10/10/17. Wounded Healers: Preventing Clinician Suicide. Disclosure. A Story of Loss. I report that I have investments in Aspire Healthcare/

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1 Wounded Healers: Preventing Clinician Suicide W. Clay Jackson, MD, DipTh University of TN Departments of Family Medicine and Disclosure I report that I have investments in Aspire Healthcare/ A Story of Loss Caucasian male in his late 50 s Psychiatrist in practice for 20+ years in a major Texas city Happily married Large, well-established practice Stressed over the last couple of years because of a Texas Medicaid investigation for up charging He disputed it hotly but lost the case Called his secretary from work, told her he planned to kill himself and hung up She called police, raced home, & found him in his study, where he had committed suicide with a handgun 1

2 Condemnation of life is madness that leads to suicide. For Every Day Leo Tolstoy Suicide Trends in America The Economist. February 28, frsc=dg%7cc. Accessed June 25, Are Clinicians, Particularly Physicians, at the Cross Hairs of Suicide Risk? Suicide rates rose by 4% between 2012 and 2013, and the rise was due mainly to one group: men over 30 The Economist. February 28, Accessed June 25, Xierali IM, et al. AAMC Analysis in Brief. 2014;14(9). Accessed June 25, Kaiser Family Foundation Data Accessed June 25,

3 Demographics and Docs Racial Distribution of US Physician Population 62% White 17% Other 11% Asian 5% Hispanic / Latino 5% Black / African American <1% American Indian / Hawaiian / Pacific Islander Number of US Physicians Female 284,828 Male 590,310 Xierali IM, et al. AAMC Analysis in Brief. 2014;14(9). Accessed June 25, Kaiser Family Foundation Data Accessed June 25, A Second Look at Suicide Trends American Foundation for Suicide Prevention. Accessed June 25, The Scope of the Tragedy 400 per year BUT WHY? Greater stress, burnout Social isolation Access to powerful drugs Barriers to getting treatment/stigma Women - Greater role conflict & sexual harassment Wible PL. Physician Suicide 101: Secrets, Lies, and Solutions. Accessed June 25, Shrira I. The occupation with the highest suicide rate. the-occupation-the-highest-suicide-rate. Accessed June 25, Sibert KS. Burnout: the perfect storm of physician stress. August 5, Accessed June 25,

4 A Broken Culture Secrecy & Shame Reductionism vs Holism Professional Distance Suicide Cover-ups Wible PL. Physician Suicide 101: Secrets, Lies, and Solutions Accessed June 25, What is Burnout? loss of enthusiasm for work feelings of cynicism low sense of personal accomplishment 20,000+ Surveys 28 Specialties How Many Are Suffering? 4

5 How Bad Is It? Severity of Burnout: 1 = does not interfere with my life to 7 = so severe that I'm thinking of leaving medicine Maslach Burnout Inventory: US Physicians Reporting ½ of doctors in critical care, emergency medicine, family medicine, and internal medicine met criteria for burnout Shift work Primary care Emotional exhaustion (38%) Depersonalization (29%) Personal accomplishment (12%) Shanafelt T, et al. Arch Intern Med. 2012;172(18): Peckham C. Physician Lifestyle Report What Causes Burnout? Scale: 1 = not at all important to 7 = extremely important 5

6 Burnout Rates by Age: Psychiatrists How Common is Depression among Physicians? One-quarter Canadian practicing MDs (N = 3213) reported 2-week period of depressed mood More common in female physicians, GPs First 2 months 2014 to 2015: 2 NYC intern suicides 740 interns; 13 US hospitals First 3 months of training: Incidence of depression rose from 3.9% to 27.1% Suicidal ideations increased 370% Compton MT, et al. Compr Psychiatry. 2011;52(5): Goldman ML, et al. JAMA Psychiatry. 2015;72(5): Sens S, et al. Arch Gen Psychiatry. 2010;67(6): Reluctance to Seek Treatment Why? Stigma acquired early in professional training Concerns over licensure issues Belief that physicians should be able to avoid depression Schwenk TL, et al. JAMA. 2010;304(11): Schwenk TL, et al. J Clin Psychiatry. 2008;69(4): Hassan TM, et al. Clin Med. 2009;9(4):

7 Strategies for Avoiding Stigma of Mental Illness in Physicians Avoiding treatment Self-treatment Samples CAM (eg, St. John s Wort) Off-the-record treatment (Rx) from a colleague Seeking treatment outside one s own community Adams EF, et al. Int J Soc Psychiatry. 2010;56(4): Shanafelt TD, et al. Arch Surg. 2011;146(1): Schwenk TL, et al. J Clin Psychiatry. 2008;69(4): The problem for doctors is that they receive information but not a true education. Bernie Siegel, MD A Warning Given 2003 consensus statement: low priority to physician mental health despite evidence of untreated mood disorders and an increased burden of suicide... transforming professional attitudes and changing institutional policies to encourage physicians to seek help. and not heeded? Center C, et al. JAMA. 2003;289(23):

8 Risk Factors for Suicidal Ideation among Physicians Patient demands Role conflicts Lack of control over working conditions Degrading experiences (eg, harassment) Conflict with coworkers Lindfors PM, et al. Acta Anaethesiol Scand. 2009;53(8): Fridner A, et al. Gend Med. 2011;8(9): Fridner A, et al. Gend Med. 2009;6(1): Wada K, et al. Int J Behav Med. 2011;18(4): The Impact of Patient Complaints Increases moderate/severe anxiety 15% if recent complaint vs 7.3% without (RR 2.08; CI ) Increases moderate severe depression 17% if recent complaint vs 9.5% without (RR 1.77; CI ) Increases suicidal ideation (RR 2.08; CI ) Deleterious mental health effects worsened with the severity of the complaint Bourne T, et al. BMJ Open. 2015;5(1):e Completed Suicide: Contributing Stressors Not statistical predictors Conflict with current, former intimate partner (OR 1.08; CI ) Problems in another relationship (OR 0.91; CI ) Physical health problem (OR 0.90; CI ) Financial problem (OR 0.81; CI ) Legal problem (OR 0.94; CI ) Suicide of family member in past 5 years (OR 1.83; CI ) Gold KJ, et al. Gen Hosp Psychiatry. 2013;35(1):

9 Completed Suicide: Contributing Stressors Less likely (clinicians are good at managing crises) Crisis in last 2 weeks (OR 0.61; CI ) Death of a friend or family member (OR 0.37; CI ) More likely (clinicians strongly identify with work role) Job problem (OR 3.12; CI ) Gold KJ, et al. Gen Hosp Psychiatry. 2013;35(1): Of Suicide Victims, Physicians Are More likely to be married (61% vs 41%) older (59 vs 47) As likely to have Known mental health disorder (46%) Known depressed mood (41%) Less likely to have Known substance abuse (14% vs 23%) Gold KJ, et al. Gen Hosp Psychiatry. 2013;35(1): Methods of Suicide Physicians Firearms (48%) Poisoning (24%) Blunt trauma (14%) Asphyxiation (13%) Non-physicians Firearms (54%) Asphyxiation (22%) Poisoning (18%) Blunt trauma (6%) Gold KJ, et al. Gen Hosp Psychiatry. 2013;35(1):

10 Grinning and bearing it is not an acceptable coping mechanism. Starla Fitch, MD One Possible Approach: 3-Tiered Solution Prevention Primary Secondary Tertiary Destigmatize MH; Listen and educate compassionately. Annual Physical Exam, MH Screening, Substance Use Screening. Physical Rehabilitation Rehabilitation Structure Physician substance use Physician Flexible (in/ outpatient; part time) Nonblaming, mental health nonshaming Physician Personal physical physician Wible PL. Physician Suicide 101: Secrets, Lies, and Solutions Accessed June 25, health oversight Ways To Avoid Burnout How to Avoid Burnout Identify Areas of Control Cultivate Meaning and Purpose in Life Stay Connected to Others Refresh or Broaden Your Skill Practice Self-care When possible, arrange schedules to reduce pressure Focus on empathy and emotional connection to patients Talk to colleagues about professional Consider a CME rewards and course on resilience challenges Develop a hobby Plan for lunch breaks with colleagues Focus on how your professional activities make a positive difference Seek out supportive and trustworthy friends Seek a mentor or offer to be a mentor Target one lifestyle behavior to improve (eg, exercise) Miller MN, et al. Psychiatric Times Accessed June 25,

11 Connection Matters! Connect with Others! Vision Statement relationships of profound trust, such as those between physicians and patients creative engagement with trusted peers in a safe environment so that patients and clients are increasingly heard, supported and empowered to become healthier and happier. The Power of Giving Back 11

12 Make A Difference! Talk about it Stand up to bullying & abuse Incorporate Baliant groups Engage in nonviolent communication Pamela L. Wible, MD Be a mentor Reach out to a colleague in need Wible PL. Physician Suicide 101: Secrets, Lies, and Solutions Accessed June 25, Although we work in a system that is broken, our work is not broken. Rachel Naomi Remen, MD How to Improve Mental Health among Physicians Improved work satisfaction Reduced emotional exhaustion Lower burnout scores Bovier PA, et al. Eur J Pub Health. 2009;19(6):

13 Practical Take-Aways Despite considerable advances in mental health care, suicide rates remain stubbornly high, and essentially unchanged over the last few years. Clinicians are most likely at heightened risk of suicide Burnout must be openly and actively addressed as it plays a role in the high rates of physician suicide. Actively implement burnout prevention practices (stay connected, practice self-care, cultivate meaning and purpose in life) to minimize the risk The stigma of mental illness is magnified among healthcare professionals, who may underreport mental health challenges. Stressors that threaten the professional role are particularly important in predicting clinician suicide I examined my hope with a magnifying glass and it caught fire. Starla Fitch, MD 13