That Monday when I asked Skip’s opinion — this time, on a troubling case of weight loss — I knew I would find him with his tie askew and his glasses crooked, which I did. He sat in his chair and listened, asking questions about food insecurity and other social determinants of health.
But that Monday was different. After we talked, Skip canceled his patients for the week, left the office and killed himself.
We were all blindsided. How did we not know? Was he depressed? Was he reaching out for help? If this could happen to him, who else could it happen to?
We would later learn about his struggles with other health issues, including possible dementia, but confusion still reverberated in our exam rooms and meetings. Administrators from the hospital met with us and talked of “making time for wellness” and “taking care,” but it rang hollow, and grief was soon swallowed up by the coming tide of the coronavirus pandemic.
I think of Skip often these days, as our community of Chelsea is one of the epicenters of the novel coronavirus in Massachusetts. He dedicated his 40-year career to the MGH Chelsea HeathCare Center caring for refugees and immigrants. I am certain he would have been the first to volunteer to see covid-19 patients in our respiratory illness clinic, or he would have been handing out food supplies. Perhaps seeing the worsening disparities in our community would have further depressed him.
Although suicide across the world is declining in some areas, this is not true in our country. Suicide rates in the United States are increasing, and now account for about 1.5 percent of deaths annually since 2000. Physicians have a high rate of suicide (though not the highest of all professions), with roughly one doctor dying every day. That is nearly double the rate of the general population.
Self-care has been increasingly difficult for patients and physicians alike during these unprecedented times. Some experts note a potential “perfect storm” of growing isolation, economic stress and decreased access to community support leading to a potential jump in suicide rates during the pandemic. For health professionals in particular, this warrants particular attention.
Physicians who die of suicide often suffer from undertreated or underdiagnosed depression, a risk factor for suicide itself. Often, due to stigma, time constraints or confidentiality fears, doctors are reluctant to seek help for depression.
Last spring, I found myself poring over the story of Lorna Breen, an emergency room physician who killed herself in New York after treating countless patients with the coronavirus. I related to the overwhelming duty and guilt described in her obituary. Breen kept saying, “I couldn’t do anything.”
I’ve never been suicidal, but I felt despair in April. I remember coming home from hours on duty at the overwhelmed covid-19 clinic and I felt overwhelmed myself. I couldn’t really describe what I was feeling — we’ve failed to normalize talking about mental health. Breen’s family established a fund for mental health care in the wake of her suicide, noting the difficulty she had seeking mental health care in a system that often failed to acknowledge the deep burden of its providers.
At our hospital, a lot of time and money is spent on wellness efforts, and physicians are surveyed annually about burnout. I can apply for grants for wellness, get coached on my career and (pre-pandemic) take yoga classes. In March, our clinic was thinking about launching a suicide prevention initiative called RU okay — and then covid-19 happened.
What these workplace initiatives — which are not specific to health care — have in common is that they create space for talking about how hard things can be beyond passing exchanges in the hallway. Participants essentially pledge to check in on one another. A program out of Rutgers called Check You, Check Two encourages people each day to take time to ask themselves how they’re doing, and to talk to two co-workers to ask how they’re doing, as well. It is something I now strive to do as part of my practice.
While I support all endeavors to talk about mental health issues and decrease feelings of isolation, we need to do more for health-care professionals. We need to create a dedicated center for the additional study of physician suicide. We lack data behind the prevention, incidence and risk factors of physician suicide.
We need to implement universal training in the prevention of suicide, particularly during these times of mental health extremes.
There’s loneliness and isolation in many professions, but there’s something specific to what’s going on in health care that doubles suicide risk. The historical culture of medicine contributes to this: massive amounts of self-reliance and lack of attention to emotional well-being. We need to dispense with the pervasive notion that to be a “good doctor” means to always be available — to always go the extra mile in advocacy (fighting for insurance coverage of that CT scan), availability (squeezing in another patient) and accessibility (logging into electronic medical records at night to fill prescriptions).
Good doctors always say “yes” to helping patients in an effort to provide high-quality care. But when that comes at the expense of the doctors’ own health, it’s not sustainable. The cost can be too high for some.
Health-care workers have been lauded as heroes during the pandemic, but all the clapping in the world doesn’t eliminate isolation and depression if one can’t hear it.
Physicians need to work in teams, share responsibilities and build in time to talk about high-risk patients and tough cases. We need to find regular ways to connect that aren’t one-off wellness activities. We need to establish boundaries around doctors’ work and home time so both patient and doctor needs are met.
I think about one of the last emails my mentor sent before he died. It was uncharacteristic, because it revealed a deep sadness. He was a beautiful writer, and the email was about how siloed we are in medicine, all doing our own things, all our own islands. He called on us to collaborate more, to share our work more. He recalled talking with colleagues and how healing it was, and he commented that he was “spending far too much time alone at a computer doing documentation and email.” He said collegial energy “was better than espresso.”
I remember reading this and feeling a melancholy pang of recognition that stopped me in my tracks: Yes, there is burnout, but the real difficulty is that we’re not connecting with each other. We’re just going through the churn. Recently, we got funding to give some talks in his honor — it’s a start.
Our practice hasn’t been the same since he died. A year later, his patients — now my patients — still mourn his loss. We left the sign he had on his old office door — now a space for triage nurses — that ubiquitous “Keep Calm and Carry On” sign. That’s the wish, isn’t it? Yet at some point this mantra lost its power. Maybe it should have read, “Are you okay?”
Correction: This story has been updated to reflect that physicians have a high rate of suicide, though not the highest among all professions.
Marya J. Cohen, MD MPH, is a primary care physician at MGH Chelsea HeathCare Center, medical director of the Crimson Care Collaborative, and a public voices fellow with the OpEd Project.
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