Why are we at Risk?Suicide in Female

Physicians

Kathryn Fung, MDDepartment of Psychiatry, University of

Alberta

Disclosure Statement:I have no relevant financial

relationships to disclose

Objectives1. To appreciate the changing demographics

of medicine

2. To be familiar with suicide statistics

3. To identify potential risk factors for suicide in female physicians

Outline• The changing face of medicine

• Suicide statistics

• Physicians… what makes us unique?

• Gender differences in suicide risk factors

• Future directions

Association of American Medical Colleges

Introduction• In the US, the percentage of female

residents has increased from 28% in 1989 to 38% in 1999

• Currently, 48.5% of new US medical students are women

Women in medicine from 1965 - 2004 (US data)

0%

10%

20%

30%

40%

50%

1965 1970 1975 1980 1985 1990 1995 2000

MD Faculty

28%

45%

MD Graduates

Introduction• In Canada, 41.1% to 73.9% of first-year

medical students are women

• Overall, 46.5% to 70.9% of the medical student body is female

Introduction• Concern with suicide rates begins as early as

medical school• Female medical students commit suicide at the

same rate as male medical students• In the general population, suicide rates are much

higher among men

JAMA 1987

Introduction• Elevated suicide rates continue after

graduation• Female physicians are reported to commit

suicide at a rate much greater than matched groups of American women (30 to 40 per 100,000 versus 10 to 12 per 100,000 respectively)

Lindeman et al. (1996)

Introduction• Compared to the general population, relative

physician suicide risk was estimated at:• 1.1 to 3.4 for men• 2.5 to 5.7 for women

• Compared to other professionals, relative physician suicide risk was estimated at:• 1.5 to 3.8 for men• 3.7 to 4.5 for women

Introduction• This pattern was confirmed in

Schernhammer’s 2004 meta-analysis

Introduction• Schernhammer (2004), 25 studies

• Suicide rates among male physicians is 40 percent higher than among men in general

• Suicide rates among female physicians is 130 percent higher than that among women in general

Introduction• With increasing numbers of female

physicians in training, identifying reasons for the higher rate is important

• Physician training is an expensive and time-consuming process

• If gender risk factors are identified, schools and hospitals can focus on reducing physician morbidity and mortality

why are we losing so many colleagues?

what can we do to prevent it?

&

The Ill Physician• Overall mortality for physicians from medical

causes is lower than the general population, but suicide is higher• Samkoff et al. (1995) found that suicide is the

number one cause of death in young physicians (26% of deaths)

The Ill Physician• Limited research on physician suicide

• Even less focused on female physicians

• Most physicians who died by suicide were not receiving psychiatric treatment just prior to their death• Only 42% in treatment

The Ill Physician• According to psychiatrist M. Myers, the

stigma attached to mental illness is greater in medicine than in the general public

• Stigma reinforces denial of illness• Contributes to delays in getting medical care• Increases physician suffering• Frustrates and worries physicians' families• Promotes self-medicating

The Ill Physician• Both biological and psychosocial factors may

play a role in physician suicides because there may be a higher prevalence of psychiatric disorders among physicians than in the general population

The Ill Physician• Psychiatric disorders most associated with

suicide in physicians are:• Major depression• Bipolar disorder• EtOH (40%) and/or drug abuse (20%)• Anxiety disorders• Some personality disorders (particularly

borderline personality)

The Ill Physician• Doctors with a dual diagnosis of a mood

disorder and a substance use disorder are most at risk

Physician Risk Factors• Various studies have analyzed stressors like

excessive professional demands, long working hours, little vacation time, and conflicts between work and personal life

• No solid evidence has linked these stressors to the elevated suicide rate among physicians

• Gender differences appear to exist however

Physician Risk Factors• Hypotheses include obsessive traits and an

altruistic defense to enter a caring profession based on past experience• “Wounded healers” concept

• UK data from the last decade estimates a 4x increased risk in female nurses, similar to female physicians, lending some validity to this theory

Depression• Physicians do not adequately detect or treat

depression in 40% to 60% of patients, making it difficult for them to recognize it in themselves

• The lifetime prevalence of major depressive disorder is 10-25% in women but only 5-12% in men, placing female physicians at higher baseline risk

Depression• Kessler’s (1994) National Co-morbidity

Survey noted that the most common affective disorder for women was a major depressive episode:• 21.3% lifetime prevalence• 12.9% 12-month prevalence

Depression• Data on depression prevalence in female

physicians is limited with conflicting results

• Welner et al. (1979) found that 51% of female physicians and 32% of female PhDs in the community had a Hx of depression (using Feighner criteria)

Depression• Frank & Dingle (1999) investigated self-

reported depression and suicide attempts among US women physicians• Women Physician’s Health Study (n=4501)

• 1.5% attempted suicide• 19.5% with Hx of depression

• This is the largest survey to date – prevalence of depression appears similar to the general population

Frank & Dingle, AJP 1999

Depression• In women, depression was more common if:

• Not partnered• Childless• Access to household gun• More stress at home• Drank alcohol• Substance abuse

Frank & Dingle, AJP 1999

Depression• In women, depression was more common if:

• Worse health• e.g. obesity, chronic fatigue syndrome

• Eating disorder• Co-morbid psychiatric disorder• Reported working too much• Career dissatisfaction

Depression• Frank & Dingle concluded

• Fewer suicide attempts in women physicians• Higher reported rates of depression was

associated with higher (but non-significant) rates of suicide attempts

• How does this explain the finding that female physicians have a significantly higher completed suicide rate?

Depression• Hypotheses

• Increased availability of lethal agents• Ability to self-medicate• Knowledge of lethal medication doses

Substance Abuse• Female physicians also have been shown to

have a higher frequency of alcoholism than women in the general population

• Drug abuse is also related to specialty• More prevalent among psychiatrists,

anesthesiologists, and emergency physicians

Relational Theory• Current psychology proposes that female

self-esteem is based on establishing mutually satisfying, reciprocal relationships• Inconsistent with the competitive and individual

nature of medicine• Carmel et al. (1996) notes that although

physicians value empathy and compassion, these traits were also found to hinder advancement and promotion

Relational Theory• In 2-physician marriages, females were more

likely to make accommodations in their career• Carr et al. (1998) found that in couples without

children, academic careers progressed equally• Once the couples had children, the academic

career progressed much more slowly for the female physician

Frank et al., AFM 2000

Relational Theory• Although academic careers may be affected,

domestic obligations do not appear to impact career satisfaction or mental health

On-Call & Lifestyle• On-call shifts as well as long and irregular

hours may have a bigger impact on female physicians

• They reported stress more frequently than males • (40% vs. 27%, p < 0.02)

On-Call & Lifestyle• Another contributor may be the shift in

mentality towards lifestyle and well-being among physician trainees

• Over the last decade, both the US and Canada have made changes in legislation surrounding work hours for residents in training

On-Call & Lifestyle• In Canada, all provincial residency

associations have a maximum of 1 in 4 in-house call

• In the US, since 2003, the Accreditation Council for Graduate Medical Education (ACGME) mandated 80 hours/week limit• This is the organization responsible for the

accreditation of Graduate Medical Education (GME) programs

1984Libby Zion wrongful death suit filed

19953 doctors found negligent in Libby Zion case

1987New York Advisory committee established to evaluate post-graduate medical education

1988-99Baldwin et al.: average surgical resident work hours = 102 hours/week

1999NIM report 44-98K deaths/yr due to medical error

2003ACGME “80 hours/week” restriction

On-Call & Lifestyle• Gender opinion differences exist on

legislation supporting reduced resident work hours and call frequency

• No Canadian data

• US data from 2004 multi-center study of 9 general surgery residencies in 8 states• 63% response rate for faculty (N=146) • 58% response rate for residents (N=113)

01020304050607080

Decreasedfaculty

standards

Enhancedclinical

decisionmaking

Improvedquality oftraining

Increasedsatisfaction

with program

Per

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t w

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ree/

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ly a

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Faculty Male Residents Female Residents

**

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*Mean responses between male and female residents significantly different, p<.05

Effects of Restricted Resident Work Hours on Education

0

10

20

30

40

50

60

70

80

90

100

Improved quality ofcare

DHR adherencegood for pt care

Lack of familiaritymajor cause of

error

Decreasedcontinuity of care

Night floatdecreases quality

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Faculty Male Residents Female Residents

*

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*Mean responses between male and female residents significantly different, p<.05

Effect of Restricted Resident Work Hours on Pt Care

0

10

20

30

40

50

60

70

80

90

100

DHR are good for residents I support DHR

Percent who agree/strongly

agree

Faculty Male Residents Female Residents

**

Overall Opinion of Restricted Resident Work Hours*Mean responses between male and female residents significantly different, p<.05

On-Call & Lifestyle• Faculty age, faculty gender and program

type did not systematically factor into the differences between faculty and resident views

• Resident gender was a strong and consistent factor in the faculty-resident gap• This may lead to discord in residency programs

and create tension between female residents and faculty

Bland et al. AJS 2005

On-Call & Lifestyle• Interestingly, Bland et al. (2005) reviewed the

impact of DHR on surgical case volume• Comparing 2003-2004 case logs to those from

1997-2003, there was no significant change in• The overall experience of major procedures per

resident• Chief resident cases (required for the American Board

of Surgery)

On-Call & Lifestyle• Different opinions on the effect of restricted

work hours may lead to different treatment based on gender

• This may create a more negative work environment• Several studies report increased bullying, stress

and harassment of women physicians

Intimidation• Cohen (2005) did a local survey of residents

in Alberta revealed that intimidation and harassment was strongly related to gender • 12% of males and 38% of females• This did not attain statistical significance,

possibly because of the small sample size

Intimidation• These findings were paralleled in a study by

Frank et al. (1998):• 48% of female physicians reported gender-based

harassment at least once• 37% reported sexual harassment

Intimidation• Williams’ et al. (2002) study findings indicate

that workplace conditions are a major determinant of physician well-being

• Health care organizations that are both "physician friendly" and "family friendly" seem to result in greater well-being

Conclusions• Female physicians have a high risk of

suicide, comparable to males

• Risk factors may include• Increased genetic predisposition for depression• Underlying personal factors• More ‘humane’ training conditions challenged by

primarily male senior colleagues• Increased workplace intimidation

Future Directions• Larger studies and demographics tracking

must be done

• Strategies are needed in the prevention, detection and management of mental health problems, recognizing the different roles/needs of female physicians