The profession of medicine is a privileged, learned journey that advances the participant from passive didactic to active, self-motivated, lifelong learner. Medical training could also be considered a balancing act between technical competence and what is typically referred to as caring or empathic competence. But here, the early journey inevitably encounters Homer's dual sea monsters Charybdis and Scylla who beset narrow waters -- two equally challenging alternatives. That is, on the one hand the impulse of undisciplined brain stem stress, anxiety, and even anger to 'fix' the problems of the afflicted. On the other, the requirement for restrained empathy, measured and coolly detached, often criticized as nothing more than technical service engaged for a patient's plight or suffering. Yet, the latter is necessary to prevent emotional hijacking or patients may crash through clinical miscalculation. As indicated in an earlier post, I attended a screening of the physician suicide-centered 2018 film "Do No Harm." I was asked to moderate a post-movie open-ended discussion. The producer of the film described her clarion call as an "emotional artistic work" and "not an academic film." I had not prescreened this life and death story. The overflow turnout of medical, nursing, and physician assistant students and faculty was impressive and validated the importance of this subject and those tragically lost. As lights brightened, I observed tearful faces, and heard what I believed to be snappish mutterings on burnout, sleep deprivation, and the hostility of the "medical establishment." I began my comments by asking attendees to share thoughts, feelings, or perceptions of what they had seen. As important as this approach appeared to be, I further emphasized the caution of Miguel de Cervantes, "Facts are the enemy of the truth [opinion]." As outlined in that earlier post, physician suicide statistics require a clearer presentation and perspective. "The plural of anecdote is not evidence." The film generalized aggregated physician base rates without a careful review of time incidence or age-adjusted rates. This approach would have provided a more accurate context of medical student and young trainee incidence rates that average, depending on the study, one sad yet uncommon death every two months for medical students, and one suicide per month for beginning residents. These rates are remarkably lower than contemporaneous, age-matched populations. I also opined that the generic use of the term "suicide" was inartful. Clear definitions, including suicide subtypes, were required for clarity. Yet, no definition was provided in the movie. In fact, I parsed for the students the 12 differential categories of ideation (fleeting, transient, impermanent, enduring, permanent, controllable, correctible, reversible, obvious, unobvious, hijacked, precipitated). These represent important prognostic, diagnostic, and therapeutic differences with distinctions as are the nine surgical and anatomical regions of the anterior abdominal wall. This lack of critical objectivity to describe a "hidden epidemic" seemed to have a direct, unanticipated effect of raising medical student and trainee anxiety to the extent that suicide was perceived as contagious or, like the Yersinia pestis plague, inescapable. In fact, medical students and trainees are 10 times more likely to die from the flu than suicide, and only a few percents more than bacterial meningitis. Notably, one medical student in attendance exclaimed, "Do something. Do anything?" Shortly thereafter, he walked out, implying that I, the personification of psychiatry lost, was responsible for this fix. In contrast, and this was omitted by the film's writers, practicing physicians demonstrate a high base rate and higher absolute numbers, approaching one physician suicide daily, but certainly not the highest among worker and occupational groups. The distinction between this older, more vulnerable, confounding group of practitioners and younger, less permeable, trainees would have benefited the "sky is falling" inevitability narrative. Reasonable reduction in physician as well as concomitant suicide rates will be achieved only when suicide risk factors, across age, gender, ethnicity, and occupational groups, are exposed to rigorous and meticulous study of near-death cases. According to the U.S. Preventive Services Task Force, universal screening results for depression, anxiety, and ideation are insufficient to benefit any group, including medical students. These ideation-centric assessments further demonstrate plentiful false positive and false negative results, construct danger or normalize risk, and are of limited value where numbers are small, and suicides often committed without warning. Surprisingly, there was no film time dedicated to any innovative AI suicide assessment methodology currently in progress. Dr. Wible, a physician suicide prevention advocate, offered more severe comments linked to potential bullying and attendings who employ "put in my place" (PIMP) infantilization, but she gave little consideration to landmark suicide risk factor analysis, risk identification, suicide prevention, or health promotion plan. So, there you have it. My presentations are often criticized for being too difficult, scientific, and meticulous. Well, let me reiterate. Saving life is difficult. If it were easy, everyone would be doing it. Indeed, everyone is doing it in suicide prevention. From the American Psychiatric Association, American Academy of Pediatrics, NIMH, foundations, coalitions, mental health first-aid proponents, and yes, even suicide ideation therapists. And, where are we? My "Rule of 50" -- This sky is falling! 1. U.S. suicide rates are at 50-year historical highs across all age and work/occupational groups. 2. U.S. suicide rates have increased by 30% since 1999, with a 50% increase in women. 3. Youth suicide rate has skyrocketed over 50% in a decade. 4. 50% of mental health disorders are either misdiagnosed or unrecognized in clinical settings. 5. 50% of those who die by suicide were not diagnosed or recognized with a mental disorder. 6. 50% of completed suicides occur within hours, days, or a few weeks of the last clinical encounter. Consequently, whether medical student, trainee, or practicing physician, constitutive and protective properties leading to individual and social well-being include a commitment to character development, life-time learning, competent patient care, and trust relationships with colleagues. Furthermore, express your uniquely human creative gifts and talents, remain active, find healthy distractions, and encourage lifelong bonds with others. Source
