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

2. Disclosure Statement:
I have no relevant financial relationships to disclose

3. Objectives To appreciate the changing demographics of medicine
To be familiar with suicide statistics
To identify potential risk factors for suicide in female physicians

4. Outline The changing face of medicine Suicide statistics
Physicians… what makes us unique?
Gender differences in suicide risk factors
Future directions

5. 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

6. Women in medicine from 1965 - 2004 (US data)
50%
MD Graduates
45%
40%
30%
28%
20%
MD Faculty
10% 0%
Women in medicine from (US data)

7. 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

8. 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

9. 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

10. 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)

11. Introduction
This pattern was confirmed in Schernhammer’s 2004 meta-analysis

12. 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

13. 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

14. why are we losing so many colleagues?
what can we do to prevent it?
&

15. 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)

16. 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

17. 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

18. 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

19. 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)

20. The Ill Physician
Doctors with a dual diagnosis of a mood disorder and a substance use disorder are most at risk

21. 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

22. 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

23. 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

24. 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

25. 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,

26. 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

27. 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

28. 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

29. 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?

30. Depression Hypotheses Increased availability of lethal agents
Ability to self-medicate
Knowledge of lethal medication doses

31. 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

32. 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

33. 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

34. 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

35. 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)

36. 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

37. 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

38. “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
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

39. 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)

40. 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

41. 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

42. 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

43. 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

44. On-Call & Lifestyle
Interestingly, Bland et al. (2005) reviewed the impact of DHR on surgical case volume
Comparing case logs to those from , 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

45. 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

46. 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

47. 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

48. 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

49. 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

50. 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