Critical Issues in the Treatment of Suicidal Physicians: Life-Saving Tips for the Practicing Clinician

Dr. Glen Gabbard and I put together a workshop with this title at the recent meeting of the American Psychiatric Association in San Diego. It’s long been known that treating symptomatic physicians is a complicated business and far too often ailing doctors do not get the standard of care that our other patients receive (1). And when the physician is suicidal, the consequences can be dire. Both of us have treated physicians for decades and we have each lost physician-patients to suicide. We intentionally kept our prepared remarks brief to allow almost an hour for discussion with the audience. It was gratifying to have a “full house” and a lively and robust Q&A with those who came. What follows are the highlights of our respective presentations and attendee remarks, summarized in point form:

1. The imperative of exemplary care of seriously ill physicians is a meticulous biopsychosocial evaluation and comprehensive treatment plan. This time-honored principle must never be sacrificed for expediency or to “protect” the doctor-patient from scrutiny. Always be wary of making exceptions or treating the physician-patient differently from how you treat other patients.

2. Stigma is huge in the house of medicine and the biggest reason why doctors delay getting help—or forego help altogether (2). We must be sensitive to the terror and shame that affect and distort treatment dynamics and appreciate why some subjective aspects of physician narratives are lacking or inauthentic.

3. Interviewing significant others is not simply good medicine; it can be life-saving. Physician loved ones have observations, hunches, worries, and suggestions that we cannot see or infer in the dyadic relationship with our patient in our offices or hospital setting.

4. Given the significant rate of substance use disorders in physicians, this part of the assessment is key. Alcohol is commonly used symptomatically by anxious and depressed physicians. Using office samples, diverting medication from the work setting, and self-prescribing (or writing scripts fraudulently) also occur and must be enquired into with empathy and a matter-of-fact manner.

5. Suicide risk assessments and suicide risk formulations must also be conducted carefully and regularly—and always documented (3). Denial of suicidal thinking and planning in the face of severe depression (or narcissistic injury) must never be accepted at face value. Dr. Gabbard’s practice is to say to his patient, with sincerity and kindness: “I want you to look me in the eye and answer this question. ‘Are you having thoughts of suicide?’ ” His patient’s verbal and nonverbal behaviors in response to this question dictate where he goes next.

6. Be prepared to hear and respond to sundry questions from your patient about the impact of treatment on his/her medical licensure and hospital credentialing applications. The questions on applications and renewals vary tremendously from state to state. Although there are national efforts being made by the Federation of State Medical Boards to eliminate any/all blanket, intrusive, and nonimpairment kinds of questions, this will take time. In the meantime, you must simultaneously urge your patient to embrace life-saving treatment and commit to helping him/her down the road with any advocacy issues regarding licensing and employment. This assistance is also offered by state physician health programs across the nation.

7. Clinically, it is essential to watch for rapidly accelerating agitation, plunging mood, intractable despair, cognitive constriction, delusional gloom, and severe insomnia. All need to be treated aggressively, including brief hospitalization in some cases. If possible and available, an immediate second opinion can help tremendously.

8. For psychiatrists psychoanalytically trained (or psychodynamically oriented) your therapeutic alliance will be foundational. And when your patient is suicidal, the real relationship must have ascendancy over the transference. Discussions that differentiate between the fantasy and the act of suicide can be very fruitful and extremely therapeutic for physician-patients. This includes exploring your patient’s notions of the interpersonal impact of suicide and looking for distortions and faulty reasoning.

9. Consultation with a colleague about your treatment of physician-patients can be salutary. This is especially helpful with ubiquitous countertransference blind spots when one physician treats another. And this may be even more relevant when we treat fellow psychiatrists (4).

10. When using a split treatment model of care, always be in active regular communication with your physician-patient’s therapist. And keep a legible record of all such discussions especially any change in medication and side effects, and change of psychotherapy modality (5).

At the conclusion of this 90-minute workshop, if there was one take-home message that stood out it might be this: when treating a medical colleague, never cut corners or lower your standard of care—and always be kind.

References

1. Myers MF, Gabbard GO. The Physician as Patient: A Clinical Handbook for Mental Health Professionals. Washington, DC: American Psychiatric Publishing; 2008.
2. Myers MF. Why Physicians Die by Suicide: Lessons Learned From Their Families and Others Who Cared. Michael F. Myers, MD. 2017.
3. Berman AL, Silverman MM. Suicide risk assessment and risk formulation part II: suicide risk formulation and the determination of levels of risk. Suicide and Life-Threatening Behavior. 2014;44(4):432-443.
4. Myers MF. The mental health of psychiatrists: an update. Presented at: Canadian Psychiatric Association 9th Annual International Continuing Professional Development Conference; February 23, 2004; Punta Cana, Dominican Republic.
5. Myers MF. When physician-patients push back against “split treatment”. Psych Congress Network website. https://www.psychcongress.com/blog/when-physician-patients-push-back-against-“split-treatment”. Published May 11, 2016. Accessed June 8, 2017.

Dr. Myers is Professor of Clinical Psychiatry and immediate past Vice-Chair of Education and Director of Training in the Department of Psychiatry & Behavioral Sciences at SUNY-Downstate Medical Center in Brooklyn, NY. He is the author of 8 books, the most recent of which are "Why Physicians Die by Suicide: Lessons Learned from Their Families and Others Who Cared" and “The Physician as Patient: A Clinical Handbook for Mental Health Professionals” (with Glen Gabbard, MD). He is a specialist in physician health and has written extensively on that subject. Currently, Dr. Myers serves on the Advisory Board to the Committee for Physician Health of the Medical Society of the State of New York. He is a recent past president (and emeritus board member) of the New York City Chapter of the American Foundation for Suicide Prevention.

The views expressed on this blog are solely those of the blog post author and do not necessarily reflect the views of Psych Congress Network or other Psych Congress Network authors. Blog entries are not medical advice.