Why are we at Risk? Suicide in Female Physicians Kathryn Fung, MD Department of Psychiatry, University of Alberta

Disclosure Statement: I have no relevant financial relationships to disclose

Objectives To appreciate the changing demographics of medicine To be familiar with suicide statistics 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 Association of American Medical Colleges

Women in medicine from 1965 - 2004 (US data) 50% MD Graduates 45% 40% 30% 28% 20% MD Faculty 10% 0% 1965 1970 1975 1980 1985 1990 1995 2000 Women in medicine from 1965 - 2004 (US data)

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

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) JAMA 1987

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 Lindeman et al. (1996)

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) Before 1974, there was no general or scientific agreement as to the definition of depression, and it was difficult to compare the findings of one study to those of another. The Feighner Criteria was established in the early 1970s by researchers at Washington University who published diagnostic criteria for use in adult psychiatric research (Feighner, et al., 1972). This criterion was designed to specify symptoms for diagnosing certain disorders. Later, the Feighner Criteria was expanded into the Research Diagnostic Criteria (RDC), which encompassed a wider range of disorders. The Feighner Criteria, along with the Research Diagnostic Criteria, served as a model in helping to develop the most widely used criteria among researchers and teachers, Diagnostic and Statistical Manual of Mental Disorders III and Diagnostic and Statistical Manual of Mental Disorders IV (DSM-III-R and DSM-IV) (Witt, et al., 1988). Feighner et al. at Washington University in St. Louis, Mo., proposed specific criteria to be used in psychiatric research for the diagnosis of depression and other major psychiatric illnesses. The Feighner criteria for depression were subsequently adopted by the American Psychiatric Association and published in its guidebook of mental illness, the Diagnostic and Statistical Manual of Mental Disorders (DSM). Feighner, J. P., Robins, E., Guze, S. B., et al (1972) Diagnostic criteria for use in psychiatric research. Archives of General Psychiatry, 26, 57-63.

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

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 Frank & Dingle, AJP 1999

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

Relational Theory Although academic careers may be affected, domestic obligations do not appear to impact career satisfaction or mental health Frank et al., AFM 2000

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

“80 hours/week” restriction 1987 New York Advisory committee established to evaluate post-graduate medical education 1984 Libby Zion wrongful death suit filed 2003 ACGME “80 hours/week” restriction 1988-99 Baldwin et al.: average surgical resident work hours = 102 hours/week 1995 3 doctors found negligent in Libby Zion case 1999 NIM report 44-98K deaths/yr due to medical error

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)

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

Effect of Restricted Resident Work Hours on Pt Care * Effect of Restricted Resident Work Hours on Pt Care *Mean responses between male and female residents significantly different, p<.05

Overall Opinion of Restricted Resident Work Hours * 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

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) Bland et al. AJS 2005

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