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Muhamad Aly Rifai, a psychiatrist, discusses his KevinMD article “Physician suicide: Addressing the silent epidemic.” In this episode, Muhamad delves into the alarming rise in suicide rates among physicians, the pervasive stigma surrounding mental health in the medical community, and the unique risk factors that contribute to this crisis. He explores current trends and the impact of burnout, as well as effective interventions and strategies to support physician wellbeing. Listeners will gain actionable insights on reducing stigma, implementing preventive measures, and fostering a supportive environment for health care professionals.
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Transcript
Kevin Pho: Hi, welcome to the show. Subscribe at KevinMD.com/podcast. Today, we welcome back Muhamad Aly Rifai. He’s a psychiatrist. Today’s KevinMD article is “Physician suicide addressing the silent epidemic.” Muhamad, welcome back to the show.
Muhamad Aly Rifai: Thank you for having me talk today about a topic that I’m passionate about—the mental health of our fellow physicians and the unfortunate phenomenon of physician suicide that we are actively trying to prevent and to decrease its incidence.
Kevin Pho: All right. Tell us what this article is about for those who didn’t get a chance to read it.
Muhamad Aly Rifai: So, the article addresses the emerging phenomenon of increasing rates of completed suicide, as well as suicidal ideation, in our fellow physician community. And by physicians, I mean physicians in training, residents, as well as medical students.
Suicide is the action of an individual ending their life. Suicidal ideation is somebody having thoughts, feelings, and urges to end their life. We believe in the field of psychiatry that this action—suicidal ideation and completed suicide—is the convergence of multiple factors: psychiatric issues, the environment, untreated or end-stage psychiatric illness. I have completed now almost 15 years as a consultant physician for the Physician’s Health Program in the Commonwealth of Pennsylvania, and I deal routinely, on a daily basis, with fellow physicians who are experiencing frustrations and psychiatric symptoms, who are seeking help, and some are experiencing suicidal ideation. I tell my fellow physicians, there are resources out there, so you should always seek help.
Kevin Pho: Now, tell us some of the factors specifically physicians face that are risk factors for suicide, in contrast to the general population.
Muhamad Aly Rifai: Physicians are health care professionals who are under a lot of pressure. Let’s talk about the environmental situation. Everybody knows the pressure that physicians are under these days—with health care administrators, with burnout, with the health insurance industry. Even the patient population is upset about their health care issues.
So physicians are under a tremendous level of pressure in terms of their professional responsibilities. Physicians are also part of this population; we’ve seen an increase in the prevalence of medical problems, we’ve seen an increase in the prevalence of psychiatric issues in the general population, and we also think there’s been a worsening in our fellow physicians’ responses to what’s happening in terms of their ability to take care of themselves, to internalize what’s going on.
We, as physicians, give advice to our patients—diet, exercise, take care of yourself—but we sometimes do not heed that advice ourselves; we do not reflect internally in terms of our ability to follow it. So physicians are at an elevated risk. We have greater knowledge in terms of lethal methods, and that can lead to a higher rate of completed suicides in physicians, both male and female, compared to the general population.
Over the last few years, there’s been an escalating increase in the number of suicides—completed suicides—among our fellow physicians. It’s as high as 500 per year. We lose one large class of medical school every year to suicide among our fellow physicians.
Kevin Pho: And sometimes, when you talk to physicians who exhibit suicidal ideation, do they express the stresses of the job as a contributing factor?
Muhamad Aly Rifai: Absolutely. A lot of the fellow physicians I treat say that job stressors are the number one cause of what they’re experiencing. Some fellow physicians have preexisting psychiatric illness, and those usually address their psychiatric illness; they’re engaged in treatment. But there’s a tremendous stigma among our fellow physicians because they do not want to talk about their psychiatric illness, they do not want to express that. They’re afraid of repercussions from their job, repercussions from licensing boards, repercussions from the community around them—that people will no longer trust them and that they will no longer be able to do their job.
So they internalize, they hide their symptoms, they do not talk about their symptoms, they do not seek treatment. Sometimes they engage in drug and alcohol use, all in an effort to mask their psychiatric issues and the stress they’re experiencing. That can end up leading to their suicidal thoughts, and then they approach the topic of suicide without talking to anybody.
Kevin Pho: So you mentioned that some physicians may be fearful of talking about their behavioral health issues because of repercussions from their medical institution, hospital, and licensing board. Are those fears well-founded? Are there episodes of retaliation against physicians who seek behavioral health treatment from, say, a licensing board?
Muhamad Aly Rifai: I have seen occasions where that has happened, but I’ve also seen a significant shift. There has been more acceptance from medical boards and more resources made available. The program I work with, the Physician’s Health Program in the Commonwealth of Pennsylvania, has made more resources available in a non-punitive fashion. So if a physician discloses that they’re experiencing issues and seeks treatment, there’s usually no punitive response in terms of reporting to the medical board, and that individual can continue to have their license without sanctions as long as they are engaged in treatment and the issue they’re facing is improving.
Hospitals sometimes could be punitive, but I’m seeing that that is also changing. Having a proactive approach, as well as having access to resources and having a psychiatrist who’s engaged and interested in the topic of physician health, is very important. For example, in Pennsylvania, we have several physicians—several psychiatrists—who serve as resources to our fellow physicians in need of psychiatric care, and we provide those resources. I also have access through the American Psychiatric Association’s Center on Physician Health, which aims to decrease this incidence of physician suicide, and it provides resources to our fellow physicians in all 50 states.
Kevin Pho: What are some of the warning signs of suicidal ideation that physician colleagues should be aware of and on the lookout for?
Muhamad Aly Rifai: A fellow physician who is withdrawn, who is experiencing mood fluctuations, a fellow physician whose performance is declining, a fellow physician who seems very sensitive to criticism, and any engagement in drug or alcohol use—these are the overt signs we would see. Sometimes it’s very simple signs, like problems with sleep, problems with being late to work, or experiencing medical problems.
We, as physicians, should always be on the lookout and check in on our fellow colleagues to ensure that we’re all together in this, that we can withstand what’s going on in the changing environment—in the health care environment, in health care institutions, with health insurance—and continue to care for our patients. We should always be on the lookout and ask our fellow physicians whether they’re OK, whether they need help, and refer them to resources.
Kevin Pho: I want to get back to the stigma of physicians seeking help, especially behavioral health help. What are some other things we can do to change the culture of medicine and remove the stigma of being vulnerable and seeking behavioral health help?
Muhamad Aly Rifai: Some states have actually lobbied actively, for example, to remove questions about mental health issues from licensing board renewal applications or initial applications. I’m seeing that happen in many states because it creates stigma if somebody has to answer “yes” about having mental health issues or drug and alcohol issues. Hospitals and hospital boards can sometimes be major contributors to stigma. Any physician who experiences psychiatric issues may be ostracized, and they perceive they’ll be under the microscope because of their psychiatric issues.
But we are seeing a lot of physician-friendly health institutions that are trying hard. Medical schools are actively screening medical students. Sometimes we see in certain classes there could be suicidal ideation rates as high as 30 percent. There have been interventions where students receive cognitive behavioral therapy, and even three or four online sessions lasting 30 minutes each can reduce the frequency of suicidal ideation by 50 to 75 percent. These are very straightforward interventions that we can do to decrease stigma and increase the acceptance that we, as physicians, are also human beings, that we experience psychiatric issues, and that we need to address them proactively so they don’t escalate and lead to suicidal ideation and completed suicide.
Kevin Pho: How about those physicians who may be at risk for suicidal ideation themselves? They’re listening to you on this podcast, perhaps. Tell us some first steps they should take to help address that.
Muhamad Aly Rifai: The first step would be to admit to themselves that they are experiencing psychiatric issues, that they are in trouble, and that they need help. They need help because they want to be there for themselves, for their families, for their patients, and for their community. A physician is a very valuable resource, and there is help out there.
If someone is experiencing issues, they should seek help with primary care doctors or with psychiatrists. They should also reach out to the 988 Lifeline; you can anonymously text 988 and communicate with a counselor who can direct you to psychiatric resources. The American Psychiatric Association also has a helpline that people can call to reach resources in their community, whether they need therapy, medications, or time off from work. Those resources exist for our fellow physicians. They should never feel alone or that there’s no help out there.
Kevin Pho: We’re talking to Muhamad Aly Rifai. He’s a psychiatrist, and today’s KevinMD article is “Physician suicide addressing the silent epidemic.” Muhamad, as always, let’s end with some take-home messages that you want to leave with the KevinMD audience.
Muhamad Aly Rifai: Yes, there are resources out there. There is help for fellow physicians who are experiencing psychiatric issues or feel they’re experiencing suicidal thoughts. You can dial 988, which is the suicide prevention hotline. You can reach out to fellow resources, fellow physicians. There are resources out there. You can reach out to me; you can Google my name and reach out to me. I am happy to direct you to resources in your area through the American Psychiatric Association, to fellow psychiatrists who are engaged in physician health programs who would help you in a non-punitive way to continue to be a productive resource for your community, live happily with your family, and benefit your patients. So there are resources out there—please seek help.
Kevin Pho: Muhamad, thank you so much for sharing your perspective and insight, and thanks again for coming back on the show.
Muhamad Aly Rifai: Thank you.
