Physician suicide: Searching for answers
■ In a profession dedicated to saving lives, doctors all too often are taking theirs. Physicians look for ways to help troubled colleagues.
Every day for weeks, Michael L. Schmitz, MD, replayed in his mind the final encounters with his friend, searching for clues and asking why.
Was there anything he could have done to prevent pediatric heart surgeon Jonathan Drummond-Webb, MD, from committing suicide the day after Christmas 2004? Why didn't his friend come to him and talk before taking an overdose of painkillers and alcohol? When Dr. Schmitz accidentally broke the hood ornament off the surgeon's Mercedes-Benz while clearing ice from the car, did that trivial incident help nudge Dr. Drummond-Webb over the edge?
Dr. Schmitz asked those questions but doubts he will ever know the answers.
"I couldn't tell that he behaved any differently the week before he killed himself than anytime before. He went into this dark, deep place and I didn't see him go there. It's like somebody's on your team and they take off without telling you anything," said Dr. Schmitz, director of pediatric cardiovascular anesthesiology at Arkansas Children's Hospital, in Little Rock. Dr. Drummond-Webb was chief of pediatric and congenital cardiac surgery at the hospital.
Physician health experts say about 250 U.S. physicians take their lives each year, leaving behind friends, co-workers, patients and families to ponder what led them to such a tragic act. Fellow physicians, nurses and other staff members struggle to cope with the death emotionally, often blaming themselves for not seeing it coming. At the same time, they are juggling the doctor's patient load and trying to come to grips with what happened.
Experts say suicides may be prevented if someone notices changed behavior in a physician and does something about it. If a doctor suspects that a colleague is suicidal, he or she shouldn't ignore the warning signs. They should reach out to that person.
"It isn't good enough for us to look the other way. It's dangerous. We must be our brother's keeper," said Michael Myers, MD, a specialist in physician health and clinical professor of psychiatry at the University of British Columbia in Vancouver.
As early as 1858, doctors in England realized physicians had a higher suicide rate than the general population, according to an article on physician depression and suicide in the June 18, 2003, Journal of the American Medical Association. Since the 1960s, research has confirmed the higher rate, the article said, and depression has been identified as a major risk factor.
Today, male physicians are about 1½ times more likely than nondoctors to commit suicide while female physicians are more than two times more likely to kill themselves than other women, said a review of 25 studies on doctor suicides in the December 2004 American Journal of Psychiatry.
Researchers say it's difficult to determine why physicians have higher suicide rates. There is no evidence linking professional stressors to the elevated rate. But about one in three physicians has no regular source of health care. Also, physicians often fail to identify depression and other health problems in themselves. According to research, those factors can translate to an increased suicide risk.
Whatever the reasons, physician health experts say more should be done to create an atmosphere in which physicians can seek help for depression, substance abuse and other problems without fear of jeopardizing their licenses, hospital privileges or career advancement.
Talking about suicide
In October 2002, the American Foundation for Suicide Prevention gathered 15 experts in Philadelphia to discuss physician depression and suicide. From the two-day workshop came a consensus statement intended to encourage depression treatment and suicide prevention for physicians and to shift professional attitudes and policies to support doctors seeking help. The findings were published in the June 18, 2003, JAMA.
The article said practicing doctors with psychiatric disorders often encounter discrimination in medical licensing, hospital privileges and health insurance. Its authors recommended that doctors establish a regular source of health care and learn to recognize suicidal tendencies in themselves. They also said medical organizations should educate physicians, licensing boards and hospitals about the public health benefits of encouraging doctors to seek aid.
Some doctors say the consensus statement has raised awareness of the problem, and another two-day workshop scheduled for July will gauge progress and make further recommendations.
"We're going to have to change the culture in medicine" to encourage physicians to look for help, said Herbert Hendin, MD, co-author of the JAMA article and medical director of the American Foundation for Suicide Prevention, based in New York City.
Physicians can and should do something if a colleague seems depressed, irritable, withdrawn and less interested in co-workers and patients, experts say.
"It's OK to have a cup of coffee with them, take them aside and say, 'What's wrong with you? You look depressed,' " said Michael Gendel, MD, a Denver psychiatrist and president of the Federation of State Physician Health Programs.
Dr. Myers, the Vancouver physician, said a concerned doctor may offer to go for a walk with the distressed co-worker. He recommends a soft touch and a willing ear to listen to a colleague's problems.
"If you approach individuals in a gentle way, you're less likely to make them defensive. If you really approach with your heart, people are more open to hear from you. That approach does save lives," he said.
Physicians who don't feel comfortable talking to a distraught colleague can get another doctor or friend to open a discussion.
Distressed doctors can also be pointed to a physician health program, which are offered in most states and provide confidentiality.
Coping with tragedy
Carla Fine agrees that it's best to say something to a troubled doctor. She believes that if a colleague had noticed unusual behavior in Fine's husband, Harry Reiss, MD, and told her, maybe Dr. Reiss would be alive today.
Dr. Reiss, a Manhattan urologist, and Fine had been married for 21 years when Dr. Reiss killed himself in 1989. Dr. Reiss was sad over his father's death four months earlier, but he was still functioning well at work.
"He operated on a patient two hours before he died," Fine said.
When Dr. Reiss didn't answer a page from Fine, she went to his solo practice and found him at his office, alone. He had taken a lethal dose of sodium thiopental and heparin.
"I found him on his examining table still hooked up to his IV," she said. "It's like a murder scene where you find the body. The only thing you don't know is the motive, and you never will."
Dr. Reiss left no note.
Initially, his wife was angry with him. She also felt sadness and guilt.
She told the office secretary not to return, and she fielded the calls coming in to the practice. She doesn't remember exactly what she told patients, but she didn't tell them her husband committed suicide.
"At the beginning, I tried to cover it up. I told everyone he had a heart attack. If I couldn't protect him in life, I would protect him in death," she said.
To try to make sense of her husband's death and to help others deal with suicide, Fine wrote the book No Time to Say Goodbye: Surviving the Suicide of a Loved One. She speaks to groups about coping with suicide, and last year with Dr. Myers discussed physician suicide at the International Conference on Physician Health held in Oak Brook, Ill. The conference was sponsored by the American Medical Association and the Canadian Medical Assn.
"I always say to survivors that it gets better. You get beyond the 'what ifs' and 'if onlys,' " she said.
Fine said doctors should comfort the deceased physician's family. Only one of her husband's colleagues called after his death. "Err on the side of reaching out and making contact. All you have to do is say, 'I'm sorry,' " she said.
Filling a void
Physician health experts say doctors, nurses and other staff should talk to each other after a physician commits suicide.
Dr. Myers has gone to workplaces to help co-workers cope with a doctor's death, and he lets people say what they're going through as a way to begin healing. Most experts say patients should be told what happened and be given an opportunity to express their grief, too.
"Usually, the entire medical community is reeling when it's a high-profile doctor," said Dr. Myers, who is co-writing a book with Fine on coping after suicide.
Responding to a handful of physician suicides in recent years, the Monroe County Medical Society in New York in 2003 created a committee to address the matter. The medical society last year held a program on spotting and stopping doctor suicides. The committee's chair said it's healthy for physicians and others to share their feelings after a suicide.
"Otherwise, what happens is it becomes unspeakable, which further increases anxiety about [the suicide]," said John McIntyre, MD, chair of the physician health committee of the Medical Society of the State of New York.
When Dr. Drummond-Webb, the Arkansas surgeon, took his life, Arkansas Children's Hospital sent cardiologists and nurses to deliver the news to patients. "A very interesting thing happened. The patients' families were comforting the staff," said Dr. Schmitz, the friend of Dr. Drummond-Webb.
The hospital assured patients that Dr. Drummond-Webb's two surgeon partners would continue providing care. Dr. Schmitz has taken on administrative duties until a replacement is found for Dr. Drummond-Webb.
Several months after the suicide, Dr. Schmitz's emotions still fluctuate among anger, guilt and sorrow. Mostly, though, he misses his friend.
Occasionally, he thinks about something he wants to run by his buddy. Then he remembers Dr. Drummond-Webb is no longer there.