Abstract
Over the course of the last century, physicians have written a number of articles about suicide among their own. These articles reveal how physicians have fundamentally conceived of themselves, how they have addressed vulnerability among their own, and how their self-identification has changed over time, due, in part, to larger historical changes in the profession, psychiatry, and suicidology. The suicidal physician of the Golden Age (1900–1970), an expendable deviant, represents the antithesis of that era’s image of strength and invincibility. In contrast, the suicidal physician of the modern era (1970 onwards), a vulnerable human being deserving of support, reflects that era’s frustration with bearing these unattainable ideals and its growing emphasis on physician health and well-being. Despite this key transition, specifically the acknowledgment of physicians’ limitations, more recent articles about physician suicide indicate that Golden Age values have endured. These persistent emphases on perfection and discomfort with vulnerability have hindered a comprehensive consideration of physician suicide, despite one hundred years of dialogue in the medical literature.
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Classification, statistical and research methods, and even AMA policies reflected significant ambivalence and uncertainty. In general, the literature agreed that suicides were significantly underreported. Among physicians, in particular, tremendous stigma and concern about the deceased’s reputation possibly led coroners to “euphemize” by citing asphyxiation or respiratory distress in cases of hanging or accidents in the case of drowning or gunshot wounds. Such obfuscation lead to under-reporting (Blachly, Dishner, Roduner 1968, 1–18; Blachly, Osterud, Josslin 1963, 1278). Disparate sources of information and the overarching conclusions generalized from them represented another source of ambiguity. Several studies utilized hospital records, questionnaires, or death certificates, which were vastly different in nature and scale; but the majority relied on JAMA obituaries, which were admittedly unreliable (Bachly, Dishner, Roduner 1968, 1–18; Desole, Singer, Aronson 1969, 294–301; Rose and Rosow 1973, 800–805; Thomas 1969, 276–285). JAMA, in particular, only began reporting suicides in its obituaries on May 17, 1965, thereby implying that it consciously euphemized them beforehand, a suggestion JAMA denied (Henshaw 1944, 345). Even after it formally changed its policy, the data upon which it relied, a mishmash of newspaper clippings, letters, and questionnaires, was highly variable and often incomplete (Henshaw 1944, 345). At times, it was even inaccurate. A study comparing California death certificates from 1970 to 1972 with corresponding JAMA obituaries found that four cases were erroneously listed as pulmonary emphysema, heart attack, cancer, and hepatic and renal failure, while another was not listed at all (Rose and Rosow 1973, 801). JAMA again denied these findings, only to indirectly confirm them several years later when, in 1970, the Special Projects Editor warned, “’a survey of JAMA obituaries would furnish descriptive data but not valid statistical data (Rose and Rosow 1973, 801).
Two physicians noted that among their cohort of 36 inpatient psychiatric patients, 5 of whom committed suicide, 15 had a psychotic diagnosis, 10 had a neurotic diagnosis, and 11 had a personality disorder. Depression was the most frequent complaint; and 69 % were alcoholics, while 58 % abused drugs (Werner and Lumry 1968, 105–112). A third physician suggested that 20–30 % of physicians who committed suicide were addicted to drugs and that 40 % were alcoholics (Bressler 1976, 169).
The track record of a resident who ultimately committed suicide was as follows: “’[H]is ward psychiatrist frequently noted his poor clinical judgment and irresponsibility. He did not attend conferences, was often late, and seemed uninterested in receiving counseling . . . . Shortly before his death from an overdose of barbiturates, he was under investigation for drug abuse by the state medical licensing board.”
A physician who treated 93 physicians as psychiatric inpatients saw 21 leave against medical advice. He commented that the physician patient “tended to be quite manipulating of his environment” and “seemed unable to assume the role of a patient in the social structure of the ward. Hostility towards the therapist was common, and once the acute phase passed, “there was often a demand for immediate dismissal” (Duffy and Litin 1964, 991).
The authors cited a study that identified suicide as the cause of death for 10 % of women with a primary affective disorder (Pitts and Winokur 1966, 37–50). They reasoned that since 6.52 % of female physicians’ deaths were due to suicide, 65.2 % (6.52 × 10) of female physicians had primary affective disorder. A study from 1981 criticized the study by Pitts et al. for its methodologic flaws (Carlson and Miller 1981, 1332). A number of letters to the editor also disparaged the conclusions (Champagne 1979, 1605).
A later study from 1974 that addressed suicide in male and female physicians together noted, in particular, that 20 out of the 41 cases were single; however, it offered no corresponding information about the male physician suicides (Steppacher and Mausner 1974, 323–328).
In 1960, a nurse encountered denial and resistance when she noticed the influence of drugs on a fellow physician. She explained, “I contacted every source available to me, and the partner went to the president of the medical society and to the coroner, but no action or assistance was offered” (Blachly, Dishner, and Roduner 1968, 17).
In a 1981 letter to the editor that responded to an article about physician suicide, one physician described how the entire profession was subjected to potentially damaging forces. He said, “Concern for professional status and the regard of peers, pursuit of professional concerns at the expense of family relationships and community networks sound dismayingly familiar as descriptors of many of our overtly unimpaired colleagues, if not ourselves” (Murphy 1981, 1526).
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Research for this paper was conducted from June 2008–March 2009 at Harvard Medical School, Countway Library, while the author was a medical student at Harvard Medical School.
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Legha, R.K. A History of Physician Suicide in America. J Med Humanit 33, 219–244 (2012). https://doi.org/10.1007/s10912-012-9182-8
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DOI: https://doi.org/10.1007/s10912-012-9182-8