Addressing the challenge of suicide among physicians and physicians-in-training

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Death by suicide is relatively rare among physicians in the United States,2,3 yet suicidal thoughts are commonly reported by physicians and physicians-in-training,4,5 and suicide is the leading cause of death for residents and fellows.6 Women physicians, unexpectedly, appear to be at greater risk for suicide compared with women in the general population and in other populations of workers.2,7 And despite immense efforts to address well-being across health systems and academic medicine, the phenomenon of suicide among physicians and physicians-in-training remains understudied and poorly understood.2,8 In this issue of Academic Medicine, 2 research reports9,10 and a commentary11 contribute to the literature on suicidality in medicine and medical training. Fischer et al9 examined data from a large U.S. physician workforce survey (n = 6497) conducted in 2020-2021 to explore how sources of occupational distress may be associated with suicidal ideation. Occupational distress factors in this study included experiencing the “imposter syndrome,” making a medical error, undergoing a malpractice lawsuit, or encountering adverse occupational events related to COVID-19. Other factors considered by the authors as potential contributors to suicidality included reports of burnout, symptoms of depression, and the impact of work on personal relationships. More positive influences that were hypothesized to buffer the adverse effects of occupational distress, such as professional fulfillment and a mindset that values personal growth and self-care, were also evaluated. This analysis showed that physicians in this study who were under 35 years of age, single physicians, and physicians without children reported higher suicidal ideation, as did physicians who indicated that work had had a negative impact on their personal relationships in the prior year. Suicidal thoughts were also more common among physicians with symptoms of depression. On the other hand, physicians in this study who attended to their personal well-being and were self-forgiving in response to making mistakes in patient care (“self-valuation”) reported less suicidal ideation, even after adjusting for depression. Remarkably, no differences in levels of suicidal ideation were identified when comparing the sex of respondents or key aspects of work burden or context, such as the hours worked per week, the number of nights on call, specialty, or practice setting. A major finding of this study is that self-care and social support, rather than the stresses of work itself, appeared to be factors of greater consequence in terms of influencing the frequency of suicidal thoughts among the physicians. In a second report, Nasca et al10 present their findings from a broad cross-sectional survey study of surgery residents (n = 6956) performed in 2019, finding that 4.4% reported thoughts of suicide. Study participants were more likely to acknowledge suicidal thoughts if they were single, belonged to sexual/gender minority group(s), or attended programs with significant problems such as duty hour violations, negative learning environments, and mistreatment experiences. In discussing their findings, Nasca et al. comment on the importance of providing social support and ensuring nondiscriminatory practices in residency training. They also emphasize the imperative for programs to adhere to duty hour requirements, build learning and work environments that are “safer” and “more just,” and enable appropriate clinical and operative autonomy so that residents find their work fulfilling. These research reports and the companion commentary11 provide valuable data and insights to better inform and strengthen our actions as we seek to reduce suicide risk in our field. Feelings of belonging and social connection are psychologically protective for physicians and physicians-in-training, as noted by commentators Thomas and Shanafelt. This observation is in keeping with the interpersonal theory of suicide, articulated by Joiner,12 who described how an intense experience of thwarted belongingness, ready access to means of suicide, and overwhelming distress may combine potently to produce a suicidal act. In this conceptual model, the self-harmful behavior does not reflect an authentic desire, or even intention, to die. Based on this model, there is value in efforts undertaken by leaders, programs, and institutions to provide emotional support, create a sense of community, and promote emotional safety in work and training environments. Moreover, there is value in learning from this work by tracking these efforts and assessing their effects. Thomas and Shanafelt also point out the need for accessible, confidential, and affordable mental health services for physicians and physicians-in-training. Finally, they emphasize the importance of managing trainees’ workloads and providing opportunities for professional autonomy and growth to deepen residents’ experience of meaning in their work. This guidance builds upon recommendations proffered in 2021 by Moutier et al13 to reduce suicide risk among physicians and physicians-in-training, strengthen mental health and well-being, and dismantle stigma and discrimination through a “strategic, multipronged, longitudinal, and evidence-based” effort. This sustained effort involves engaging structures and stakeholders on multiple levels, encompassing regulatory agencies and licensing boards, professional associations, medical educators, and individual clinicians, among others. Such a broad-based approach is necessary, Moutier et al. suggest, largely because of the ways in which these structures and stakeholders can reinforce shame, stigma, and negative professional consequences for physicians who seek help for mental health concerns. The death of Lorna Breem in 202014 is but one tragic illustration of the profound but invisible barriers experienced by physicians in the grip of mental anguish and distress. In academic medicine, the need for additional research to understand the phenomenon of suicide among physicians and physicians-in-training is evident. At this time, systematic and comprehensive documentation of deaths of medical students, residents, fellows, and faculty members, from any cause, does not exist in the United States.2,15,16 Consequently, the number of suicide deaths that occur each year among faculty physicians and physicians-in-training is uncertain, the drivers of suicidality have not been fully characterized, and tailored solutions to reduce suicide among members of these groups remain elusive. Studies on the prevention of suicide and disruption of suicidal ideas and impulses for physicians and physicians-in-training are also necessary. Evidence in the published literature, although limited and sporadic, reveals important clues that require careful and focused investigation. One example relates to the timing of suicides by residents and fellows—it appears that there are well-defined periods during training, such as in the “first academic quarter” when a trainee enters a program, that are especially high-risk.6 A second example relates to difficult experiences as an undergraduate student or graduate medical trainee, such as making a mistake, being on academic probation, or being threatened with litigation.10,11 These experiences appear to heighten the risk of suicide acutely and may contribute to psychological distress chronically. A third example relates to the experience of isolation, which may be particularly salient for trainees who belong to certain sexual/gender minority groups or who do not have the support of a loved one or community, increasing suicide risk.10,11 Translating these findings to develop novel interventions that are effective and well-timed, can be rapidly deployed, and are strategically focused on higher-risk groups represents a vital opportunity for the field. It is well established that depression and other mental disorders also contribute to suicide risk in individu

Ce résumé expose les affirmations des auteurs. BNTIC ne l’interprète pas comme une validation indépendante des résultats.