Can high reliability training help prevent physician suicide?

Steven D Freer

Steven Freer, M.D., FACP, chief medical officer, Providence in Oregon; Isidor Brill Chair, Department of Medicine, Providence St. Vincent Medical Center

A few weeks ago, I learned that a physician colleague on our medical staff had died by suicide. This happens with shocking frequency; it is the second such tragedy I am aware of within Providence St. Joseph Health in the past year. It’s difficult to know exactly how many physicians die each year by suicide. A number commonly cited is 400 annually … more than one physician per day. That’s the equivalent of a large medical school class dying each year by suicide. Statistics are unreliable because attributing a death to suicide is not always clear, but studies have shown consistently that the suicide rate among physicians (28-40 per 100,000) is two to three times higher than for the general population (12.3 per 100,000) (1)

The reasons for this have been the subject of extensive analysis. Non-physicians may find it difficult to imagine why physicians would be suicidal at rates so much higher than the general population. If you talk to physicians about these appalling statistics, however, many express grief and sorrow but not really surprise. In addition to the high suicide rates, many of the risk factors for suicide -- depression, burnout and substance use disorders -- are high among physicians when compared to the general population.

The reason for this probably is rooted in our shared experience of becoming a doctor. Medical training has sent a similar message to all physicians for more than a century – achieve  perfection. Errors are a personal failure.  It’s our fault when something goes badly. We, and only we, are primarily responsible for what happens to our patient. Compounding this indoctrination is an intense sense of personal responsibility -- to our patients, our colleagues and to the very image of the physician in society. When the outcome of our actions and decisions is the health and safety of another human being, the pressure and the self-recrimination can feel overwhelming.   

Our profession has created very little space in which to navigate the emotional trauma that physicians inevitably experience. We are expected to “shake it off” and move on to the next patient and the next case -- often within minutes of giving devastating news or experiencing a bad outcome. We are conditioned to “power through” the fatigue and emotional stress inherent in the work we do. The stigma of failure and a culture of silence can create a sense of social isolation, especially when it comes to discussing our struggles with depression, personal failure, alcoholism and other substance use disorders. In addition, many of us face a work environment that sets unsustainable expectations around productivity, while monetizing every moment of a physician’s time and devaluing work that doesn’t generate revenue.   

The issues of physician burnout and suicide have gotten a lot of attention lately, and rightly so. The human and societal cost of losing physicians this way is horrendous. Providence physicians and leaders in Oregon are working to confront this challenge proactively by establishing coordinated wellness efforts, developing peer-to-peer support mechanisms, and making structural changes to address the difficulties in the work we do every day. Lisa Vance, chief executive for Providence in Oregon, is the executive sponsor of this work, and Dr. Todd Caulfield chairs a new medical executive subcommittee on wellness and burnout. These problems, however, have accrued over decades of entrenched thinking and practice, and it will take time and resources to correct them.  

Four years ago, Providence in Oregon committed to becoming a high reliability organization (HRO). Part of that commitment is the expectation that all privileged physicians with a certain level of hospital contact must be trained in the concepts, tools and behaviors that foster a culture of safety. Can the principles of high reliability prevent physician suicide? Perhaps not directly. The problem is too complex for any single solution. The deep and pervasive cultural factors within our profession – the training, work environment and societal norms – all make it difficult for physicians to get the help we need. Correcting this will require structural changes. Yet any system that relies too heavily on human factors is destined to fail, and we know that these failures take a tremendous emotional toll on physicians. No matter how hard we try, we still make mistakes.  

The entire point of high reliability training is to reduce those mistakes through well-designed systems and intentional behaviors. In Oregon, thousands of physicians have undergone high reliability training. It’s a bit like vaccines and herd immunity: The more people are trained, the more likely it is to prevent errors. We know we have reduced serious safety events dramatically since our journey began four years ago. If a few hours of training for all physicians and caregivers can prevent a single catastrophic error, the kind that might drive an already fragile physician over the edge, isn’t it worth it?

I will never know what circumstances finally pushed our colleague to take this tragic and irretrievable step. But it would not surprise me to learn that there were unfortunate events for which he felt personally and overwhelmingly responsible. Every physician has experienced this.  

Just last week I heard about a young doctor, recently out of residency, who made an error that left a patient significantly impaired. I can’t say for certain that our high reliability tools, such as a peer check, a clarifying question from a teammate, or a validation and verification sequence, would have changed the outcome. I sincerely hope this young doctor is resilient enough to endure the self-recrimination many of us have experienced after such errors. 

The goal of high reliably training is to make health care safer and better for patients – but it also makes it safer and better for physicians, nurses and everyone else on our care teams. By lowering the chance of an error reaching a patient, it might even turn out to be a backstop against physician burnout and suicide. 

1 Healthcare Professional Burnout, Depression and Suicide Prevention, American Foundation for Suicide Prevention