Can Arts and Communication Programs Improve Physician Wellness and Mitigate Physician Suicide

At Stanford, the suicides of two resident physicians stimulated an increase in attention to the broader problem within our profession. As colleagues who work in the areas of physician communication and medical humanities, we are distressed by the high suicide rate in medicine, yet encouraged that some intervention might positively affect the situation and save lives. The suicide rate for physicians is higher than that of any other profession—in the past year, more than 400 physicians have committed suicide. Physicians have a far higher suicide completion rate than does the general public; the most reliable estimates range from 1.4 to 2.3 times the rate in the general population, perhaps, in part, because of their greater knowledge of and better access to lethal means. The stresses related to the field of oncology can lead to burnout, and the conditions of practice can predispose to depression and substance abuse. A recent survey showed that 45% of oncologists are experiencing burnout, emotional exhaustion, and/or depersonalization on the scale of the Maslach Burnout Inventory. A 2014 report in General Hospital Psychiatry, “Suicidal Behavior Among Physicians Referred for Fitness-for-Duty Evaluation,” indicates that little progress has been made in acknowledging and addressing the issue of physician suicide. “The intense shame and stigma, particularly associated with mental health and substance abuse issues, preventsmany physicians from seeking care, unless they are coerced.” Physician suicide is not a new problem, but the profession’s reaction to it has changed over time. In the early twentieth century, the rigors of the profession were cited as a probable cause, and recommendations for self-care were made. In an 1897 article about physician suicide, the Medical and Surgical Reporter recommended that physicians “get the greatest possible amount of innocent enjoyment out of life by maintaining friendships, attending the theater, and enjoying pleasures outside of medicine.” The recommendation was, “if you cannot succeed or cannot philosophically accept what your profession has to offer, get out of it and give someone else a chance, while you give yourself the chance to live more happily in more congenial surroundings.” The attitude toward physician suicide began to change during the early twentieth century, when “Americanmedicine experienced an unprecedented rise in status, stature, and eminence.” During this “Golden Era” of medicine, articles on physician suicide began to blame the individual for not being sufficiently strong or upstanding to be in the profession. We have noticed a parallel between physicians and military personnel. Suicides in the military are also very high, reaching a stunning 22 deaths per day. Doctors and soldiers are inducted into self-identified communities that include uniforms, specialized language, chain of command hierarchies, life-and-death decisions, limited margin for error, and compliance with high standards of conduct based on the level of public trust they receive. There are some shared terminologies that extend to the language often used in reference to confronting many diseases, and especially to cancer treatment: battle, courage, attack, losing the fight, and winning the fight. Two of the primary methods of attack in cancer treatment, chemotherapy and radiation, have their developmental roots in the Department of Defense. Physicians and soldiers often operate within a code of silence that discourages perceived personal weakness or acknowledgment of mistakes while encouraging restraint when discussing feelings of doubt, inadequacy, sorrow, or burnout. Physicians and soldiers share internalized expectations for keeping deep personal feelings to themselves. This idea of detachment as a survival mechanism is prevalent in medical school and medical practice, but ongoing detachment takes a toll and can lead to burnout and depression. A recent commonality in both communities has been keeping rates of suicide hidden, but that is rapidly changing, because mainstream and social media have revealed the tragic realities of burnout, depression, and suicide in our soldiers, medical students, residents, and physicians. Just as great medical advances have emerged from practices on the battlefield, in