How Will This Toolkit Help Me?
Learning Objectives
Identify risk factors and warning signs for suicide
Apply standardized processes for physicians seeking support in your practice
Create an environment of support and wellness within your organization
Eight hundred thousand deaths worldwide were attributed to suicide in 2016.1 In the same year in the United States, age-standardized suicide rates were 21.1 and 6.4 deaths per 100 000 persons, for men and women, respectively.1,2
Historically, data collected up to the 1980s showed age-standardized suicide rates were significantly higher for physicians than the general population, including much higher rates for female physicians and moderately higher rates for male physicians.3 However, more recent data suggest that while female physicians continue to have higher suicides rates than the general female population (standardized mortality ratio of 1.46), male physicians actually have a lower suicide rate than the general male population (standardized mortality ratio of 0.67).4 Further research on this digression based on sex is crucial.
Physicians are not at greater risk for suicide than the general population because they are “weaker” or less resilient; rather, the opposite is true. Despite their high levels of personal resilience, physicians are often placed in situations of recurrent stress. Recurrent stress can lead to physiological and physical exhaustion, otherwise known as burnout.5 Burnout now affects almost half of US physicians. In late 2021 to 2022, three in five physicians reported at least one manifestation of burnout, a problem consistent across nearly all specialties.6,7 Physician burnout is often characterized by depersonalization, including cynical or negative attitudes toward patients, a feeling of decreased personal achievement, and a lack of empathy for patients.8 Physician burnout and distress have been associated with higher rates of alcohol use disorder and depression, increased risk for suicide, lower quality of life, reduced cognitive functioning, and poor quality of patient care.9 While burnout and suicide are very much organizational-level problems and not individual ones, this toolkit addresses both individual actions (obtaining and offering support) as well as organizational ones (promoting an environment of wellness).
Even though physicians agree they have an ethical obligation to intervene when they believe a colleague is impaired, many fail to report it appropriately.10 Taking proactive steps to identify and address physician distress can help to ensure the well-being of physicians, reduce the risk of suicide, and support patient care by protecting the health of the physician workforce.11 Although the information in this toolkit may be applicable to other clinical team members, the focus is on physicians' vulnerability and treatment needs. Furthermore, physicians-in-training, a vulnerable population with potentially higher risks of depression and suicide, are not specifically addressed in this toolkit; there are separate toolkits discussing medical student and resident/fellow burnout and well-being.
Four STEPS to Identify and Support At-Risk Physicians
Identify Suicide Risk Factors and Warning Signs
Promote Care-Seeking Behaviors
Train a Physician Advocate
Make it Easy to Get Help
STEP 1 Identify Suicide Risk Factors and Warning Signs
Suicidal behavior is a complex problem with no single cause or absolute predictors. Risk factors for physician suicide include13- 18:
Diagnoses of major depressive disorder, bipolar disorder, alcohol use disorder, anxiety disorder, or borderline personality disorder
Prior suicide attempt
Adverse childhood experiences, such as experiences or witnessing violence, abuse, or neglect
Family history of mental health issues and/or suicidal behavior
History of physical, psychological, and/or sexual abuse
Major life events that affect a person's stability and support network
Relationship problems or domestic violence
Situational stressors, including:
Being named as a defendant in a lawsuit
General career concerns (eg, job security, increased demands)
License restriction
Financial problems
Professional isolation
Recent patient with a poor outcome
“Because of [the physician health program's] attention, I have my self-esteem, confidence, and health. My license, too. Now my career is taking off in new directions, for which I am grateful.”
—Anonymous
Quiz Ref IDMany physicians closely tie their identity to their professional image, making these physicians more vulnerable to distress when problems arise at work.19 It is important for all physicians to be aware of the warning signs of suicide, which can include19- 21:
Increased substance (alcohol or drug) use
Feeling or expressing that there is no reason for living; no sense of purpose in life
Anxiety and agitation
Changes in sleep patterns, such as difficulty sleeping or sleeping all the time
Feeling trapped, like there's no way out
Expressions of hopelessness
Withdrawal from friends, family, and society
Rage, uncontrolled anger, seeking revenge
Acting reckless or engaging in risky activities, seemingly without thinking
Mood changes
Threatening to hurt or kill oneself or talking about wanting to hurt or kill oneself
Looking for ways to kill oneself by seeking access to firearms, pills, or other means
Talking or writing about death, dying, or suicide
“[The doctor] was amazing in helping me work through my depression and issues with residency…I cannot thank [her] enough for her support and assistance during what was a very difficult decision and time of my life.”
—Anonymous
It is vital to take action if you suspect a colleague is demonstrating warning signs for suicide. While not every suicide may be preventable, people with suicidal feelings can be helped. Speaking directly with your colleague is a good first step. You can say, “I'm concerned about you. Have you had any thoughts of harming yourself?”
You do not need to be an expert to offer to help. Often, a simple recommendation to talk with a mental health professional can be an important first step. Facilitate confidential referrals to mental health care professionals by keeping an updated list of local and national resources that physicians can access discreetly (see further guidance in STEP 4). Physicians may be hesitant to talk to a colleague or supervisor because of the stigma or privacy concerns and may be more willing to access help from an outside source.
Access [Suicide Risk Screening Questions].
Access [Sample Script for Approaching a Distressed Physician].
STEP 2 Promote Care-Seeking Behaviors
Quiz Ref IDAlthough physicians recognize the value of obtaining treatment, they often are the most reluctant to access medical care and frequently receive poorer care than other patients (eg, fewer laboratory tests, less rigorous medical evaluations).23,24 Thus, it is essential for physicians to recognize the importance of self-care, model wellness behaviors, and encourage others to do the same.
As a practicing physician, start by taking steps to maintain your health, including:
Get enough sleep, eat nutritiously, and exercise regularly.
Allow yourself to recharge. Take personal time off and make time for relaxation with friends and family members.
Learn to say “no” to requests that interfere with personal or relaxation time. Many physicians have difficulty turning down requests from work and the community. Sometimes saying “no” is the best medical care for both the patient and the physician.
Learn to recognize signs of stress, depression, and burnout in yourself.
Reach out to colleagues for assistance and support. Sharing your experiences with colleagues may help others in similar situations. Additionally, the support of colleagues can be a great source of comfort during difficult times.
If these self-care tips are not enough, it is time to seek additional help. Physicians should refer themselves or colleagues to internal or external programs that, in most cases, can provide confidential services for voluntary referrals (see STEPS 3 and 4).
As an organizational leader, foster a positive culture within your organization. Communicate widely and often with your team about the need to intervene if they suspect a colleague needs help. You can try some of these strategies:
Encourage and model support for colleagues
Support requests for time off for vacations or sick leave
Support flexibility in schedule
Provide mental health days, either mandatory or voluntary
Use appreciative inquiry to create a more positive work environment
Promote effective and healthy communications with positive feedback and praise24
STEP 3 Train a Physician Advocate
Quiz Ref IDCreating a supportive atmosphere in the workplace can be instrumental in addressing physician distress. You may consider having a person within your organization serve as a physician advocate. Enlist an individual, such as a human resource professional or a hospital wellness committee member, whom physicians would feel comfortable approaching. This individual must be trustworthy, discreet, and knowledgeable.
Training the physician advocate is critical and should focus on explaining internal and external policies and implications regarding privacy, confidentiality, and care-seeking. The physician advocate should be prepared to answer physicians' questions about the potential impact that receiving mental health care may have on job security, medical licenses, medical liability insurance, and disability coverage. The physician advocate is responsible for distributing guidance on physician distress and suicide—and where to find support.
Once a physician advocate is selected and trained, widely communicate this person's role and what type of support services are available.
“The past six months have been the most devastating, frustrating, and disappointing in my life. …Knowing you took the time to unravel and analyze my circumstances is maximally reassuring…. My wife and I will land on our feet sooner because of you.”
—Anonymous
Forms of support include:
Screening physicians for depression, distress, and burnout
Encouraging physicians to establish and use a regular source of health care
Reducing the physician's patient caseload in the short term
Developing internal peer network programs and opportunities for physicians
Referring to internal and external assistance programs (see STEP 4)
STEP 4 Make It Easy to Get Help
Quiz Ref IDYour organization should keep updated referral lists for confidential resources inside and outside your organization and make them readily available to all team members, including physicians. Almost every state in the country has a physician health program (PHP). Although programs vary, physician health programs provide or facilitate in-depth evaluations, appropriate treatment referrals, and, if necessary, monitoring for residents, physicians, and sometimes medical students. Because physician health programs are not affiliated with clinical practices or hospitals, they allow physicians to access private and confidential care. The Federation of State Physician Health Programs maintains a list of state physician health programs with a description of the services each program provides. Display these resources in a highly visible location that does not require a password and assures users that there is no tracing of page visits or downloads.
“I strongly feel that [the physician health program] saved my career [by helping me] deal with stressors.”
—Anonymous
Access [Suicide Prevention and Support Resources].
Access [Self-Assessment for Medical Malpractice Stress Syndrome].
Identify policy barriers to care-seeking in your organization and take steps to minimize them. Work with organizational leadership to examine and modify (if necessary) your internal policies to encourage care-seeking by physicians.
In this review of organization policies, ask yourself:
Can physicians receive care confidentially?
What type of information is recorded when physicians seek treatment?
If a physician receives care internally, are the records private? Is access to these records controlled?
Are physicians' jobs secure if they seek extensive care for mental health treatment? If so, is this job security widely known by physicians within your organization?
Is access to mental health care on par with access to other forms of health care?
Are physicians in your state required to report a history or diagnosis of mental health illness or treatment when applying for or renewing their medical licenses?
Are physicians in your organization required to report a history or diagnosis of mental health illness or treatment during credentialing or recredentialing?
Are your policies visibly posted (online and/or in print) and easily accessible for physicians in your organization to review?
If concerns about confidentiality prevent physicians with distress from seeking care, their condition may worsen. Policies allowing confidential access to treatment are more likely to encourage physicians to seek the care they need. Organizational leadership should consider this factor when developing confidentiality policies, as the risks of untreated physician distress often outweigh the potential benefits of mental health disclosures.
Physicians have a higher risk of suicide than the general population, yet they are often reluctant to access care. It is our obligation to look out for physician colleagues, and reassure them that they deserve to care for themselves as they would their patients—this can be accomplished by simply approaching and speaking with a colleague experiencing distress. This toolkit will help you teach your team to identify at-risk physicians, normalize care-seeking in your organization, and facilitate access to appropriate care.
Journal Articles and Other Publications
American Association of Suicidality. Warning signs of acute suicide risk. https://suicidology.org/wp-content/uploads/2019/07/Warning-Signs-Flyer.pdf
Moutier CY, Myers MF, Feist JB, Feist JC, Zisook S. Preventing clinician suicide: a call to action during the COVID-19 pandemic and beyond. Acad Med. 2021;96(5):624-628. doi:10.1097/ACM.0000000000003972
Ji YD, Robertson FC, Patel NA, Peacock ZS, Resnick CM. Assessment of risk factors for suicide among US health care professionals. JAMA Surg. 2020;155(8):713-721. doi:10.1001/jamasurg.2020.1338
Menon NK, Shanafelt TD, Sinsky CA, et al. Association of physician burnout with suicidal ideation and medical errors. JAMA Netw Open. 2020;3(12):e2028780. doi:10.1001/jamanetworkopen.2020.28780
Doupnik SK, Rudd B, Schmutte T, et al. Association of suicide prevention interventions with subsequent suicide attempts, linkage to follow-up care, and depression symptoms for acute care settings: a systematic review and meta-analysis. JAMA Psychiatry. 2020;77(10):1021-1030. doi:10.1001/jamapsychiatry.2020.1586
Danhauer SC, Files K, Freischlag JA. Physician suicide—Reflections on relevance and resilience. JAMA Surg. 2020;155(8):721-722. doi:10.1001/jamasurg.2020.1345
Rotenstein LS, Torre M, Ramos MA, et al. Prevalence of burnout among physicians: A systematic review. JAMA. 2018;320(11):1131-1150. doi:10.1001/jama.2018.12777
Yaghmour NA, Brigham TP, Richter T, et al. Causes of death of residents in ACGME-accredited programs 2000 through 2014: implications for the learning environment. Acad Med. 2017;92(7):976-983. doi:10.1097/ACM.0000000000001736
Guille C, Zhao Z, Krystal J, Nichols B, Brady K, Sen S. Web-based cognitive behavioral therapy intervention for the prevention of suicidal ideation in medical interns: a randomized clinical trial. Mo Med. 2016;113(1):19. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6139738/
Kuhn CM, Flanagan EM. Self-care as a professional imperative: physician burnout, depression, and suicide. Can J Anaesth. 2017;64(2):158-168. doi:10.1007/s12630-016-0781-0
Moutier C, Norcross W, Jong P, et al. The suicide prevention and depression awareness program at the University of California, San Diego School of Medicine. Acad Med. 2012;87(3):320-326. doi:10.1097/ACM.0b013e31824451ad
Salvagioni DAJ, Melanda FN, Mesas AE, González AD, Gabani FL, Andrade SM. Physical, psychological and occupational consequences of job burnout: A systematic review of prospective studies. PLoS One. 2017;12(10):e0185781. doi:10.1371/journal.pone.0185781
Videos and Webinars
Websites