be reluctant to seek
attempt to diagnose and
seek and receive “VIP
treatment” from other health care providers.
No reasons have been found for the difference in
suicide rates among male and female physicians. A
heightened rate of suicide is found early as in
The various stressor factors
commonly associated with depression have been
studied and no solid evidence of any of these
factors have been found to precipitate
The one issue that stands-out regarding suicides
among physicians is that physicians are much more
apt to succeed at it because of their medical
knowledge… and are
good at it.
A newer focus on diagnosis and treatment of
depression and risk of suicide seems to be aimed at
medical students. Medical students are intimately
interactive with large numbers of physicians during
their training and their mental state can be
much more quickly recognizable by experienced
Help can be offered before students become fixed
in their personal protective camouflage patterns
hiding their mental state up to the time of their
The belief and attitude that physicians can’t
practice great medicine when they are depressed,
under treatment, and followed by knowledgeable
psychiatrists is unfounded.
The test of your
personal feelings about that can easily be
determined by asking yourself, “Would you be
comfortable with referring a patient of yours to
that doctor under these circumstances?”
You might be surprised about how many physicians
around you are receiving psychiatric help and you
will never know it. Depressed physicians rarely
confide with their medical peers about
their depression even when they recognize it is
The professional obligation you have is to pay
close attention to the common signs and symptoms of
acute mental stress and depression in the physicians
you associate with… then offer to help them somehow.
One of the more recent and outstanding articles
published by Robert Bright, MD and Lois Krahn, MD
from the Mayo Clinic Psychology and Psychiatry
departments in 2011 on the topic of physician
depression deserves special attention (Current
Psychiatry, Vol. 10, No 04, April 2011).
are the predictors of depression in physicians?
Symptoms of depression vary so much that we have
to depend on the predictors of depression.
Predictors are the things that are understood to be
overly stressful to most people when they happen.
Most of the predictors are present to some degree in
every physician during their medical school and
medical practice years.
During the less stressful time between episodes
of severe stress our mind has time to recover from
the poison that comes with severe stress.
severe stress is continuous, either because of the
weakness of the doctor’s mental defense mechanisms
to compensate for or because of the kind of
stressors that rarely subside… like marriage
conflicts, the depth of the
about how these predictors have affected you...
relationships with senior
doctors, staff, and/or patients
2. Lack of sleep on a regular basis
3. Dealing with death of loved ones
4. Making mistakes either in
treatments or surgical procedures
5. Loneliness, so common among
6. 24-hour responsibility… such as
7. Self-criticism… perfectionist as
8. Peer-Pressure and criticism both
overtly and covertly
Better yet, manifestations of mental illness that
goes beyond what a physician can hide or can find
ways to compensate for...
ongoing irritability and
sudden bursts of rage
followed by remorse
2. Marked vacillations in energy,
confidence, and productivity
3. Erratic behavior at the office or
(such as... performing
rounds at 3 am or not showing
up until noon)
4. Inappropriate boundaries with
staff, or peers
5. Isolation and withdrawal
6. Increased errors in or inattention
work and patient calls
7. Personality change, mood swings
8. Impulsivity or irrationality in
decision-making or action
9. Inappropriate dress, change in
10. Sexually inappropriate comments
11. Diminished or heightened need
12. Frequent changes in job focus
13. Inconsistency in performance,|
As you know, many of these manifestations can
result from causes other than depression and can be
temporary in nature. Persistency is the tip-off to
more serious conditions.
No one is immune to depression!
Regardless of your level of intelligence, tolerance
to stressors, and your power of your self-discipline
every medical practice professional is susceptible
to depression and the consequences
A longitudinal study of medical
residents at the University of California, San
Francisco revealed how much of an increase in the
depression rate is caused while in medical training
and education modes…
A study of 123 pediatric
residents at three
U.S. children’s hospitals by
Fahrenkopf et al revealed that 20% of them were
depressed. Follow-up was even more of a concern
because these depressed residents made 6.2 times
more medication errors than did their non-depressed
Some personality traits can be your enemy...
Lifetime prevalence of depression among physicians
is 13% in men and 20% in women… which are comparable
to the general population.
Even though a Firth-Cozens study
of primary care
doctors revealed many factors that increase the risk
of depression (see the lists above), a Vaillant et
It showed that they did not significantly
increase suicide risk in physicians… at least not in
those medical students who did not have underlying
psychological difficulties when they entered medical
The greatest personality trait
to stimulate depression are self-criticism
and perfectionism. These two personality
traits that most doctors have are silent avengers
that work inside the minds
From a distance, no signs can be seen of such violent turmoil
of self-intimidation and guilt feelings, but when
these progress into feelings of hopelessness and
worthlessness you know that thoughts about
suicide and deeper depression are not far behind.
When observing a colleague’s response to a
severe and known
traumatic stress situation they have recently gone
through, most physicians who care about the welfare
of their peers will notice such
as quick temper, declining performance, lack of
focus, intolerance of perceived incompetence, and
conflicts in relationships, even turning to drug or
alcohol use and isolation are a few.
increases the risk of suicide?
risk of suicide in physicians compared with the
general population is between 1.1 and 3.4 for men
and 2.5 to 5.7 for women, according to a review of
14 studies about
A survey of 4,500 women physicians
female doctors are less likely to attempt suicide
than the general female population. Their attempts,
however, are more often lethal, logically because
they have greater knowledge of toxicology, access to
lethal drugs, and much better knowledge about how to
Suicide-risk comparisons among the various
is it that pushes a physician over the edge?
General consensus agrees that nearly all physicians
are candidates for suicide if the right
circumstances exist. This hits home when a
depressed physician finally comes to a mental
decision for suicide based on lack of reality and
The Silverman study created a profile of a
for suicide, including the following…
white male age 50 or female age 45
divorced, or currently experiencing marital
problems and already depressed
abuse and history of high-risking ventures
pain or illness
changes in occupational or financial status
losses and diminished autonomy… disability
to lethal means (firearms, medications)
Protective factors that lower the risk of
actual suicide include effective treatment, social
and family support, resilience and coping skills,
religious faith, and restricted access to lethal
Behavioral studies have demonstrated that
decisions between suicide and murder have closely
related emotional factors that come-up suddenly as a
result of circumstances present at the time.
It’s why there are laws that require a short
period of incarceration for psychiatric evaluation
when a lethal weapon is involved and the person is
"talked-out" of suicide. This factor is validated by
hundreds of murderers who kill people, followed
shortly by suicide.
Barriers against getting help...
Physicians fear exposing their mental weaknesses
because of social stigma, trusting a local
psychiatrist, confidentiality, and recrimination by
colleagues and especially the licensing boards.
The Givens and Tjia study showed that only 22%
of medical students screened positive for depression
sought help. And only 42% of medical students with
thoughts about suicide tactics received treatment.
Basically, medical students had similar fears to
With the subjective and often threatening
actions of medical licensing boards, most physicians
intentionally avoid any action that might lead to a
medical board action
especially true when a physician’s disturbing
actions in the hospital forces “restriction” of
hospital privileges and they are by law forced to
report that action to the medical board… hence,
“probation” time is substituted which is not
So when you are assisting another surgeon and he
or she suddenly blows-up into an unprofessional
barrage of expletives not fit for human ears, you
have a professional and ethical obligation to try
and ease that physician’s pain that you know is
underneath it all.
And it will happen more frequently over time if
nothing is said to that doctor and no help is
Remember to walk a mile in that physician’s
shoes. Put yourself in his position as it can happen
to you sometime. You may need a reciprocal helper to
avoid bad results.
As you probably know, avoiding
any restrictive actions by the medical staff leaders
keeps the entire situation away from medical boards
and inside the hospital arena. Many physicians in
such a circumstance that requires local action
choose to accept a period of
It’s a smart move.
The lack of
distinction between a psychiatric diagnosis and
impairment stigmatizes physicians and impedes
Medical boards function like the crowd at bull
matador is gored by the bull the crowd cheers. When
the bull is killed or defeated, the crowd cheers.
Medical boards are
not responsible to
who come before the board for violations. They are
responsible to the state Governor who appointed them
to the medical board, in a high position of
It’s true, no matter how many physicians are
board members. Board members are satisfied with
their actions whether you are punished or exonerated
completely, like the crowds at a bull fighting
Americans with Disabilities Act (ADA) is forcing
bodies, clinics, and hospitals to make similar
queries to pursue mental health histories of
applicants for medical licensure.
credentialing bodies, the same investigations are
being pushed to sort out physicians with mental
disorders that might be dangerous to their patients.
study reported a successful appeal to the Arkansas
State Medical Board to revise its licensure
questions related to psychiatric impairment
following a cluster of medical student and physician
When the questions asked by the board are too
specific about one’s psychiatric history, and the
applicant is denied licensure because of truth
telling, it increases
So they loosened
up the questioning enough that applicants don’t need
to lie about their psychiatric history.
medical board decisions are made by assigned board
members that are not all physicians. Consider that
board decisions are made subjectively by all
members. Their voting is influenced by their moods,
attitudes, and opinions at that time.
I witnessed a complete change in a medical
boards favorable decision to that of a unfavorable
decision when only one physician board member who
disagreed, stood up and proceeded to attack the
defending physician with biased opinions, personal
insinuations, and remote possibilities of problems
stemming from the background of the defendant
The rant completely changed the favorable
vote of every other member of that board
to an opposing vote in 3 minutes.
The "set-up" for that to happen, is something every
practicing physician should know about. Board
members are from all different medical specialties.
When, for example, an OBG
board member doctor brutally whiplashes
the defending OBG physician, the other members of
the board hearing the rant have no credible
knowledge in OBG to refute the other board member's
opinion, insinuations, and personal biases.
causes all members of the board being forced
ethically and morally to go along with the "bitchin"
The common sense and fair option in regard to this
situation is for the board president to delay the
board's decision, order a personal OBG doctor
interview and review of the defendant physician's
The board president has the power to do
this, however, in the uncomfortable and conflicting
circumstances present they rarely think to do
this process. A personal attorney for the
defendant doctor would see that this is done and
save the physician a good deal
It makes one wonder how many other medical board
decisions like this occurs in the U.S. annually. No
wonder practicing physicians have great fear of
being in front
of their state medical
board, especially those with treatable psychiatric
The unchained power of a board member to destroy a
doctor's career and life forever continues to be an
egregious element of every medical board's
vulnerability... and no doubt continues to be a
credibility issue of all medical boards.
Is it any
wonder that physicians fear medical boards and their
unpredictable decisions and outcomes? I have advised
any doctor who has been summoned before the medical
board for any simple or complex infraction to always
have an attorney
Acknowledgement of the psychiatric history and
treatment by the applicant does require a deeper
investigation of the problem… probably requiring
psychological and psychiatric consultations. At
least that is a much more realistic means to weed
Changing psychiatric diagnostic terms and
definitions creates more confusion. The difference
between a diagnosis of depression and bipolar II
diagnoses is the difference to an applicant of being
board-reportable and non-reportable.
The thrust of
it is to persuade medical boards to use screening
questions to ensure
that they are seeking information about degree of
not simply the presence of a medical disorder.
problem with physicians treating physicians...
It’s called the “VIP” treatment which can end
up being a friendship courtesy action taken rather
than a clinical relationship action. The treating
psychiatrist or psychologist has a strong tendency
towards under-diagnosing the seriousness of the
problem to avoid hospitalization of the doctor and
attached to it.
In doing so, there’s an increased risk of suicide in a
faces an imminent risk of self-harm and should have
been hospitalized for treatment instead. The
suicidal ideation can easily be covered up by a
physician-patient by saying the right things to
throw off the questioner.
What do we physicians do when we recognize that
other doctors are depressed?
And what has this article to do with
the topic of medical practice business and
Are there any more good Samaritans left in our
profession? Since state laws having to do with being
a good Samaritan and the increased risk of lawsuits
against doctors who stop at auto accidents to help
the injured have changed the face of physician
samaritanism, do you continue to stop to help the
auto accidents? It is a risk for medical malpractice
Just keeping up with each state’s Samaritan laws
is a difficult process in itself. They are all
different. Violations of the law are so variable
from state to state it requires that you have a
printed out copy of the state laws in your car as
you travel across those states on your vacation
I discovered that the risk of a lawsuit for
doctors who stop at accidents to assist is more of a
risk than I’m willing to take.
I say that because of my experience as a flight
surgeon and flew on over 80 medevac missions in
Vietnam where medical supplies and drugs were
Discovery that a Navy Corpsman
trained for six months could do everything that I
was able to do on a helicopter medevac mission meant
that the same circumstances are present at roadside
accidents where most people are smart enough to do
all that a
can do to help, until the ambulance and EMT team
arrives at the scene.
I connect these issues with the fact that most
physicians who experience or witness an obvious
unprofessional happening by another doctor do not
want to get involved, walk away, keep silent, and
figure he or she will do it again in front of others
and one of them will say and do something about it.
One day I happened to become one of those irate
physicians during a difficult abdominal surgery
case. It shouldn’t have happened but at the time I
felt there was no other choice.
assistant was a credentialed surgical assistant male
nurse that I had operated with many other times
previously. And I had been repeatedly irritated by
his previous inattention to the surgical procedure
while continuously talking, primarily to the
This patient had extensive adhesions which were
attached to the iliac vein and artery. Retractors
and their placement were critical to visualizing the
I purposely voiced my difficulty doing
the process on several occasions, thinking that the
assistant would respond appropriately by holding the
retractors exactly where I placed them to see what I
I even waited for the anesthesiologist to sense
my distress and stop communicating with the surgical
assistant, egging him on.
I would place the retractor in the
perfect spot and within about one minute the
assistant let it slip out of place and occlude my
vision and dissection. After the fourth time, I blew
up at the assistant and proceeded to dress him down
verbally for his poor assisting activities.
inattention to a difficult surgery situation was
intolerable and later I refused to have him assist
me in the future.
Of course, his arrogance pushed him to deny
everything I accused him of. Since I had never done
anything like this previously, it shocked everybody
in the operating room, silence followed.
They saw a
side of my personality they hadn’t seen before, and
it must have scared them all. I was near the end of
the procedure so I elected not to demand a new
assistant. The assistant continued to talk, but only
intermittently after that until I closed
It’s obvious that this assistant irritated other
surgeons because of his antics, but nothing was ever
done about it.
I need to connect all the above issues now to
describe what may often result from a physician’s
behavior patterns, good and bad.
It’s about how much
your behavior influences your medical practice
business income and your reputation among your
colleagues… and your whole medical career. It all
fits into the categories of marketing called public
relations, promotion, and customer services.
First, the positive effects of your actions...
reaction to a peer’s mental problems or suicidal thoughts…
Perhaps your experiences in the medical
profession may be quite different than mine. After
my medical practice experiences in the military for
5 years, HMO Kaiser Permanente for 3 years,
hospitalist for 5 years, and private medical
practice in OBG for almost 20 years, I write about
what I have seen throughout my practice of medicine.
If you are aware of another doctor’s mental
problems and make no effort to help them at a time
when their deviations from normal behavior become
obvious, you will place yourself with the 95% of
physicians who do the same.
If you try to help that doctor when their
problems are recognizable, you confirm the great
compassion and empathy you have
doctor you helped, even if it was simply to point
out to them their own symptoms that they may not
recognize as abnormal were abnormal, will always be
remembered by that distressed doctor.
This is especially true when they have not asked
you for help them self. When they get better, they
will repay you somehow due to a law of attraction
Other people who know about
the help you gave puts you in a position of being in
“more demand” and more highly respected in the
It also demonstrates that you also have the same
compassion for your patients… another valuable
attribute that draws
Saving the life of another physician is no
different from saving the life of a patient. It
certainly is a badge of honor to be responsible for
such an action. Sometimes we do far more for others
that no one knows about, but you know the pleasure
you feel from it.
The ongoing debate about how to prevent
physician suicide continues with no answers.
One thing is true; physicians who are trained to
recognize the early and common behavior of those
who are most susceptible to suicide are the ones
that will have the best opportunity to make
the greatest impact on prevention of the suicide.
A word or sentence of support and comfort spoken at
the right time can create miracles to happen.
You aren’t obligated to perform ongoing
psychological counseling. But a few gentle words
expressing concern about for their welfare is key to
moving them on to the professional counseling level.
The importance of lessons we learn from experience…
If you weren’t reminded about the behaviors of
physicians heading for career or life mental
problems, how would you know what to look for in
your own patients as well?
Suicide results from a graduated sequence of
increasingly strong emotions and feelings. First, we
are irritated by something that is usually forgotten
soon after. The persistence of the same irritation
moves you to anger about it.
We as physicians often repress our anger, we’re
professionals! Ongoing repressed anger over time
moves on to significant frustration, as you know.
Persistent frustration that is not dissipated by
some form of release or distraction moves on to
depression, usually because of the belief that
nothing will change, help is not possible,
Bipolar depression is the early and treatable
mental problem. Doctors tend to do anything to avoid
this problem and to avoid the stigma and effects of
being considered impaired, losing referrals, assumed
to be unreliable and unpredictable.
Severe depression pushes the physician to react to
their intolerable behavior, otherwise they may have
to quit medical practice or be forced to stop
practice. When forced to make decisions while under
distress, the decisions are made emotionally, not
Emotional decisions are made without
consideration of future consequences. Suicide
decisions are commonly made instantly and at an
instant when all hope of recuperation seems
The decision is often forced on them by a single
triggering occurrence that pushes them over the
edge, is all they can tolerate. They feel that they
have to get rid of the “pain” at any cost right
then. Nothing else matters to them.
2. Second, the negative business
effects resulting from a doctor's pre-suicidal actions and
You lose patients when you fail to treat them well.
There goes money down the tubes. Temper, bad moods,
and lashing out will also cause office staff
The dominant reason that patients quit a medical
practice is because of the bad way they are treated.
your reputation includes a
confrontational attitude you will
lose all referrals.
Because patients are your single
of income in
most cases, any personal issues
have that bothers your
patients will come home to
Your demeanor, dress, and words
can cause far
more harm to your
medical practice business than
minor mistakes you make in
treatment of patients.
Most physicians will look at this article and
wonder why I wrote it. Suicide among physicians is
not a well tolerated topic of conversation anywhere.
But, you have to admit that when it happens it is
always a tragedy for everyone around that doctor.
If this conversation stirs up at least one physician to
save another from suicide, it’s worth the time it
took to write it. I had no idea about how many
physicians commit suicide annually, my guess would
have been maybe 50… not 400.
That amounts to a whole medical school full of
medical students and doctors. Considering that about
19,000 medical students graduate medical school each
year, we lose 4,000 doctors each decade in our
country that could be prevented.
Further, figuring that each medical doctor averages
about 5,000 patients in their practice over time,
then the 400 doctors lost to the profession would
never get to treat about 2 million patients in their
careers that other doctors will have to treat.
No matter how you look at this issue, suicide
of physicians is a huge tragedy that affects many
more people than just relatives, family, and