Adam Hill sat in the woods, contemplating suicide after months of debilitating despair. He'd moved to a new state for a demanding job in a profession he was no longer sure was right for him. He was overworked, sleep-deprived, stressed and abusing alcohol to cope, but that no longer eased his pain. More than five years later, Hill said he's not sure why he didn't go through with it. Instead, he called his wife and started what he calls the "long, fractured, beautiful road to recovery." Hill is a doctor — a profession that has a higher-than-average suicide rate but one in which admitting to a mental health struggle can still carry a stigma and potentially affect one's license to practice. Hill, who now treats seriously ill children with Indiana University Health, recalled how another doctor even cautioned him not to seek treatment, despite his admission of suicidal thoughts. "That's why people die," said Hill, who has spoken out in hopes of changing the culture in the field. "The great irony and paradox of all of this is that in the medical profession, we should know better." Male doctors are nearly 1.5 times more likely to take their lives than non-physicians; for female doctors, the disparity is even greater, according to an often-cited study published in the American Journal of Psychiatry. Dr. Peggy Watanabe stands in her Indianapolis home on May 2, 2017. Since her husband, Dr. August Watanabe, died by suicide in 2009, she has been involved in efforts to bring physician wellness programs to hospitals in her area. Experts estimate about 300 to 400 physicians in the U.S. take their lives every year. The long hours, high expectations and regular exposure to life-and-death situations can all contribute, experts say, and the impact is often felt early on: Many doctors who experience a mental health issue first report depression when they're in medical school, where competition can be intense and many students accrue significant debt with the promise of a big payoff years later. While the problem isn't new, what's changed in recent years is greater willingness to acknowledge it and a number of new programs aimed at addressing physician wellness. The Chicago-based American Medical Association has called physician burnout — often a precursor to more serious mental health problems — a public health issue. And, a Chicago-based group that oversees residency training programs will soon require teaching hospitals to adhere to various initiatives designed to improve physician wellness. For many, the tipping point came when two young doctors jumped to their deaths in New York City just days apart in 2014, said Dr. Michael Myers, psychiatrist and author of books on physician wellness and suicide. He exclusively treats physicians and their families. Myers' medical school roommate took his life during the Thanksgiving break in 1962, though Myers wouldn't learn the truth until years later. "It was all just swept under the carpet," he said. Doctors are notoriously reluctant to seek mental health treatment. Sometimes they lack the time; more often they suffer "catastrophic fears" that they will lose their license or have to pay more for malpractice insurance. "Physicians sometimes believe they have to seem indestructible," Myers said. "We tend to be perfectionists. We can beat ourselves up." In researching his book "Why Physicians Die by Suicide: Lessons Learned from Their Families and Others Who Cared," Myers said he found cases where doctors who later took their lives refused their families' pleas to get help or promised to get counseling but never went. Yet Myers said he's encouraged by the increased focus on physician wellness. He's helped medical groups and schools identify the reasons doctors suffer from depression and ways to help them. "It sounds simple," he said, "but it's really complicated." 'No longer ashamed' For Hill, signs of depression surfaced in medical school, and prescription antidepressants helped for several years. But by the end of his medical training, he found the medication wasn't enough. The changes were piling up. After being raised and schooled in the Midwest, he, along with his new wife, had moved to North Carolina for his fellowship at Duke University. He was sleep-deprived, didn't "have a really good self-care plan or coping skills" and turned to alcohol. "I'd grind through the day, then go home and after a few drinks ... I could feel better," he said. Soon, alcohol became a necessity to fall asleep. And, while Hill, now 36, said he'd "put on a brave face for work," he wasn't enjoying it. "I was wondering why I went into medicine in the first place. It was to help people. But I was drowning in paperwork ... and doing charts and not connecting to or helping people." "I kind of lost my identity," Hill added. "That's how I ended up in the woods." After coming that close to killing himself, Hill, at the urging of his wife, immediately sought help, including outpatient and inpatient therapy and treatment for alcohol abuse. Hill disclosed this to his state's medical board and his employer. He did the same when he had a relapse, and then was required to complete another treatment program. Now, several years later, Hill's medical license is still on probation. He is able to practice while on probation and is required to take random drug checks and receive counseling. "I want to normalize this conversation," Hill said of his choice to speak out, including in an essay in the New England Journal of Medicine. "I was no longer ashamed. I have this story too. ... I've recovered from that." Hill said he also felt compelled to share his experience because doctors are still dying; he's lost two colleagues in the past year to suicide. Hill also hopes state medical boards will reevaluate the way they ask personal health questions on license renewal applications, which he sees as a deterrent to treatment. When Dr. Nathaniel Morris was in medical school, he said, he fell victim to the mentality that doctors are not allowed to get sick. Morris started to show signs of depression about halfway through Harvard Medical School, but he said he hid his feelings. "I would throw out the (empty antidepressant) bottles outside of the house so my roommates wouldn't see," said Morris, now 26 and a psychiatry resident at Stanford University School of Medicine. "And, we're all caregivers, right? And we can't even ... talk about it ourselves." Morris decided to challenge that culture when he went public last year about his treatment for depression in an op-ed piece in the Washington Post. In the essay, he described drawing the shades and setting his browser to private to take an online quiz on depression. "It's a bizarre experience trying to hide like that when you're surrounded by a wonderful medical institution," he said. Morris said he had a lot of the typical stress of a medical student trying to learn copious amounts of information in a competitive environment. But, he soon noticed his despair went beyond his studies. A low point was breaking down and crying in the bathroom during a dinner party. With treatment, Morris said he's now doing better, and he was pleased by the positive response from going public. He took advantage of programs set up at Harvard and did not have to take time off of school. Morris also said he's received support at Stanford. But he still has that fear of what he'll be asked on future medical license applications and how he might be judged. "The larger struggle is mental health stigma," he said. "If doctors can't overcome stigma, how is everybody else going to do it?" Dr. Christine Moutier, chief medical officer at the American Foundation for Suicide Prevention, said physicians tend to have trouble admitting they need help and "for many reasons have a need and want to see ourselves as highly superior." The foundation has produced a documentary on physician suicide and has also created a website and toolkit on prevention for hospitals. Professional hazard Virtually every major medical organization is also developing wellness initiatives. "Everybody is trying to address this," said Dr. Victor Dzau, president of the National Academy of Medicine. The academy is researching how doctor well-being relates to patient care in hopes of providing suggestions on curbing burnout and untreated depression. "If I told you airplane pilots were having burnout and (dying by) suicide, would you be worried? We don't want to scare the public ... (but this is) a professional hazard we need to fix," he said. The American Medical Association has also addressed burnout and depression. Last fall, it publicly called on state medical boards to stop asking physicians about past medical treatment on license applications and instead focus on applicants' current mental state. The association has also asked medical schools to establish mental health awareness and confidential screening programs. Medical student mental health is one of the topics the AMA plans to address at its annual meeting in Chicago this weekend. The Association of American Medical Colleges seeks to spread the word about programs that emphasize physician wellness, and its website offers resources for med students on coping with burnout. About two years ago, the Chicago-based Accreditation Council for Graduate Medical Education, which oversees residency programs, established groups to study physician suicide and burnout, resulting in new requirements for residency programs that directly address common stresses for doctors in training, chief of staff Timothy Brigham said. Beginning July 1, new rules go into effect for teaching hospitals, such as providing residents time off to see counselors and allowing at-home work, such as updating patient charts, to count toward the weekly 80-hour maximum. "We took a much bigger view than just suicide. That's just the tip of the iceberg," Brigham said. While most of the work-hour restrictions will remain the same, the council did raise the shift length limit for first-year residents from 16 to 24 hours. Some critics say that's a move in the wrong direction. But Dr. Rowen Zetterman, chairman of the council's board, said a task force studied the work restrictions for the past year, gathering input from residents themselves. While there was wide support for the 80-hour weekly restriction, many residents thought the 16-hour cap for interns "interfered with team-based care." It was frustrating for interns to have to hand off particularly sensitive cases to avoid going over the cap, he added. Hospitals taking action The physician wellness program at Oregon Health and Science University in Portland has been used as a national model because it was designed to address barriers that often prevent physicians from accessing treatment: mainly, time and the need for confidentiality. The program has two psychologists and a psychiatrist who exclusively provide confidential, free treatment to residents, fellows or faculty who works at least half time, said Mary Moffit, psychologist and program director. Counseling is offered on campus but in a location where patients aren't likely to run into anyone they know. Launched in 2004, the program served 5 percent of residents and fellows in its first year and 23 percent last year, Moffit said. "We sense now that this is an acceptable thing to be participating in," Moffit said. "People are talking openly about accessing this resource." Northwestern University's Feinberg School of Medicine last year tapped a psychiatrist to launch a confidential, 24-hour hotline solely for residents and fellows at Northwestern Memorial Hospital. A hospital-wide peer support program also is in the works, said Dr. Joan Anzia, residency program director for the Department of Psychiatry and Behavioral Sciences. The hospital also continues to provide open dialogue about how doctors and med students are affected by "adverse events," the term used in hospitals to describe any bad outcome, including the death of a patient. At a recent talk open to all clinicians in the hospital, a speaker asked those in attendance about such adverse events; most said they did not seek help in dealing with them. One doctor speaking to the group called the death of a patient "a wound I'll have forever." Anzia said doctors often experience that "secondary trauma," but instead of talking about it, "you tough it out. You don't share with others when you don't feel adequate. ... It's a culture of medicine of needing to be the team leader, of not showing vulnerability, of having to be strong for the patient and the team." At the University of Chicago Medical Center, residents participated in a "resilience week" earlier this year that included daily meditation, information on when and how to seek help and small-group discussions. In the obstetrics and gynecology department, doctors are given time off for especially difficult situations, and counseling is provided through an employee assistance program. At Loyola University Medical Center, faculty physicians and residents who are struggling can be paired with a colleague who serves as a "coach," said Dr. Greg Ozark, professor of pediatrics and internal medicine at the Stritch School of Medicine. "We recognize if we aren't taking care of ourselves, we can't help others either," he said. Failed expectations For some doctors,the stigma of mental health treatment is only part of the problem. There's also feelings of failure and self doubt that play a part. "Physicians can be the most empathetic people" but "they can't take care of themselves," said Dr. Peggy Watanabe, whose husband, Dr. August Watanabe, took his life in 2009 at age 67. The two were married 45 years after meeting at Wheaton College. Peggy Watanabe said her husband, a cardiologist and an executive at the pharmaceutical company that developed the antidepressant Prozac,started to get depressed when his elderly father died in 2008 after refusing to eat for two months. "He felt so guilty about his father dying that way," said his widow, herself a retired physician in Indianapolis. "He said to me several times afterward, 'There must be something I should have done.'" In the following months, his anguish was compounded by several other blows, all while the economy crashed and the couple was building a large new house. Two of their three children were going through divorces, which August Watanabe took as his own failure and felt a sense of responsibility, said Watanabe's son Scott Watanabe. "It was that God complex," he said, "not that he thought he was God, but he thought he had the power to prevent certain things we cannot." Then, the Watanabes' only daughter, Nan, died at 44 following complications from surgery. "It was as though somebody pushed him over the edge," Peggy Watanabe said of her husband. "He thought he failed his father and our kids and he failed me." Although August Watanabe agreed to see a psychiatrist after the loss of his daughter, Scott Watanabe said his father knew what to say to appease the therapist. About five weeks later, August Watanabe told his wife he was going to attend a symposium. Instead, he drove to the couple's cabin in southern Indiana and shot himself. "The thought of suicide never entered my mind," his widow said. "He was the last person who I thought would do a thing like that." After August Watanabe's death was publicized, Peggy Watanabe did not shy away from talking about suicide and depression. She has since been involved in efforts to bring physician wellness programs to hospitals in her area. "This is probably a better way to approach physician suicide — to make sure people don't get depressed to begin with and promote wellness," she said. Depression "is not a sign of weakness. It's nothing to be ashamed of and nothing to hide." Feelings of shame might have contributed to Dr. Glen Pfister's decision to end his life, said his wife, Robin Pfister. The Minneapolis-area pediatrician didn't enter the profession in a conventional way, his wife said. After years as a commodities trader, he decided to pursue medicine at age 35. The couple later had twin sons, and Robin Pfister quit her job in finance. Throughout the years, Glen Pfister grew his practice. "Everything, I thought, was fine," Robin Pfister said. "We had the normal struggles everybody has." But everything wasn't fine. On a Sunday following a seemingly pleasant weekend in 2014, Glen Pfister went into the clinic to work and didn't return home on time. When he failed to respond to texts, a colleague was called to check the clinic. The colleague called Robin Pfister back and told her to call the police because her husband had taken his life. Robin Pfister said she and her sons, by then 14, were blindsided. It wasn't until she read the letter her husband wrote to her before he died that she began to understand. She knew her husband hadn't passed his board exams, but she didn't know he was at risk of losing his job over it. "He wanted to fix everything and keep things inside. It still bothers me now because he had a lot of people behind him. ... We would have figured it out," she said. She believes her husband's feelings of failure and fear of losing what he'd worked to accomplish were what pushed him over the edge — that and a hesitancy to seek help. "There's a no-talk rule," she said. "Don't say anything. Don't reach out." Balancing act Despite efforts by hospitals to bring confidential treatment to physicians, many are still asked to divulge such treatment when renewing their license. Dr. Humayun Chaudhry, president of the Federation of State Medical Boards, said he appreciates both sides of the argument but explained said questions are asked to protect patients. "It's a balancing act of sorts," he said. "The primary duty of state medical boards is to protect the public, to make sure that only those equipped to practice medicine do that." Yet the federation is concerned about doctor suicide, Chaudhry said, and formed a group to examine physician wellness and job burnout. The organization plans to come up with recommendations for state medical boards across the country. Medical history disclosure, he said, is not "black or white." Each case is handled individually, and someone with a substance abuse problem or a serious mental health condition is handled differently than someone who sees a therapist to deal with everyday stress. "We are really trying to ask a question so we don't create a stigma," he said. In Illinois, medical licensees are asked to disclose any "mental or emotional" condition that could affect their ability to perform job functions. The Illinois Department of Financial and Professional Regulation has not changed the form in the past decade, spokesman Terry Horstman said, adding that a disclosure does not automatically bar someone from being licensed. State medical boards across the country are looking at how they ask such questions in light of evolving attitudes toward mental health, Chaudhry said. He pointed out North Carolina's recent change to its approach. Applicants aren't asked if they've had mental health treatment but are told that failure to address a health issue that impedes their ability to practice could lead to the loss of their license. "In other words, they're saying, it's OK to be sick," he said. "It's OK to seek help." Source
