Healthcare Insights: Suicide and Physicians

National Physician Suicide Prevention Awareness Day was September 17th.

This month I have the privilege to work with colleagues from Doctors Council SEIU and the New York City Health + Hospitals (the nation’s largest public health system) to participate in a labor-management presentation on the topic of destigmatizing mental health.

From what I have learned from that labor management presentation along with additional reading, I must say that It is impossible not to share a depth of the tragedy in this column. Just as important is to learn how organizations and individuals are addressing this crisis of mental health and the potential for self-harm and suicide among healthcare professionals, and having some success in prevention. You will see in the video clip below that overcoming the stigma that prevents doctors and other healthcare workers from seeking help is among the essential steps for healing.

“With one completed suicide every day, US physicians have the highest suicide rate of any profession. In addition, the number of physician suicides is more than twice that of the general population, new research shows.”

To gain an in depth understanding of the experience of far too many health practitioners, please watch this video to gain an understanding of the causes of mental health crises among health care professionals:

It is entitled “Removing the Mask” and delivered by Carrie Cunningham, MD, MPH, President of the Association of Academic Surgery (Warning, the video contains speech which may be disturbing). Dr. Cunningham started her early life as a high-ranking tennis professional on the Women’s Tour, went to medical school, and had an extremely successful career in the practice of surgery and academic teaching and research. Her story shows that mental health crisis, addiction, and other conditions that have made it impossible for her to practice medicine or carry on any type of healthy life for a long period of time can strike anyone!

As we see from this video the root causes of and the inability of physicians and other health professionals to be able to care for themselves in times of crisis can and must be addressed.

The Physicians Foundation has done an in-depth survey of doctors, residents, and medical students about their well-being. Please read the entire report here: 

Some of the key findings include:

Feelings of burnout are profound:

• For the third year in a row, six in ten physicians often have feelings of burnout, compared to four in ten in 2018.
• Like their physician colleagues, six in 10 residents often have feelings of burnout.
• Whereas, seven in ten medical students report often have feelings of burnout.

Stigma associated with these feeling is also profound:

• Nearly eight in 10 physicians (78%), residents (79%) and medical students (76%) agree that there is stigma surrounding mental health and seeking mental health care among physicians.
• Approximately half of physicians (48%), residents (48%), and students (55%) said they know a physician/colleague/peer who said they would not seek mental healthcare.
• Four in 10 physicians were either afraid or knew another physician fearful of seeking mental health care given questions asked in medical licensure/credentialing/insurance applications.

Additional tragic realities:

• More than half of physicians know of a physician who has ever considered, attempted or died by suicide, increasing in comparison to 2022 and 2021.
• Nearly four in 10 residents (38%) know a colleague/peer who has ever considered suicide.
• Almost half of students (45%) know a colleague/peer who has considered suicide ever and one-quarter know of a colleague/peer who has considered suicide in the past 12 months, which is significantly higher compared to residents and physicians.

In this Healthcare Insights column we have discussed many times the growing consolidation of the healthcare industry into larger and larger systems. We have shown how this consolidation has not met its promise of reduced cost and improved care.

There is evidence that the growth and consolidation in the industry has so negatively impacted physician practice that it is cited as a contributor to the negative mental health trends among health professionals.

Healthcare consolidation is causing a drastic shift in the healthcare practice environment, and physicians are often not involved in the decision-making process.

• At least three in ten physicians and residents have experienced merging with another practice/hospital or acquiring another practice/hospital over the past five years.
• Among those physicians experiencing the respective merging/acquisition scenarios, only one-fifth have been involved in the decision process.
• Half of residents and more than four in ten physicians expect their hospital/practice will acquire another hospital/practice within the next five years.
• One third of physicians and more than one-quarter of residents anticipate merging with another practice/hospital.

The survey concludes with recommendations about how to improve the future of medicine and with it, the well being of our healthcare professionals.

• 80% of physicians and 85% of residents found reduction of administrative burdens to be helpful.
• 64% of physicians and 80% of residents found confidential therapy, counseling or support phone lines to be helpful.
• 59% of physicians and 64% of residents found change/removal of credentialing application questions to be helpful.
• 64% of residents and 63% of students found change/removal of medical licensure questions to be helpful.
• 57% of physicians and 72% of residents found peer-to-peer support groups to be helpful.
• At least half of physicians and residents report insurance requirements, documentation protocols, regulatory policies and mandatory training requirements as often or always hindering their autonomy to deliver high-quality and cost-efficient care.

There is hope!

This past summer, 2024, NYC Health + Hospitals along with 19 other health systems were recognized for their leadership in providing support for the well-being of their healthcare workers.

On September 17, 2024, Doctors Council SEIU and NYC Health + Hospitals shared a presentation for the System Wide Collaboration Council, a quarterly meeting which brings together executive and frontline physician leadership to discuss issues of mutual interest. The Collaboration Councils are derived from the collective bargaining agreement between the Union and the Health System.

Here is a summary of the presentation developed from experiences at NYC Health +Hospitals/Bellevue which illustrate an important example of how Wellness Programs are developed and implemented:

1. 1. The program was developed from the Critical Care Intensive Unit. The unit acts upon stressful, complex care every shift of every day
   2. Through this experience, the staff must deal with death or prolonged illness on a regular basis.
   3. In the immediate aftermath of such events there is a common experience including tears, sometimes blame, and a period of disengagement from such events.
   4. The team has developed what they call “essential debriefing” which includes the following principles: it is confidential, supportive, respectful, staff know that they are in a safe space for self-expression, and that responses from group leaders are non-judgmental.
   5. The debriefing sessions recognize that the staff is suffering from burnout, dealing with severe illness in patients in almost all the cases they see, and that team dynamics are often negatively impacted.
   6. The team support offered includes a recognition of burnout, maladjusted coping mechanisms, acute grief, moral distress, and the possibility of poor team function.
   7. The strategy for the emotional debrief includes:
      • A “hot debrief” which recognizes the stress everyone has just experienced
      • Knowledge leveling to help everyone understand exactly what happened and why
      • Emotional support
      • Error/near miss identifications for learning
      • Burnout and moral injury mitigation

The work of the CICU staff who have developed these protocols are looking for ways to expand their successful practices throughout Bellevue and the system as a whole. The System Wide Collaboration Council provided the means for this spread of best practices.

These are the kinds of settings, though hardly limited to critical care that trigger daily episodes requiring that clinicians expend untold amounts of their personal, emotional and physical selves to the care of their patients. Many patient outcomes end tragically, and the people who cared for them are directly impacted with grief and loss.

The daily stresses of staffing shortages and pressure to see more and more patients creates ethical stress which builds into burnout and moral injury.

While healthcare systems, unions, government, and academic research are working toward the improvement of healthcare in our country, the impact of our disaggregated non-system of care delivery continues to underserve patients, and causes great harm to the workforce.

It is good to know that health systems leaders and frontline clinicians are collaborating on the development of steps to mitigate the impact of deep emotional stress in the healthcare setting. These are investments that must be made today in the immediate crisis that healthcare workers face while we as a nation come to grips with the deep dysfunction of American healthcare.

John August is the Scheinman Institute’s Director of Healthcare and Partner Programs. His expertise in healthcare and labor relations spans 40 years. John previously served as the Executive Director of the Coalition of Kaiser Permanente Unions from April 2006 until July 2013. With revenues of 88 billion dollars and over 300,000 employees, Kaiser is one of the largest healthcare plans in the US. While serving as Executive Director of the Coalition, John was the co-chair of the Labor-Management Partnership at Kaiser Permanente, the largest, most complex, and most successful labor-management partnership in U.S. history. He also led the Coalition as chief negotiator in three successful rounds of National Bargaining in 2008, 2010, and 2012 on behalf of 100,000 members of the Coalition.