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“Don’t Let This Darkness Fool You. All Lights Turned Off Can Be Turned On”

LEXINGTON Singer-songwriter Noah Kahan penned the above line about his struggle with mental illness. The line encapsulates what mental health practitioners and fellow physicians would like to impart to our colleagues struggling with what has been called a silent pandemic—the loss of physicians to suicide. It is important that this is not forwarded as a platitude or a false reassurance that all will be well, but rather as a call to action and improvement in awareness. As a health care system, we have been faced with barriers over the last four years that were largely unprecedented in our current workforce.

The strain on an already struggling system has shed light on failures that have been present for far longer than the strain of COVID19. The impact of the increased burden and stress is still being felt and will be felt for decades to come. The answers to the rebuilding of the medical systems are far too vast to touch on here, but one very important issue that needs to be discussed is physician suicide.

Dr. Lorna Breen was an emergency physician who toiled on the front lines of the pandemic. She died by suicide in 2020. Her family has worked to advocate and bring awareness to suicide in physicians, and in March 2022, the Dr. Lorna Breen Health Care Provider Protection Act was signed into federal law. This piece of legislation provides a framework and funding for implementing measures aimed at addressing and educating about mental health care and suicide in healthcare professionals.

The higher risk of suicide faced by physicians was first described in 1858, so this is not a novel situation. It is widely reported that there are about 300-400 deaths of physicians by suicide each year, and that physicians are about two times more likely to die by suicide than the general population. It has been hypothesized that these numbers may surge in the post-COVID era, but that data is not fully available.

There are many risk factors that are known contributors to suicide in physicians, including depression, anxiety, and substance use disorders. A study published in 2020 by JAMA Surgery highlighted some other factors, including a slightly older age at the time of suicide than the general population — though there also appears to be a bimodal distribution with the second increase being during the time of training and early career, being of Asian or Pacific Islander ancestry, or having health problems, job stressors, and civil legal problems. These additional factors, some of which appear to be specific to physician cohorts, can be areas in which further research could help elucidate ways to intervene.

Ending the Stigma

Other information that highlights physicians’ personality types, as high achieving or Type A personalities are potentially at higher risk of suicide. Often physicians are held to superhuman standards by their colleagues, patients, and society. Physicians are human, and we suffer from mental illness, including depression, anxiety, and substance use disorder, all of which predispose individuals to death by suicide.

An additional burden cast upon our profession is the fear of getting treatment — licensing boards, which vary state to state, ask us about psychiatric treatment every year when we renew our licenses. The Kentucky licensure asks broadly if you have an illness that would keep you from practicing medicine — which is in line with the Federation of State Medical Boards, the governing body that makes recommendations about state licensing boards. As part of an immediate action by the Dr. Lorna Breen Act, the licensing boards were required to uphold the recommendations of the FSMB, which included attempts to decrease stigma and encourage physicians to seek help by removing barriers, one of which is fear of disclosure to licensing boards. Kentucky was already following the guidelines, but there are many states that were not. In Kentucky, Senate Bill 12 was passed in 2022 as well. It also encourages physicians to seek care, while ensuring confidentiality Like so many of the readers of this publication, I have been there for my patients the day after I received a cancer diagnosis, and when I realized I had to have radiation treatment, my first concern was, “Can I work?” This left me to ponder, what if my diagnosis was not physical? What if I or any of my colleagues had to miss work to receive treatment for depression or another mental illness? Should our licensing boards handle mental illnesses differently than physical ailments, or should this decision be left between the physician and their care providers?

In my career, I have grown to understand the resilience and humanity that is inspired by suffering in one’s own life, whether that be of a physical, psychiatric, or spiritual nature. I do not support the different treatment of psychiatric illnesses when it comes to decisions of licensure. Luckily, our licensing board is attempting to remove barriers to care of mental illnesses in physicians by attempting to remove stigmatizing language in board renewal processes.

Advocating for Each Other

Nearly every month, I hear of the loss of another physician by suicide. Each one of these individuals bears testimony to the struggle that is being a physician in the current times. Each deserves the quiet contemplation of how to make things better and then the advocacy that should follow. The last moments of our colleagues’ lives are harrowing, no doubt, as we physicians die with guns to our heads, pills in our mouths, or a myriad of different ways, all aimed at ending pain. We indeed are human. With these lives pass knowledge built over years and thousands of hours of study as well as the essence of the person who acquired all that knowledge and accomplished all of what a career in medicine entails — even one that has been cut short.

At the end of the day, we are not defined by our accomplishments, but speaking for myself and likely a lot of readers, it absolutely can feel that way. Our training contributes to our belief that we are only as good as our last success, and we all know the flip side of that coin.

We need to advocate for the ability to take time to go to medical appointments, to be able to seek help without fear of losing licensure or our jobs. We are making strides, but so much more needs to be done. Collectively, we need to be a part of this change — part of that is working on our own stigma about receiving mental health care, and part of that is working with health care agencies to make sure that when we need support, that support is in place and easily accessible. We need to speak the names of our colleagues that have died by suicide and advocate for current and future physicians for improved access to care unfettered by fear to utilize the very same lifesaving treatments we recommend to our patients.

I hope this piece will serve to increase awareness and to encourage us all to work on decreasing stigma. Please keep on hand these numbers, which are some important resources to individuals struggling.