hard for them to see what’s going on, Shapiro says. Patients who aren’t doctors often seek out therapy much earlier, because they can’t tolerate the level of psychological discomfort they’re feeling. “It's deeply painful,” he says. “Being depressed is like having a basketball bounced against your head. Anyone who's had major depression knows that it… well, it eclipses the sun. It is deeply unpleasant. And yet physicians come much later, often only when the system has noticed them. They've yelled at their patients, or they've canceled clinics at the last minute, or, god forbid, they've made a serious mistake.”
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Now as the Vice Dean of a medical school, Shapiro is trying to address physician mental health from another angle: addressing burnout before physicians reach that critical stage. He has a survey he’s created over decades of experience that tries to identify which doctors are struggling and get them help, while also addressing the many other factors of burnout: long hours, isolation, and lack of basic health practices.
He also thinks it’s important for therapists to be aware of how challenging doctor patients may be, and not let themselves be enamored by patients who have done impressive surgeries or studies, work long hours, or—like John—are charismatic and smart.
When Myers trains young therapists and psychiatrists to care for doctors, he stresses that they need to treat them just like any other patient, and to watch for any unconscious biases they might have. Don’t assume that because your patient is a doctor, that they know what’s wrong and will fill you in. Or, don't assume that a doctor will be completely transparent and truthful.
Shapiro says he aggressively asks his doctor patients about substance use. “Two or three times about their drinking, for example,” he says. “And I ask them two or three times about thoughts about hurting themselves. I don't trust them at first because they're used to protecting that stuff.”
Myers tells me that therapists treating doctors need to be careful of their use of medical jargon. “If a patient starts saying, ‘Well I've been having anhedonia,”—now, you know what that means, and they know what it means. But I don't hesitate to say, can you tell me what you mean by that?”
At a deeper level, Brog thinks that clinicians may also identify with their physician patients. “We may want to admire them, the way we admired our own medical teachers,” he says. “We may want to be friends with them as if they were our medical school classmates. There's a variety of reasons that we may fail to completely tune into their desperation, and the desperation that they may be hiding behind this sort of smiling veneer of professional competence. We may too easily fall into a pattern of colluding with them around their own denial. ideally, it shouldn't be different than seeing any other patient. But because of all of these factors sometimes, it can be.”
Losing a patient to suicide is an excruciating experience for any psychiatrist. But when I ask Brog if there’s something more to deal with when that patient is also a doctor, he says when he lost John, it felt like losing one of his own. “You know, their lives are our lives," he says. "Their struggles mirror our struggles. I think their losses are more threatening to our own cohesion because they remind us of our own personal vulnerabilities as physicians, and then we ache not only for them and their families, but we think of the countless patients who have lost a cherished caretaker.”
Brog had to take care of himself after John's death. He re-entered treatment himself, connected with John's parents, with whom he still has a relationship, and made sure he was honest with himself about any anguish he was feeling.
Today, he still sees physicians. He finds himself more suspicious of whether they have suicidal thoughts or intentions, though he’s trying not to let his past experiences overwhelm the present. Mostly, he tries to educate his doctor patients of their risk.
“From the first meeting, I let them know that this is just a potential hazard of the profession they've chosen," he says. "They're going to be more susceptible to depression, they're at higher risk for suicide, and that we just from the beginning need to recognize: that this is always something that together as a team, we need to keep a watchful eye out for.”
*Name has been changed.
If you or a loved one are in need of help, call the National Suicide Prevention Lifeline at 1-800-273-8255. In Canada, visit suicideprevention.ca for more information on how to get help.
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