Submitted by Loice A Swisher MD (Drexel University College of Medicine)
on behalf of the Mental Health Task Force of the Resilience Committee
Which resident is at-risk of suicide?
Overall, it seems resident suicide is a rare event. And although we don’t have exact numbers, in fact, it is. In my quarter century with my program, I don’t ever remember one of our department’s residents or faculty dying by suicide. Yet when it happens to a program, it is like a grenade was tossed in the program. There is devastation. Is there any way to predict who is at-risk?
Joiner’s Interpersonal-Psychological Theory of Suicide
In 2005, Thomas Joiner explained in his book Why People Die by Suicide that people kill themselves when they have acquired both the desire for death and the ability to carry it out. Joiner proposes that the death desire occurs when two mental states, thwarted belongingness and perceived burdensomeness, are held simultaneously for a long enough period of time. The capability to kill oneself requires means and a fearlessness which overcomes the innate instinct of self-preservation. When all these factors overlap there is a high potential for suicide.
Graphic by Cara Kanter MD (Temple University)
Thwarted belongingness is just as it sounds- social isolation, loneliness, alienation. Which resident isn’t at risk of this? Many have transplanted across the country starting in a place without anyone at a time when their new job requires an incredible amount of time and focus. Even those who have not moved are likely to be in a new environment with new colleagues. Most rotate frequently among hospitals. It would seem almost a given that incoming interns, particularly those who are single, are vulnerable to thwarted belongingness.
Perceived burdensomeness is less obvious but clearly is just as high a threat to our residents as a lack of connectedness. This is the feeling that one’s existence and choices cause an excessive burden which could be rectified by one’s death. Examples of this ‘burden’ might be seen as excessive debt, making an error that causes mortality or morbidity or that the career choice was a mistake. Often there is a sense of failure. It would seem many residents would be susceptible to perceived burdensomeness.
Desire is only part of the equation for departing this world by one’s own hand. People also have to have the capability. They need to know and have access to lethal means. This is hard for doctors, particularly emergency medicine physicians. We are to have expertise in both trauma and toxicology- two of the main ways to voluntarily exit life. In addition, one must lose the fear of death. It is hypothesized that exposure to other’s pain, injury and death alters that natural resistance against fatality. Basically, we know death and lose our trepidation toward it.
It would seem possible that many residents would drift in and out of these circles depending on their personal circumstances, patient interactions and level of sleep deprivation.
Non-disclosers and Deliberate Suicide Risk
It is often said that most suicidal people will give warning signs. There will be ‘tells’. Although this is true, there are four problems.
First, there are non-disclosers. In the general population this is a quarter to a third of suicidal folks. Since the perceived risk is often higher within the medical profession, it is likely that the percentage of non-disclosers is even higher. When one talks with suicide prevention professionals who work with pilots, they will say that pilots know not to mention suicide because if they do their license to fly will be pulled.
Secondly, the verbal or behavior ‘tell’ may be exceedingly subtle- perhaps only recognized in retrospect. Without a high index of suspicion, it will be written off as normal or just needing sleep. In my own circumstance of saying “there was nothing a 100 units of insulin couldn’t cure” some thought it was a shot at dark humor never questioning the seriousness of every word.
Thirdly, medical education taught us to be very good at ‘faking it until making it’. We have learned how to have a ‘game face’ in times of high stress when we don’t feel prepared. We have learned to be extraordinary compartmentalizers. We can move in seconds from a coded 40-year-old to a patient with a sprained ankle with minimal emotion. What you see is not necessarily what lies within.
Finally, and most frightening, there are some that are deliberate suicide risks. Most people contemplating suicide are ambivalent. They don’t want to die but they haven’t found a different way to live with the pain that they are feeling at that time. Most of these folks are searching for an alternative. In a study of people who were stopped from jumping off the Golden Gate Bridge, 90% never attempted suicide again. Deliberate suicide risks are not those people. Deliberates believe suicide is the answer and have no wish to be stopped.
It is impossible to predict which resident is contemplating suicide or which will attempt it. Given the right parameters, anyone could be at-risk. A better tactic may be ‘vaccination’ or ‘prophylaxis’ of the entire population against suicidal tendency by clearly discussing coping strategies to manage these feelings should they occur.