KU Medical Center and University of Kansas Health System screen documentary on physician suicide
January 25, 2019
By Kristi Birch
It's a tragedy hidden in plain sight: Physicians, who train for years and take an oath to protect health and save lives, take their own lives at an alarming rate. Every year, around 400 physicians in the United States, enough to fill three large medical-school classrooms, die by suicide. Doctors have the highest rate of suicide of any profession, one nearly twice that of the general U.S. population.
This mental health epidemic among physicians is the subject of "Do No Harm: Exposing the Hippocratic Hoax," a new documentary that was shown the evening of Jan. 16 in the Health Education Building at the University of Kansas Medical Center. More than 200 students, residents, faculty, physicians, counselors and administrators, as well as representatives from the Kansas Medical Society, attended the screening. The event was hosted jointly by the KU Medical Center and the University of Kansas Health System.
The medical center and health system worked together to bring the film to the Kansas City campus after Jeff Norvell, M.D., MBA, who chairs the Office of Graduate Medical Education wellness subcommittee, saw it while attending an emergency medicine conference in October 2018 and recommended it. Gregory Unruh, M.D., associate dean for graduate medical education at KU Medical Center, followed up. "We reached out to the producer," said Unruh. "We've been interested in and looking at these issues-physician wellness and burnout and suicide-for a long time."
"Do No Harm" chronicles Hawkins Mecham, a first-year resident whose suicide attempt during medical school in Iowa was thwarted by a call from his wife just before he nearly bled to death, and John and Michele Dietl, grieving parents whose son killed himself just three months before graduating from medical school in MIssouri. Through these personal stories, as well as interviews with medical faculty and a physician activist who runs a retreat for physicians struggling with mental health issues, the film takes a hard look at a stressful, often unforgiving culture that leads some doctors to become depressed or take their lives.
The documentary was followed by a panel discussion that included Robyn Symon, the film's producer and director, as well as the Dietls, who have made it their mission to speak out and help other medical students and physicians. "We want students to watch out for one another, to talk to another, and not see this [needing help] as a sign of weakness, but as an opportunity to help each other out and get help if they need it, because nothing is worth dying for--nothing," said John Dietl.
Symon became interested in making the documentary in 2014 after reading about two residents in New York who killed themselves by jumping off the roofs of their hospitals. She says that generating discussion is a goal of the film because a dialogue is crucial to helping change the culture and making physicians and medical students feel safe in reaching out for help.
Symon also acknowledges it can be a tough discussion for the medical community. "I am aware the film is controversial. We are looking at an institution that is centuries old," she said of medical education. "But it [the response] has been amazing. I have been very surprised and inspired by so many medical schools and hospitals, such as the University of Kansas, who are willing to look at their own practices to help their students."
A perfect storm
The documentary focuses mainly on physician training largely because the stress of being a physician starts the first day of medical school. Typically, medical students begin their training as academic superstars accustomed to working hard and doing well, but then they find themselves in an environment in which everyone is a high achiever. Suddenly, things are different, and the competition is tough.
"As I often say, half the class is going to be in the bottom half the class," said Mark Meyer, M.D., professor in the Department of Family Medicine and associate dean for student affairs. "That's unusual for them. And it can be quite unsettling."
Meanwhile, those students are working harder than they ever have to learn the overwhelming amount of material needed to score well on frequent exams. Add to this workload sleep deprivation, competition with peers, being away from friends and family, criticism and judgment from some faculty, and the fear that even if they succeed they won't be able to pay off their massive student loans, and the result is a perfect storm of stress.
Although most students enter medical school emotionally healthy, more than one quarter of them experience depression or depressive symptoms during medical school, according to a meta-analysis published in JAMA in 2016.
That's an astounding statistic. But for Michelle Dietl, the most stunning thing was the stigma that can accompany seeking treatment. Her son feared that getting treatment would keep him from getting a residency. When he did get inpatient treatment, he asked his parents to pay cash to keep it off his record.
Meyer said that his office works hard to create the opposite kind of environment, one that encourages what he calls "help-seeking behavior." When he became associate dean for student affairs in 2000, there were very limited counseling services available to students. "But it was obvious we had a number of students who needed professional help," he said. "People often think when you get into medical school it's all fine and dandy, but there are a number of milestones along the way that you still have to face."
Meyer and Dorothy Knoll, the first Dean of Students at the KU Medical Center, worked together to expand counseling services by creating the Counseling and Education Support Services office, which today is staffed by four doctoral-level psychologists and three learning specialists. The learning specialists help students manage their workload more efficiently, while the psychologists help with more general life issues and emotional problems.
The School of Medicine encourages students to use these services during orientation, and it has added wellness elements to the new curriculum. In addition to individual counseling, the Counseling and Educational Support Services office offers workshops on mindfulness, overcoming anxiety, assertiveness, and other topics.
Meanwhile, students are encouraged to report any instances of harassment, abuse or mistreatment. Bad treatment by superiors is sometimes referred to as PIMP-ing (Put In My Place). "Most faculty and residents don't intend to mistreat students, but, often because of burnout, they do not always perform in an optimal fashion," said Meyer. "So we work to change the behavior of people who are behaving badly. And dismissals and removals do occur."
Do no harm
After graduating from medical school, students begin training for their specialties through residency programs that typically take three to seven years. This phase of training can bring its own stressors.
Medical residents, who earn an average of $55,000 a year, work many hours a week and long shifts. This has historically been considered good preparation for a career that will require long hours and demanding work. But as noted in "Do No Harm," for public safety reasons, truckdrivers and airline pilots are not allowed to work more than 16 hours straight. Meanwhile, in 2003, the Accreditation Council for Graduate Medical Education limited the number of hours a resident can work to 80 hours a week, with no more than 24 hours on-call.
Restricting work hours is important not only for physician mental health, but for patient safety. Medical errors are now the third-leading cause of death in the United States, and sleep deprivation contributes to depression. The documentary cited a study that showed that depressed residents make errors 6.2 times more often than non-depressed ones.
And even sticking to the limits set in 2003 can be difficult. Some residents even want to work the additional hours to get more training. Unruh said that at KU a work hours subcommittee of the graduate medical education office monitors those hours, which must be reported, for violations. "We also look at programs that never have violations just to make sure that they are reporting correctly," said Unruh. "We want to know who is working long hours and might be on edge."
Medical residents also may be faced with dealing with the deaths of patients for the first time in their careers. In the film, Mecham remembered struggling to cope with having three patients die within a month, and he noted that he didn't have a mechanism for processing his pain.
For the last five years, Unruh's office has been conducting an annual resident wellness survey to try to identify sources of resident wellness, burnout, and depression as well as to pinpoint the times when residents are under the most stress so that focus groups and wellness programming can be planned accordingly. His office has also arranged for residents to be able to use, free of charge, the same counseling services available to medical students. Meanwhile, the University of Kansas Health System has trained a group of employees known as the HOPE (Helping Our People Endure) Team to support peers, including residents, who are coping with an unanticipated adverse patient event, medical error or patient-related injury.
Changing the culture of medicine and medical training is going to take efforts on the micro and macro level. But the first step is getting people talking and thinking about it, which is Symon's mission. As the producer of the documentary, she has this message for her film's audience: the "Treat young docs with respect. Treat them like the healers they are."
It's a great idea, but one that requires a multifaceted solution. "The culture of medicine is long and deep and multigenerational," said Meyer. "To change things will take a concerted effort over all programs, over time."