Each year since 2018, doctors around the country recognize National Physician Suicide Awareness Day on September 17.
One of the co-founders of this awareness campaign, Loice Swisher, MD, of Drexel University College of Medicine in Philadelphia, shared her own experience of suicidal thoughts after her daughter was left “neurologically devastated” following surgery on a malignant brain tumor.
Swisher told MedPage Today that ultimately her struggle and the fact that she overcame that dark period in her life have made her a better person and a better physician.
She also shared her recommendations for managing personal crises and advice for anyone who suspects that a friend or colleague may be having suicidal thoughts.
Sometimes just sharing one’s own vulnerable experience can make a difference, she noted.
The following interview has been lightly edited for brevity and clarity.
What goals did you have in establishing National Physician Suicide Awareness Day?
Swisher: When we, the five of us on a mental health task force for the Council of Residency Directors in Emergency Medicine, had a phone call, and started this discussion, suicide prevention didn’t seem to fit in any one place.
By making a day that could be recognized as a day of awareness, that then became a time where it was acceptable to talk about suicide, to remember people who had died, and for those who had experienced suicide attempts or suicidal ideation to maybe tell their own stories, and just talk about the future, talk about suicide, and maybe change the trajectory.
What makes this — in the midst of a pandemic — an important time to talk about suicide prevention?
Swisher: I consider COVID a mass mental health casualty event because everybody in one way or another is being hit with the trauma of COVID.
One of the major risk factors for mental health problems, depression, suicidal ideation is a sense of isolation and decreased connectedness, and clearly that has happened with COVID. We are not close to each other anymore. People don’t gather in the cafeteria or the physician lounge, or go out to lunch or for a cup of coffee. And certainly at the beginning of the pandemic people isolated from their family for fear of bringing the disease to their loved ones.
I think we’re seeing increased professional loneliness. Also, there’s an unexpected threat to many healthcare workers, that a year ago we were looked at as heroes, and now there are people who will threaten violence against physicians for talking about vaccines and masks. It’s creating a moral injury that is going to be very hard to get over.
You’ve shared your own personal experience with having suicidal thoughts. What caused you to speak up?
Swisher: When I first got into this, a resident from the University of Kentucky had killed himself, and the program director there, Christopher Doty, MD, wrote to the emergency medicine graduate medical education community about his death, and said that in 15 years he had never gotten any training about this risk for physicians, and that he felt like a failure because he hadn’t kept his residents safe.
It had been 16 years since I’d walked down that road and I hadn’t told my story.
My daughter had a malignant brain tumor and after her surgery she was neurologically devastated. As her mother and a doctor, I felt that either I was a bad mother or a bad doctor. I either wasn’t around enough as a mother, or I didn’t know enough as a physician to do the one thing that I should do, which is keep my child healthy. I had not searched for second opinions. I didn’t know enough about radiation. I felt like I condemned her to that life.
I felt responsible, and because of that, I felt there must be a punishment for that. And one of the thoughts that came in my mind was to think about suicide.
My understanding of the suicidal story has changed over the years. I think that when somebody has suicidal thoughts, really, what it is is that the pain that they’re having is exceeding the coping tools they have. And because we don’t see that as an imbalance, we can be overwhelmed with suicidal ideation, and what do you do? It’s paralyzing. If instead, when I had had those thoughts, I had some coping tools given to me, I think it would have made a difference.
Some 16 years later, I thought about what would have happened if I would have told my story. Would that have made a difference for Chris? And I realized I could still reach a different “Chris” that might have a resident die by suicide, 2 years, 4 years in the future.
I wouldn’t want them to feel that they didn’t have the resources and that they weren’t prepared when this has happened before. The only way to make a difference is to bring that awareness and to change.
Had you made a plan for suicide or attempted? And if not, what stopped you?
Swisher: I had never attempted and that is important, because once you’ve gotten to the point where you’ve had an attempt, that gives you another risk factor for dying by suicide with later attempts.
Did I make a plan? Yes, I made a plan. I’m an emergency physician, I make all kinds of plans. I hoped that I would never get to that point, but if I did, I wanted to be prepared.
Suicidal ideation is a con artist, a drug dealer. In a time when you see your life having limited choices, having the choice between life and death can seem like this very powerful thing. Then having that choice is not enough. And you start to say, “What other choices do I have? I have a choice of a location. I have a choice of a means.” If you’re not helped to stop that, it makes it a zillion times harder.
What stopped you from carrying out your plan?
Swisher: My daughter never had unending torture.
In 2018, the CDC released a study showing that about 50% of suicides are related to mental illness, but 50% are situational — that can be legal, financial, divorce, loss of a spouse — and those situational issues can be just as powerful.
And so for me, it was an “if-then.” If my daughter is being tortured and there’s no relief, no positive end in sight, then I was responsible as a mother to end that. It never came to be. So, I never will know if I would have done that.
I think that’s why you see with other people who have died by suicide, friends will say, “They looked fine, I was with them just yesterday.” And something trips that “if-then,” something happens and a switch was flipped.
In our past conversations you’ve spoken about “personal crisis management plans.” How can these plans help physicians?
Swisher: Much of it is based off the Safety Planning Intervention created by Barbara Stanley, PhD, and Gregory Brown, PhD. The personal crisis management plan is similarly a tool for when you have a personal crisis, to consider how you want to react.
Suicide prevention advocate Kevin Hines — one of the few people who has survived a leap from the Golden Gate Bridge — spoke about his plan to manage his suicidal ideation, and that was the first time I had ever thought about managing suicidal ideation, the same way you manage asthma or diabetes. He spent a long time talking about sleep and exercise and these tools that he used to be able to control these thoughts.
We know that the vast majority of physicians, and certainly the vast majority of emergency physicians, are going to suffer some way in their career, because of the profession that they chose. It could be a mass shooting. It could be malpractice. It could be developing an addiction. It could be that a patient assaults you. Knowing that we will make hard decisions, we’ll see hard things, having steps that keep us safe is important and this is one of the tools.
What’s your advice to someone who senses that a colleague or friend may be suicidal?
Swisher: The number of physicians who die by suicide is an important number, but there’s a bigger number of physicians suffering, who have suicidal ideation, and feel like they shouldn’t talk about it.
You’ll know about the ones who have attempted a lot of times, and you’ll know about the people or suspect the people who have died by suicide, but the ones who are just thinking about it, we can’t see. They’re the iceberg under the ocean.
Once you start talking about it and realize that other people have gone through this, a lot of times the shame and the weight of those thoughts — the suicidal ideation — changes.
When you’re in a dark place, it’s really easy to see the dark paths, but it’s very difficult to see the positive path. And so that’s why stories of hope and recovery are so important. For people actually to be able to see somebody else has crossed that darkness and came out the other side OK is really powerful.
Are there specific steps that people can take if they encounter this type of situation?
Swisher: Chris Doty, MD, has a strategy for this that uses the mnemonic “BREAK.” First, Breathe and try not to have a “deer-in-the-headlights” look, because that can make people back away. Then, Relate to the person. Ask if there’s something worrying them. Then Evaluate, ask what they’d like to do next. Then Acknowledge what they’re feeling. Finally, Kindle, ask if it’s OK to check in and reconnect at a specific time, perhaps the next day.
I think just listening and allowing somebody to express those thoughts, to know that somebody cares enough to spend a few minutes with them, can make a huge difference.
What are the main barriers for someone with a mental health problem or someone who is experiencing suicidal thoughts to seeking help?
Swisher: Culture and stigma are huge. Also, I think that because we don’t have a lot of role models who are willing to say, “I went through this tough time, I survived, I overcame it, and I’m better for it, I’m more understanding with patients,” that that’s a problem.
Have you heard of kintsugi? It’s the Japanese art of putting broken pottery back together with gold. It’s built on the idea that by embracing flaws and imperfections, you can create an even stronger, more beautiful piece of art.
Life is hard, things will scar and things will break different parts of you, and just because you’re broken doesn’t mean you have to be thrown away. That can actually be a strength to reach other people and to understand your patients’ lives. And the fact that we hide that, I think, is doing a disservice to all of us.
What about other barriers? Will changing the questions related to mental health on medical licensure forms help prevent physician suicides? Are you hopeful about the advances you’re seeing there?
Swisher: I am hopeful. But I do think that it’s a slow process.
In 2018, the Federation of State Medical Boards asked states whether they should be including these overly broad mental health questions, like “Have you ever seen a psychiatrist?” as well as questions that could include long lists of mental health diagnoses.
State medical boards want to protect patient safety. The problem is that asking these questions has not been shown to increase patient safety, but it has been shown to drive physicians away from help-seeking.
Since then, many states have modified and even removed some of their questions. Over the past year Florida and Minnesota have made changes in the right direction.
Just changing questions on state licensure forms is only the first step, but it is a really important step, because until the states change, other places — hospital credentialing committees, medical malpractice insurers — won’t either.
Nurses and lawyers also deal with these questions, and I think the questions should be changed for all of them. Just because you’ve had a stressful period in your life doesn’t mean you can’t overcome that and it shouldn’t be counted against you forever.
If you or someone you know is considering suicide, call the National Suicide Prevention Hotline at 1-800-273-8255.