On the night of June 21, 2012, Greg Miday, MD, scribbled a note before settling in for a hot soak with candles flickering, music playing – and a scalpel in hand: “This is just the end of the line for my particular train,” he wrote in a goodbye note. The following morning, his body was discovered, major arteries severed.

Miday, 29, an instructor of medicine for the Washington University School of Medicine (WUSM) and a hospitalist with Barnes-Jewish Hospital, was days from beginning an oncology fellowship when he committed suicide. In his obituary, his parents – both MDs – wrote: “With all his talents and accomplishments, he struggled in a world that didn’t fully understand him.”

“Greg knew it was a career killer to ask for (mental health) help,” said his mother, Karen Miday, MD, a psychiatrist from Ohio. “At the end, he must’ve felt there was no way out.”

Every day, a medical student or doctor calls it quits in the most permanent way.

Because of the stigma surrounding mental health issues, medical students remain wary of seeking help.

“We must see change to de-stigmatize mental illness,” said Miday. “From the beginning, medical students should be allowed to seek help if they’re struggling. Unfortunately, medical people seem to be the most judgmental when it comes to mental illness.”

Colin West, MD, PhD, co-director of the Mayo Clinic Department of Medicine Physician Well Being Program, told The New York Times: “If this is the way that students view each other – survival of the fittest – how do they view their patients who are depressed or struggling with mental illness?”

Medical students are prone to maladaptive perfectionism and imposter syndrome disorders, cautioned Stuart Slavin, MD, MEd, director of curriculum for Saint Louis University School of Medicine, where he successfully implemented program changes to improve the wellbeing of medical students and received a national teaching award for restructuring medical education.

“Maladaptive perfectionism is always setting the bar so high for yourself that you’re continually disappointed,” explained Slavin. “Imposter syndrome is the belief of being incompetent despite overwhelming objective evidence to the contrary. Both maladaptive perfectionism and imposter syndrome are particularly risky when medical graduates are starting residency. All of a sudden, they have their MD, they’re writing orders and making decisions for which they may feel terribly unprepared. They’re terrified of doing something wrong. Both can be setups for emotional distress and potentially suicide. The fear of being ‘discovered’ or disappointing those who have supported you along the way … suicide is sadly an out as having potential advantages when you’re desperate.”

Haunting Actions

Because of their intrinsic knowledge of medicine, suicide success rates are alarmingly high among medical professionals. Nearly every physician knows of colleagues who took their own life.

Many remain haunted by their actions.

Jay Bitar, MD, FACC, an interventional cardiologist at Cardiology Care Center in Lake Mary, Fla., recalled an intern – Brent Branham, MD – from Detroit, Mich., who committed suicide in 1985.

“On the night Dr. Branham was on call (alone), he’d start having anxiety as my time to leave approached,” said Bitar, then Branham’s rounding resident on the infectious disease floor of a medical complex in downtown Detroit. When Branham’s one-month rotation ended without incident, Bitar wrote a favorable evaluation.

Two months later, as he was about to take night call on another medical floor, Branham had a meltdown at the nurses station. A psychiatrist called to evaluate Branham determined he wasn’t suicidal and recommended the night off, calling for further psychiatric evaluation.

Branham didn’t return home that night. Instead, he checked into a hotel room, injected himself with insulin he’d stolen from the hospital, and lapsed into a hypoglycemic coma.

“The next morning, when the hotel maid found him unconscious, he’d already sustained permanent brain damage,” lamented Bitar. “He lived for a few months in a vegetative state before succumbing.”

Over the years, Bitar has wondered what went wrong, how the signs were missed, who was to blame, and if actions could have been taken to positively impact Branham.

“Each one of us has a Brent Branham inside,” said Bitar. “The system is quick to weed out physicians who cannot survive long, sleepless nights, withstand the pressure, and take abuse from senior staff … with pride. The system of residency training doesn’t address collateral damage like the physician’s marriage getting destroyed, or when the children become neglected, or when the physician’s physical or mental health is permanently degraded.”

After hearing about a nearby physician who committed suicide, Pauline Chen, MD, wrote in The New York Times that his death came up repeatedly in conversations for days afterward.

“It wasn’t the details of his life that haunted us; it was the details of his death,” she noted. “He’d locked himself in a room in the hospital, placed a large needle in his vein and injected himself with a drug that so effectively paralyzed his muscles, he was unable to breathe. Or call for help.”

Pam Wible, MD, a family physician from Oregon and a national voice for physician suicide prevention, pointed out the ripple effects of such tragedies. A year after Kaitlyn Elkins, a third-year medical student at Wake Forest School of Medicine, died by asphyxiation due to helium inhalation, Wible attended the funeral of Kaitlyn’s mother, who chose the same method to end her life.

Miday was so devastated by her son’s suicide that “the first year after Greg died, I don’t think I could string three words together,” she said.

Wible admitted: “Many of us have considered suicide, but we’re so resilient that we smile and head back into the next room to see the next patient.”

Seeking Solutions

Missouri jumped ahead as arguably the first state to introduce legislation aimed at facilitating change at the medical school level. Keith Frederick, DO, one of four doctors serving in the Missouri Legislature, and a state representative (R-Jefferson City), proposed the “Show-Me Compassionate Medical Education Act” in the 2015 regular legislative session. House Bill 867 raises awareness about medical students’ mental health and encourages Missouri medical schools to collaborate to identify best practices, particularly those efforts most effective at de-stigmatizing mental illness and encouraging students to seek support and services to cope with mental health issues.

In June, the American Medical Association (AMA) launched an ambitious new initiative to address physician burnout, a step toward addressing mental health wellness in the profession. The interactive practice transformation series, AMA STEPS Forward, was developed after research revealed the overall burnout rate of U.S. physicians approaching 40 percent.

That’s “more than 10 percentage points higher than the general population, which is why the AMA is taking a hands-on approach to meeting their day-to-day concerns,” said AMA CEO James L. Madara, MD.

The Accreditation Council for Graduate Medical Education requires that programs assess fatigue and burnout among trainees and provide access to confidential counseling, “but these regulations should go further to require specific strategies to promote mental health among all trainees,” according to an article published March 4 in JAMA Psychiatry by Matthew Goldman, MD, of Columbia University Medical Center and New York State Psychiatric Institute and colleagues.

Depression and burnout are separate entities, some medical professionals cautioned, noting that some overlap exists.

West believes that mental health wellness begins eroding with “first-years”: “We have to assume that starting in medical school, a pipeline of experiences leads to an increased risk of suicide,” he said. “That’s where we need to start.”

Editor’s Note: Please see series companion articles in this month’s edition: “Missouri Leads States on Medical Student Well-Being Advocacy” and “The Saint Louis University School of Medicine Experiment.”

LINKS:

Accreditation Council for Graduate Medical Education: http://www.acgme.org/acgmeweb/

American Medical Association: http://www.ama-assn.org/ama

Barnes-Jewish Hospital: http://www.bjc.org/Default.aspx

Missouri Legislature: http://www.moga.mo.gov/

Wake Forest School of Medicine: http://www.wakehealth.edu/school/

Washington University School of Medicine: http://medicine.wustl.edu/