It's now my pleasure to introduce
Dr. Michael Myers who will be speaking on
Physician Suicide: What you can do to
save a life. Dr. Myers is a professor of
Clinical Psychiatry and the Immediate
Past Vice Chair of Education and the
Director of Training in the Department
of Psychiatry and Behavioral Sciences at
SUNY Downstate in Brooklyn. Dr. Myers is
a specialist in Physician Health and has
served on the advisory board of the
Center for Physician Health of the
Canadian Medical Association. The section
of Physician Health of the Canadian
Psychiatric Association and the
Committee on Physician Health Illness
and Impairment of the American
Psychiatric Association. Dr. Meyers has
produced an educational videotape for medical students,
physicians, and their families called
Physicians Living with Depression and
his videotape When Physicians Die by
Suicide: Reflections of Those They Leave
Behind, won the 1999 APA Psychiatric
Services Award. With no further ado Dr.
Myers. I almost walked into that..
Hi good afternoon everybody. Thanks for staying
around. It's a delight to follow Dr.
Nemiroff
because he's really set this up very
nicely for some of the slides that I'll
be presenting and you'll get a chance to
see those in just a moment.
This is my disclosure slide. I do two to
three lectures a year for this
organization. This year I think it will
be much less, sort of thing, so it's not a
lot. So the learning objectives you have
with you I want to spend just a moment
with these because there's some of you
may have stayed for this talk because
you're kind of concerned about maybe
what we can do better as clinicians when
we look after physicians which is true
that's going to be part of this talk but
also to quote Dr. David Satcher the
former US Surgeon General, "suicide
prevention is everyone's business".
And I don't know about you but there are
many physicians who actually are sort of
were in our midst who were never
patients of ours but who have ended
their lives and some of the some of us
are kind of left to wonder, is there
anything that we might have done as
their friend or as their boss or as
their student or something like that? I'm
going to touch on those things today.
So these so I'm going to set this up by
kind of going over some general things
and then talk about the ways in which we
can actually actually save a life even
if we're not the clinician looking after
a physician. And I want to talk about
some new knowledge and state-of-the-art
things we have and also talk about a
skill set which will be helpful. So in
terms of this slide addressing the need
I wanted to just again spend a little
bit on these bulleted points. That first
point is that this is something that
I've known for a long time that our non
psychiatric medical colleagues are
really anxious to have information from
us and as you know we're living in an
age of burnout. We haven't really talked
about that much today but you know the
ballpark figure is roughly 50% of U.S.
physicians suffer from burnout, it's
probably the same around the world
actually. So but they're interested in
information I'm going to talk about ways
later that we can provide that.
Now the second bullet I want to tell you
about a project that I've been doing and
I've been working on it's ongoing I
started it in January of 2014
and the preliminary data from this study
I've actually put in the form of a book
that was just released yesterday called
Why Physicians Died by Suicide: Lessons
Learned from Their Families, Those Who
Care About Them. It's available on Amazon
and the reason I did this is because
what I've been learning in these
interviews is quite profound. At the
moment I've interviewed approximately 75
individuals and and they and this is
with regard to 45 physicians who have
died by suicide, the people I've been
interviewing are family members of
doctors who have died but I haven't
ended it there I've interviewed friends
and medical colleagues of doctors, nurses
who have worked with them, I've
interviewed training directors who have
lost residents and fellows to suicide,
I've interviewed medical students who
have lost professors to suicide, I've
interviewed psychiatrists and other
mental health professionals who have
lost doctor patients to suicide and
finally I've interviewed patients who
have lost their doctor to suicide so
it's quite a it's quite a diverse base
of individuals it's a quantitative study
I saw a qualitative study and so it's
basically semi-structured interviews
many of these interviews I've done in
person but because some of them are far
away because people I've interviewed are
not just here in this country but also
in Canada the UK and Australia, I've
interviewed them by telephone. So that's
kind of the database where I'm coming
from there's one thing that really
stands out from these grieving people
and that is there's a cohort of
physicians out there who have never
received any care at all, nada, nothing.
They have gone to no one, they've gone to
no primary care physician, they haven't
gone to a counselor or a therapist in
private practice, a non-medical person
they certainly haven't gone through a
psychiatrist, they don't have a primary
care physician and they've gone from wellness
to illness to death without any care and
I was quite shocked about this finding
because we tend to know about the ones
who actually did perhaps knock on our
doors and we looked after them for a
while or somebody else did so they
received some type of treatment and then
died by suicide. But to know that there
are a significant number of doctors out
there who have received no treatment at
all I think is unprecedented because you
know we have a tendency to delay going
to our physicians for help when we
notice things in ourselves but yet my
colleagues who work in urology or in
oncology
yes they'll say that this woman doctor
waited a while to kind of go on
have that breast mass looked at or same
my urology colleagues would say that
about somebody with prostatic CA but yet
they've come but yet to know that there
are physicians who have gone to no one I
think is really quite alarming it's been
actually devastating for their families
and this is part of the driver for this
continuing research that I'm doing
because these families are very bereft
and really wants something to change in
the world of medicine that we that will
make it easier for doctors to actually
go for help the third bullet has to do
with with request for an enhanced
skillset that when you're actually
looking after physicians for I think it
was 21 years I taught a course each year
with my colleague dr. Leah deck stain
called treating medical students and
physicians at the annual meeting va PA
we no longer do that but I'm still doing
some form of this and my colleague and
co-author Glenn Gabbard and I have put
together a workshop for a PA this coming
spring in San Diego and we've called it
critical issues in the treatment of
suicidal physicians because we really
wanted to hone down in some of the
specifics so that's the background to
all of this is dr. Nemiroff mentioned in
these are old data because since I made
this slide the figure is over 44,000
Americans died by suicide in 2014 and
it's continuing to go up over the last
12 years so when it comes to doctors
though the ballpark figures at 3 to 400
physicians die by suicide each year in
the United States we don't have data
from other countries that's a doctor a
day that we lose to suicide there's a
gender difference the suicide rates a
little bit higher for men and medicine
and quite a bit higher for women and
medicine compared to their gender and
it's believed that 85 to 90% of people
who kill themselves of a psychiatric
illness and we feel that that applies to
physicians as well now these these are
some old figures from a publication a
book chapter the dr. Silverman
wrote his a suicide ologist psychiatrist
so those are the most common things that
we see in physicians and then I decided
to update this over the last while and I
put burnout in there because there are
doctors who do die from burnout by
suicide and so I've added some things
that fit nicely with dsm-5 especially
substance medication induced depressive
disorder because of the vast number of
physicians who self-medicate traumatic
stress disorder and I'm glad that dr.
Nemiroff talked about this as well
because we're seeing this much more
commonly in physicians than we ever did
and I think that's partly because we're
looking for it as well and we know what
to look for but it is complicated and
tough to treat as he mentioned other
personality disorders in double
depression complicated ones in the
comorbid conditions I'm sure that many
of you who are not necessarily looking
after physicians the core mitad
comorbidity and so many of your patients
and that exists and we in us as
physicians ourselves from where we come
out so the first ones very common but
anxiety disorder that complements it
complicates progressive medical
disorders and bipolar illness and
personality disorders etc etc and don't
forget that adjustment daughters
adjustment disorders can kill as well
with overwhelming stress okay so
previous history of a depressive episode
I wanted to just run through some of
these things that are considered high
risk in all of our patients but to tell
you though that sometimes it's hard to
get this information from a new
physician who is sitting office at you
and if that individual continues to see
you you may then get sort of more
accurate and authentic data as the
therapeutic alliance builds in the same
way with previous suicide attempts I
think that we mustn't forget that
there's a lot of embarrassment in shame
and guilt that's attached to previous
suicide attempts and it's especially
high in doctors who have attempted
suicide and by the way we do stand out
as a group of individuals who are known
to have a lower incidence of attempted
suicide
I and then and to end up completing
suicide but now that I think about some
of those factors I think it's that we're
probably not getting accurate answers
because it's just not easy to talk about
okay so that may come out down the road
I've seen that so much in my own private
practice the family history of mood
disorders and suicide like I know that
this is kind of suicide elegy 101 but he
gets particularly tricky when you're
looking after a physician who's sitting
opposite you and is kind of scared and
it's not going to be easy for him or her
to talk about this stuff sometimes in
the first visit we know about the other
things lawsuits investigation to medical
licensure and poor treatment adherence
which is very very common and I'm going
to talk more about that because most of
it is rooted in stigma and then
treatment refractory psychiatric illness
I want to tell you with regard to the
ladder it really troubles me at times
the number of physicians who are being
treated by a generalist
in the physician the patient is not
doing well and the the physician patient
has not been referred for a second
opinion and has never been referred to a
psychopharmacologist and I think that's
extremely important that that be done
because you know how difficult many of
your patients can be and it's important
to have that expertise as well and I do
feel that physician patients well what
will welcome that even if they have to
travel 200 mile miles you know to the
nearby treatment center at an academic
center we've been hearing a lot this
afternoon about undiagnosed and
untreated bipolar illness we have to
always keep that in the back of our
minds as well in our unipolar physician
patients and the rapid cycling patients
as well in next mood disorders and
affective states so those are really
important things that can kind of make
our patients ill very quickly our doctor
patients comorbid conditions that I
touched on impulsivity and sometimes
with a good longitudinal history you'll
be able to see that this is a man or a
woman who actually had a lot of
impulsive behavior going way back to
their childhood or if there could be an
untreated and unrecognized attention
deficit disorder as well
in unrecognized emergent psychosis when
I think of some of the physicians who
become dangerously suicidal there's
something going on that is is very scary
in those final hours or days of their
life that is driving them to do
something so precipitous the other the
next bullet is is important as well the
severe sleep deprivation especially in
some training programs that do require a
lot of shift change it's not unusual
that some emergency physicians if
they're closely evaluated by a sleep
disorder specialist and have found
actually to have a primary sleep
disorder and combined with a mood
disorder that they will not be able to
continue to do shift work so that's
where we may become involved in that
regard but it also involves physicians
too who you find are actually quite
stable in their mood disorder and yet
then they make major circadian rhythm
changes as they travel around the world
so to giving talks or things like that
and they report mood slippage that
occurs as well and they have to be
recognized and treated appropriately so
now the last one I'm not sure how many
of you might have heard of this
diagnosis it's kind of an emerging
possibility for a dsm-5 revision and
this comes out of the Vuitton joiner
group I'll have a slide about his work
in just a moment but it's very serious
and I think it warrants more
consideration because of its acuteness
and basically what you see is an
individual becoming dangerously suicidal
within minutes and hours and the
families note this and I think that we
have to pay very close attention to this
it's usually in an agitated state with
severe insomnia and also convictions
which I believe are either overvalued
ideas or bordering on delusions that
they are completely untreatable and
hopeless that sort of thing you can't
reason with them so in why this gets
really important is because there's kind
of a myth out there that because the
person is a physician that maybe you
should be able to reason with them but
any of you who have looked after very
ill physicians will know
that we're no different than anyone else
when we get into that kind of a state
the fact that we know how to kill
ourselves has been long considered a
risk factor for us and this accounts for
higher suicide rates in physicians
although not all doctors who die by
suicide use a medical means to end their
lives but if you ask carefully in your
Mental Status examination of your
patients about suicidal planning you'll
get some if they trust you you'll get
some pretty important answers we do have
access to means and I believe that
medical students actually learn how to
kill themselves pretty early in medical
training and this is where probably many
of you note have noticed that the jokes
that are sometimes told in our emergency
rooms in the presence of medical
students and physicians are no longer
funny this obviously is lack humor but
still existed very scary so medical
students learn about the toxicology and
the availability of certain prescribed
and street drugs that indeed do kill
with regard to stigma I touched on that
earlier and I say this quite strongly
that stigma kills any of you who follow
my blog on psych Congress will know that
I've written many different articles on
stigma in physicians and how it is very
very permit pernicious and again that
came out a lot of my qualitative
interviews with family members of
doctors as well of how much stigma was
sort of causing problems in their loved
one receiving accurate and I think very
good care and then of course don't
forget any of you
those of you in the audience who are
indeed physician slash psychiatrists who
look after other physicians we must
always be mindful of the main many
transference and countertransference
issues that are going on when we treat
our own that's sort of thing and I won't
go into details and perhaps there'll be
some questions about that in the in the
question and answer period
so here's a story from my own practice
my dad never really stuck to the
treatment you provided for him dr.
Meyers he just hated being a patient he
felt so ashamed I tried hard too but
even my support wasn't enough this is
the medical students son of my patient a
psychiatrist who killed himself and he
came up to me and Iraqi I came up to him
because I had met him in a family visit
at the memorial service of my patient
that's an example I think of the stigma
internalized stigma that my psychiatrist
patient was living with and by the way
because you are not an audience of
mental health professionals don't forget
that despite the fact that we work we
were were drawn to mental illness and
psychiatry and in that that we don't
always fully purge ourselves as stigma
though even through our careers we do
this work every day but it's not unusual
for us to have residual internalized
stigma in ourselves and that accounts
for the fact that when and if we fall
ill ourselves we can be extremely hard
on ourselves in terms of the secondary
effects or why sometimes we can be
judgmental of other mental health
professionals who are living with
psychiatric conditions explains a lot
and stigma is extremely important what
about the culture of Medicine we know
what medical school of course it's come
a long ways that's a lot better and
that's why these adjectives that I'd
used here are quite they're quite bold
actually but in the other hand they
haven't quite gone away and that's why I
used things like unforgiving praise
deficient bullying because some trainees
will respond to that that they do feel
bullied I've been appointed the
Ombudsman for our medical school for our
medical students by the former dean so I
investigate all of the complaints that
our medical students have about abusive
behavior toward them in their medical
training so look at the personality
variables as you know we're a very you
know
eclectic group of people who study
medicine but so I just lifted some of
those things which are kind of at one
level nonspecific but in various
constellations though they can really be
contributing factors to desperate
thinking that type of thing to just pick
one of those out there I would choose
probably the first one perfectionism
which we know so much about but it's
very important sometimes any of you who
are doing psychotherapy with physicians
with somebody like this to make sure
that you you help them with what you
what appears to you as excessive
perfectionism because as you know it's a
mixed bag it's perfectionism that gets
within to medical school and into plum
residences but on the other hand it can
be our undoing as well because we just
are too hard on ourselves and that gets
hypertrophied when we're ill so ok this
is a woman I interviewed who wanted to
remain anonymous in the loss of her
brother he was a 33 year old fellow who
had completed his residency and now
moved to another place to do his
fellowship and so this is how she
described him and I'll let you read that
but what I what this is a category that
I put in my book and these are these
superstars in medicine these are the
ones that you least expect would ever
kill themselves I mean for some people
it's shocking that any physician would
kill himself or kill herself but there
are these superstars that we are all
shocked about in their cohort that we
don't know a lot about but that's
basically how she described her brother
who had died who died very precipitously
the only thing is that she felt you
might have sunk into an acute depression
that's the third line from the bottom a
case went badly his judgment was
criticized and there was no support no
safety net for him you know we all look
on a suicidal act of course as being
multifactorial and that's going to come
up in another slide but yet there could
be times actually when maybe not
everybody is
instead of a multi-modal situation that
leads to their suicide and this is a
woman I or I interviewed she's a
physician herself her father was a
physician and she herself has suffered
from depression but she basically is
talking about the culture of medicine
and there are many others out there who
said this that you know we we tend
toward altruism in this sort of thing so
if we put ourselves first and I know
this is put in a rather concrete way it
can seem as if then we're letting our
patients and colleagues down and she
feels strongly and so we make changes in
the culture that we're going to have a
lot of difficulty saving physician lives
and this is one of the approaches of
course that we have to take but somehow
changing the culture of medicine and
you'll get some ideas toward the end of
this talk this is the work of Thomas
joiner who is a psychologist his work is
extremely important and this is a triad
that he describes to precede
burdensomeness okay so we know this and
our patients who are quite depressed
when I see it in my physician patients
it's when they have that sort of sense
of really being a burden on their family
and feel that they're no longer really
serving any sort of a purpose and you
would know that the failed belongingness
really resonates with me those are the
physician patients I've looked after who
in the midst of treatment say don't call
me dr. Smith anymore my name is mr.
Smith so they have removed themselves
from the medical field because they
don't feel that they belong any longer
that because they're no longer working I
have them on extended medical leave that
they're no longer a physician they don't
and that's the unworthiness that that
illa physicians feel and the third one
is extremely important the so called
learned fearlessness that these are
these are patients who really aren't
afraid of death it could be a
philosophical attitude that they have
could be their life stage or they're
just not really very afraid and but it
can heighten their
their risk of a suicide attempt
so dr. joiner goes on and this is from
his book the kind of exposure to pain
and fear that people also might learn
through such experiences as mountain
climbing
well lots of physicians mountain climb
performing surgery a lot of physicians
do surgery fighting in Wars we have a
whole sort of military cohort of
physicians are being afflicted with
anorexia some physicians of eating
disorders so what he's getting at there
are these individuals who maybe been
flirted with that or doctors who also
look after a lot of people with massive
injuries and that he felt he feels that
some of them are actually sort of not so
afraid of death themselves and so he has
particularly singled our surgeons in
this regard and he's got some work going
on it but specifically with trauma
surgeons because of the work that they
do in August of 2014 in New York City
you may have heard of this two interns
died by suicide within four days of each
other and so there was a kind of
universal response among all of our
medical centers in the city and then
very recently afterwards and in the New
York Times what this was this piece by
an intern dr. Sinha which I read and I
was immediately captivated by this
because it was an op-ed piece it was so
timely that he did this and it was
basically really about very basic things
that need to change in our training
programs and the culture of medicine and
he really put it I felt very poignant
lady he was an intern at Yale at the
time and so I stayed up all night to
prepare a letter to the editor which
fortunately was published and that's
just an excerpt from it because I was
very grateful for this young man I
saluted his initiative but I felt that
we need you to go further so this is an
appeal to all of us who are supervisors
and mentors of these young doctors that
we need to set an example because we
don't do that enough that's why I said
we need to share our insecurities
because very often supervisors don't do
that and unmask what I called our
humanity this includes disclosing our
own psychiatric treatment well that sort
of went over like a lead balloon and
then I quote this kind of intimacy and I
use that word very strongly because it
is intimate when an if a supervisor
discloses his or her own struggles with
a psychiatric illness with their
trainees as those people who do with the
general public they make very courageous
decisions I called it intimacy I also
call it call it loving kindness it
creates kind of a loving-kindness type
of treat of a supervisory dyad that
basically the messenger giving is we
care about you in this four four year
program we don't want you to do anything
to harm yourself
that's the kinds of messaging that I'd
like to get out there this slide may be
familiar to some of you and it's it's a
bear meant to built on that's why that
notion we do so much with our people who
we train
certainly the part of the predisposing
and precipitating factors and then
perpetuating factors and protective
factors if you look over to the left of
course you see all the biological
factors that put people at risk and
we've been hearing a lot about that
today
then the predisposing factors those are
the diagnosis and also down at the
bottom of the severe medical
neurological illnesses and then we get
over to the proximal factors as we work
our way right and these are the
dangerous things that can precipitate
then a suicide attempt in our patients
and so that's why we need to really kind
of pay attention to all of these these
as I could say a multifactorial thing
that's coming together that really so
there's a last straw the last straw
could be public humiliation or shame and
that's when for instance a physician
who's in trouble with Medicaid fraud or
having sex with his or her patients or
something then there's sort of a media
release of that and what that does not
just to the physician but to the family
and to the neighbors and things like
that that can be very familiar and
defeat and worsening prognosis and I'm
glad so that when doctor
Nemiroff talked about
treatment-resistant depression and
that's also when our physician patients
give up that they feel they're not
getting better you read you really need
a very hopeful psychiatrist looking
after you or a team that's looking after
you and say look at yes this is tough
but we're going to get through this
that's all the background here's what
you can do to educate your colleagues
okay you can offer to give a Grand
Rounds at your medical center on
physician burnout and depression trust
me if nobody else is doing it locally
please give some thought to this they
really want this kind of information you
can do in services you can write pieces
you can the local CNE planning committee
bring in speakers who will talk about
burnout or talk about the sort of
interface between burnout and
psychiatric disorders and doctors you
may be the best qualified to do that
and is usually a physician wellness
program as well they're springing up all
over the country and beyond so you could
get involved in that you can volunteer
to serve on your state's physician
health program one of the problems with
many of our state physician health
programs and it's that I was in Canada
for many years physician health programs
and our provinces as well is we don't
have enough psychiatric expertise so
that's another error or way that you can
get involved this is all part of my
subtitle what we can do to save a life
in resources that we can put together
that we can educate our colleagues this
is dr. peggy watanabe who is a retired
gynecologist at indiana university she
lost her husband august Gus to suicide I
didn't want other people to go through
what I've been to I know so much more
now since Gus was sick we need to learn
more about this about depression we got
to talk about it more Peggy has felt
she's very committed to this that they
bring in more resources to educate
non-safe at non psychiatrists in
medicine about what what to look for in
our colleagues that could mean if that
individual is slipping into a depression
she's a wonderful woman as a I've
interviewed her two sons
well now getting into the treatment
program what you're looking for of
course is the suspicion I call it
suspicion of suicidal thinking and
planning because it may not come out and
please don't be sort of seduced by
somebody who seems squeaky clean on the
area of suicide elegy that individual
could be just not sharing it with you
yet you've got to do a very artful
that's why I use the word artful because
this is not as you know a checklist and
it's not just a suicide risk assessment
but it's a formulation of your patient
and that's where you will use your
clinical expertise from my medical legal
work that I've been doing in the
aftermath of suicide documentation is
absolutely essential it must be done
very carefully and in a timely manner
ask about stockpiled meds even the ones
that you're prescribing I don't know how
many patients I'd looked after that I
assumed that they were responding to the
SSRI or SNRI or whatever only for them
to come out of the closet six months
down the road that they not once took
one of the pills that I prescribed for
them so they got better but they were
embarrassed to tell me that they had not
taken now fortunately these were not
people who were stockpiling medication
to kill themselves but it's important to
find out whether or not your doctor
patient could be doing that as you know
you can get anything over the Internet
they could be purchasing toxic meds over
the internet and when we hospitalized
and if we have to hospitalized a
physician it's strictly for safety and
if you're not sure get a second opinion
because it can be life-saving but if you
inappropriately certify or hospitalized
a physician say against three wishes you
could turn them off psychiatry for the
rest of their lives so that's why it's
got to be a very careful decision to
make sure that you're not just panicking
and that you're worried about some sort
of medical legal risk when actually this
is really about saving a life I have
found that there are so many physicians
out there with a lot of suicidal
thinking they're really welcome you to
go into that dark place with them and
you feel so much better afterwards when
you do that
and they're glad that you haven't
panicked in forced them into the
hospital because you know we have to
look after a certain number of suicidal
patients on an ambulatory basis anyway
so for them to be able to kind of share
these scary thoughts and plans with
somebody is greatly relieving and it
will also enhance your therapeutic
alliance the last bullet of course is
important that's the close follow-up
after discharge because of the risk of
suicide for anyone who are in those
early days and weeks of discharged from
an inpatient unit now obtaining old
records extremely important and you're
going to get pushback from some doctor
patients they don't want you to do that
you're going to have to find out why and
get those old records because there
could be a ton of stuff about what other
treating professionals have diagnosed
the person with that they haven't told
you about because they just either don't
want to or don't trust you or whatever
that information is extremely important
and the way I do that oh by the way and
the way if the records are no longer
available because of the duration of
time then get the names of that treating
professional and call them if they've
retired you may be out of luck so in
what I use to kind of to push through
the pushback that I get from dr.
patients is I use that old the untitled
canard in medical training that we've
been taught since we were first or
second-year medical students that old
records are absolutely pivotal so that's
why it's extremely important you can use
that on your patients that this is about
you wanting to be extremely thorough in
your assessment in care of this doctor
and that's how they will then give you
consent as I said earlier get second or
third opinions work closely with a
physician health program and don't
forget that we're trained in and we must
apply a biopsychosocial treatment model
with our patients now these are the
words of Dave M Sanders a paleontologist
he lost his wife who was a psychiatrist
and his young daughter Freya to this is
what they call it in the UK extended
suicide where she took her baby's life
in a psychotic depression she was had
bipolar illness and he lost both of them
I interviewed David in the fall when I
was in London and he's working very hard
in the UK with the British Medical
Association and the so called Sikh
doctors program there to kind of get
families involved and you can read this
later when you get more time but he
believed very strongly that we have to
be involving our family members of our
doctors and their cared he calls them
carers unofficial carers we have to
think more about involving family
members split treatment in general is
very common in the United States very
important and again I'm thinking medical
legally that everything be charted in
close communication between you and the
co treater
so if you're the psychiatrist you're
then agree to be treating with
communicating with the therapist or vice
versa if you're the therapist be
communicating with the psychiatrist
who's prescribing especially any changes
that are going on in either one of your
offices with regard to this patient it's
very important and that's really not
only safe treatment but it's also very
important from a standpoint of meeting
the standard of care and again we have
to watch for things that could emerge
and I put substance use disorders there
because I can be a very important
comorbid condition again just to
remember the transference and
countertransference issues don't forget
that actually who you've got obviously
it was a hurting individual who just
happens to be a physician it's very
important that you not change your
standard of care that you would use in
all of your patients who are not
physicians okay it's very very important
because you can be seduced and also
don't forget these very important
suicide specific forms of therapies
they're all based in CBT principles
including DBT but as well as cams
there's a lot of research going on
collaborative assessment and management
of suicidality it works very nicely with
physicians by the way all three of those
do again it's just an alert to the
dangerous symptoms that you could get
your approach has to be kind and
compassionate remember we're colleagues
that sort of thing but you're also going
to have to be firm and parental at times
and that there's a lot of terror and
shame that could lurk behind those
symptomatic behavior can't rely just on
the self-report if there's no suicidal
thinking that does not mean that they're
not at risk you know this that the
majority of patients who die by suicide
have been squeaky clean on the last
suicide risk assessment and recent
research shows that passive suicidal
thinking is no less risky than active
suicidal thinking so that's very
important to know and then the last part
is really basic medicine these are the
words of a physician who I interviewed
for the videotape that was mentioned
when physicians died by suicide he's a
physician himself his brother was a
psychiatrist this is what he said
psychiatrist should double their
compassion but double their skepticism
and what he means is is that we have to
be careful that we may not be getting
the full story Kay Jamison I thought of
her earlier when actually dr. Nemiroff
was talking because of the fact that she
has written so eloquently not just a
better bipolar illness but it but mixed
mood states as well but the last part is
very important about competence because
we don't have those same sorts of things
like they have an oncology or in cardiac
disease and grading things and that's
why it's very important that we really
do all of those things too with a with
regard to our patients that competence
is extremely important so here's how
things are changing there's a lot going
on by the way at the Association of
American Medical Colleges and I'm quite
active with the Accreditation Council of
Graduate Medical Education there have
been two symposia sand those interns
died by suicide there's going to be a
whole new program that's being rolled
out to kind of keep our residents and
fellows safe apps for CBT for
suicidal interns burnout prevention
strategies are being rolled out a lot of
this stuff is emanating from the Mayo
Clinic which is doing the best and the
biggest evidence-based research on
depression in burnout in physicians in
the world and those last three things
are all first-person accounts dr. leslie
dr. Miller and dr. Carroll all going
public with their psychiatric illnesses
now I want to close by telling you about
your another way that you can save lives
is after a doctor dies by suicide
because you may be the only one in the
medical community with expertise and
I've had a lot of experience in being
sort of parachuted into into your
community where doctors died by suicide
and the whole medical community is
grieving and so there's a lot that you
can do there to help them as they get
through this and be prepared for very
raw emotions and there's all a full
range of mourning and medical colleagues
a lot of contagion fears who's going to
be next in this small medical community
a lot of guilt and blame that they feel
that the individual was maybe either you
know asking but we didn't see it that
kind of thing a lot of this is second
guessing after suicide it's not uncommon
that you can reassure them about that
and then anger and rage that the
deceased I've heard absolutely
everything about this that they're angry
at the person for killing himself
because now I have to look after all of
her patients and I'm already have burned
up myself so these are not irrational
but if you create a nice sort of safe
milieu for doctors to talk they will get
at these very primitive and raw emotions
and then the last one of course are the
ones that are using maybe it's
association maybe it's just the
characteristic defenses that we use of
intellectualization that it's like
suicide is just an occupational hazard
when you're a doctor it's the same thing
as people say like shit happens
you know these things it's a way of kind
of shielding themselves I think from the
profound emotions
a colleague dies by suicide so you've
got to be welcoming make sure that you
push confidentiality it's very very
important that people feel is that it's
safe it's like an AAA meeting you know
where they can really say things that
won't go outside this room try not to
judge because this stuff can be pretty
powerful human beings first you were
back to the same thing that we're all
human beings first who just happened to
be physicians very many different stages
of grief and answer questions for them
dr. Gabbard and I have written a lot
about this in the past okay they'll have
a lot of questions for you it's very
important though that you be a group
facilitator okay that you don't just
sort of give them a mini lecture on
physician suicide or something that
won't go over well postvention is
prevention for the next generation so
we're doing a lot when we do something
like that if we take care of ourselves
and accept the painful reality of
physicians suicide we reach out to those
left behind I think we really are making
a difference see historically physician
suicide has been kind of swept under the
carpet we haven't talked about it that
sort of thing we're doing it more now
that's why I wrote that book because I
really wanted it to be front and center
out there some people feel we shouldn't
be talking about this there we're going
to scare our patients we're going to
scare the general public and they won't
want to come to us because they think
doctors are at risk I see it the other
way around
you become a change agent someone who's
a part of the movement to stop doctors
from killing themselves those are the
references they're all listed there and
that's my appreciation slides I mean
it's very seriously I feel very grateful
to these individuals whom I've
interviewed who sort of let me into
their hearts and their homes actually to
talk about a very painful subject
because I feel like their envoy as well
and that sort of in part why I'm here
today is sort of the spokesperson for
them I bear witness actually to their
pain and grief in losing
physician log run in their homes I want
to thank all of you for coming and being
here today
these are insights I hope that you can
take home with you because there may be
colleagues where you work will say you
know what did you do with that
conference in Las Vegas you know what
were some of the things that you learned
about or whatever so that maybe there's
something that you can do back in your
home communities and of course I honor
the positions who what I would call have
had tragically interrupted lives and
they have certainly informed this work
so thank you very much I appreciate your
attention thank you very much I was a
very very good thank you very poignant
talk I do have a lot of questions
particularly regarding some of the
stigma in regarding reporting Raza a lot
of concern about what needs to be
reported what are responsibilities what
legally we may be required to report and
even what we have to self-report on
licensing applications for example last
year have you ever been treated for yeah
ok a good question big question and it's
a universal question there's a lot going
on right now because it isn't working I
mentioned that my involvement with the
ACGME by the way there are reaches is
going way beyond trainees it's going
their liaison with the federation of
state physician health programs and with
the federation of state medical boards
these blanket questions have to change
in some states they actually are in
violation of the Americans with
Disability Act and so these things are
very serious because what could be more
terrifying than have to exploit to
disclose so you know a blanket question
so actually the ideal question and this
has been around for so long and some of
the or I want to believe that most
medical boards have have come on to the
ideal question is supposed to be
something like this in the past year
it's finite in the past year or two
years had you suffered from
any illness that is necessitated your
taking time away from your studies or
from your practice and if so please
explain because see medical birds are
feeling that they have a right to ask
that just in case something could recur
that sort of thing
but you can see that question is still
going to kind of you know it's still
going to have to identify some people
but there's so many others who would be
able to say no to that question so in
but then even if you say yes and that's
got to be done very humanely because
these things are done sometimes so
bureaucratically if people don't realize
you know what a tender subject that is
and we know because sometimes people are
afraid to go for care that lets certify
so that's just one example of some of
the questions it's the same thing with
disability insurance and if we lose
those you know the clauses that that
don't penalize you for having
pre-existing conditions there were going
to be back right where we were seven or
eight or nine years ago so they're all
things that really have we all have to
keep working on sort of at a systemic
level but they are very very real issues
we're human human beings and the final
thing I want to say on this I mentioned
Dave Emerson he sent me a wonderful
piece of what is actually going on with
the national initiative in the UK that
there are many physicians who are
realizing I need to just be more
transparent and they're just they're
just doing that in the next going a long
ways to reduce thing or eradicating the
stigma in the House of Medicine we still
have we still have a ways to go I was
asked to clarify if you could speak a
little bit more on you spoke about
passive suicidal ideation being as
important an indicator and kind of
active sua sterilization and certainly
my understanding is passive suicidal
ideation kind of indicates there's no
real plan or intent right yeah that's
right and so I think why that has been
found to be just as pernicious for
instance if somebody says well yeah I
mean you know if I when I leave your
office today if I get run over by a bus
that would be okay but am I thinking
you're killing myself no
and I don't have a plan this order so
you know if you look at some of the
interviews that I've looked at by for
instance the people who are working with
individual suicides specifically the
following question will be I'm surprised
that you're not having thoughts of
suicide see many of us weren't trained
that way because we felt that's kind of
intrusive but that's kind of provocative
or whatever but again if it's done in a
caring way you're sort of saying given
how ill you felt so the person might say
yeah one of a kind of surprise - I don't
know I just been one of those people who
does and you as we know not all severely
depressed people do have suicidal
thinking so it may actually be true this
individual doesn't but the individual
might be able to say well well it was
sort of but not real eh okay let's let's
kind of go there if you're comfortable
with it obviously you're going to make
them feel more comfortable but it goes
back to the old business of a importance
of just clinical intuition and doing say
if you've done a very careful Mental
Status examination and yet the suicide
part is pristine and yet there's so much
other stuff there that makes you feel
that this person's at high risk well
that's going to be addressed because
that's going to be somebody you're going
to want to hold on to if they're in the
emergency room you will not want to let
them out by the way the one final thing
is that there are a number of physicians
out there now who've gone public
including psychiatrists with their own
history of suicidality and some of them
are in our training programs and they're
very good with our residents because
they just administered look at I lied
like crazy to my psychiatrist when I
attempted suicide I'm so glad I didn't
die of my suicide attempt I finished my
residency and now here I am so when you
hear those kinds of first-hand
first-person accounts it's very humbling
I think it really makes us reflect and
think that it's all about I think
carving out a very kind of
safe mutually respectful relationship so
that the person can say I have felt very
much like that revisiting the issue of
stigma many of us work in more rural
kind of communities or small communities
I think there's a fear that a couple of
people have expressed about getting
treatment going to a clinic running into
your own patients are being hospitalized
and everybody kind of know what you're
you're very intimate history is yes can
you speak to what fictions might be
available for yeah yeah and I think they
vary a lot with the individual and even
with the rural town and and if I could
use just a little bit of humor on this
when I practice in Vancouver for many
years and many of you will know that
it's a large City at the bottom of the
province but it wouldn't be unusual for
me to see in consultation positions from
the rural north that sort of thing but
there was one time actually would I get
in realize it because I always tried to
make sure that any new patients who
might know each other we're not back to
back but what happened was that these
two individuals had actually come from
the very same small town and all had
first appointments with me on a Friday
afternoon one at two o'clock and one at
3 o'clock and they bumped into each
other in the waiting and so there was a
moment of shock like oh my god I mean it
turned out to be fine but at first they
felt extremely exposed with that sort of
thing but it's an example though of at
least going down for an initial
assessment and then some of the
follow-up I would do by telemedicine and
that's what you do need to do I mean we
know that telepsychiatry is going on in
a lot of areas so that's the one thing
the other thing too is that you can also
though get sometimes some very good sort
of psychotherapy from somebody who's
maybe sort of in your community you may
even refer patients to that person but
yet they're not in your kind of medical
circle you're not necessarily running
into them at the hospital or in the
clinic or something so you can get
really good care there as well or if not
thing it's it's the next community so
but those are those are some of the some
of the doable things and especially to
when people are really high profile
that they really want to go to another
medical center and that would happen I
found with some people I would see who
would come to see me in consultation
from say Washington State or from the
next province over Alberta but however
what I found though is that if many of
them began to improve a lot of that
stigma dropped away and they were no
longer so nervous about seeing somebody
locally in their community here and some
of them had even disclosed in the
workplace that they were undergoing
treatment for depression and so it says
something I think about us as well that
if we get feeling better and we feel
grateful for that then we just speak
about it and the person I think to look
at in this regard is dr. kay Jamison
she's a psychologist but she said she
couldn't live with herself anymore she
just felt so fraudulent and so that's
why she had to come out she had to tell
her story that she indeed was diagnosed
with who was living with bipolar illness
she writes about it very eloquently and
she lost some colleagues through that
they felt that she should have done that
most saluted her she's phenomenal as we
know could you speak to the prevalence
and some of the risks about prescribing
for ourselves and a depressants for
example the family members friends in an
effort to help but yeah it's probably
most complicated when we when we
self-medicate and I think what I've seen
in so many physicians are like the easy
call is dr. axe he called and so dr.
Meyers my name is dr. X
I mean feeling kind of depressed lately
I thought it might be depressing so I
put myself on an antidepressant I'm
feeling a lot better now but I don't
want to be one of those doctors who
treats themselves will you take over my
care list ed of course and I meet with
them that sort of stuff so those are the
easy ones when it's more complicated
though it's when doctors then can't tell
whether or not they need to up the
medication or maybe even lower the
medication because they're trying to
sort out side-effects from sort of
untreated symptoms and then they might
decide maybe I should switch to another
drug because the pharmaceutical rep was
just in and it's given me some samples
and this drug I think is cleaner than
the one I'm taking
so they stopped one start another and
that's very hard to do and when I've
looked after doctors like that they feel
so relieved to actually have somebody
sort of looking after them in that
regard so but again that is rooted in
stigma and the groups who do this the
most are primary care doctors and
psychiatrists themselves when I wrote a
piece on my blog as to why psychiatrists
self-medicate I when that was published
I got six phone calls within a week from
psychiatrists who called me looking for
psychiatrists to take over their care so
I mean it's something that I think is
done but yet it's somewhat ego-dystonic
and you know the person really does
indeed want somebody to treat them so
that's when your tutors that when we
treat our family members that's also
setting up all kinds of dynamics which
could exist with I've seen some doctors
do it because they're kind of arrogant
and they think nobody can treat my
family like I can because I'm so good
some though I've seen other doctors who
are actually seduced by their family
members that they don't want to be
treating them but but the Rice's look at
but I'm not going to go for any
treatment that if you don't treatment
and so they're trying to save a life in
their own family and they don't like
doing it but you know family dynamics
can be very very tricky so it is very
complicated but the more of course that
we can you know make sure that it's done
properly the better there's some
questions about some your information
and data on physician suicide if that
extrapolates
to mid-level practitioners and nurse
practitioners and pas you know we don't
know that I was with a group that we did
a program on clinician suicide and I
just did the physician suicide piece
because that's the only one I feel
qualified with in medical students the
other person who did psychologists
nurses clinical social workers found
that there was there's very few days I
think there's some data on psychologists
but they're very few data on other other
group
within the mental health professional
umbrella so you know I just don't think
that we really have those data yes
there's still stigma there but you know
I think again the more that we can kind
of despite stigma in general in the
mental health that's the kind of sad
part that we I think we're afraid that
we're going to be judged you know when
I've looked after psychiatrists who have
lost kids to suicide that's first of all
whole to lose a family member to suicide
to lose a child to suicide then to lose
this in when you're a psychiatrist you
just feel how could this happen
under my watch well you know you're the
parent not necessarily the treating
person but it's so hard and you feel
judged by others like what kind of
psychiatrist has a child who kills
yourself or kills himself I mean this is
we live in a harsh world at times so
it's very hard we all have to be kind of
more forgiving and open judgmental
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