We Lost Another Great Doctor Today to Suicide

About 300 to 400 physicians die by suicide each year, averaging one per day. Physician suicide is part of an epidemic—an epidemic of burnout, depression, and departure from medical practice through early retirement or a change to a nonclinical career. Physicians who complete suicide represent just the tip of the iceberg of clinicians who have had suicidal thoughts at some time in their careers, estimated to be about 10%.(1,2) And, like an iceberg, the circumstances surrounding physician suicides may be submerged and shrouded in mystery, which makes it difficult for patients and colleagues to understand and come to terms with the loss.

“Page Not Found”

I found this to be the case following the suicide death of my neurosurgeon. Less than a week after he died I clicked on his “link” to an affiliated hospital’s website, only to be informed: “page not found.” The neurosurgeon’s online obituary was likewise unrevealing: “Dr. David Thomas Keller (a pseudonym) passed away suddenly. He was 55 years old. He is survived by his loving family . . .”

Tributes poured in from colleagues and patients, and a memorial service was held at a nearby church. However, there was no mention of suicide or the circumstances surrounding Dr. Keller’s death. Remembrances and condolences posted online were incredibly heartfelt but also silent about the cause of death. One could only wonder why a brilliant neurosurgeon in the prime of his career decided to end it so abruptly. Without knowledge of the events leading up to Dr. Keller’s suicide, how could his patients accept it and move on? How could the medical profession possibly learn from Dr. Keller’s suicide and prevent the same tragedy from happening to another physician, inflicting untold pain and suffering on the family?

A Trustworthy Person

Let me be clear. I was Dr. Keller’s patient, not his colleague. I did not know him professionally, and what little I knew about him personally was mostly by word-of-mouth and from his online biography before it disappeared from the Internet. Everything I read about Dr. Keller led me to believe this was a person I could entrust with my life—educated and trained at top institutions, an instructor for the American Association of Neurological Surgeons’ Board certification review course, an honorably discharged naval officer, chief of his hospital’s surgery department, and an overseas volunteer performing brain and spinal cord surgery on people who could not afford healthcare.

My first appointment with Dr. Keller occurred in 2015. I was experiencing excruciating pain and loss of strength in my right leg. I needed a walker to ambulate. For the past month, I had been seeing a chiropractic doctor who diagnosed iliotibial band syndrome, but I had not improved with treatment. A radiologist’s reading of my lumbar MRI did not pinpoint the source of my problem. When Dr. Keller entered the office he smiled, extended a firm handshake, and said, “Hi. I’m Dave Keller. What’s going on?” I explained my symptoms and told him they began after bending awkwardly while making some home repairs.

Dr. Keller independently reviewed the imaging study. “The radiologist missed it,” he exclaimed! “See this area here,” pointing to a far lateral lumbar (L3-4) disc herniation. “This type of herniation is uncommon but very painful because the disc sits right up against the nerve root ganglion,” he commented. Dr. Keller correctly diagnosed my disorder as a severe lumbar radiculopathy. He scheduled surgery in three weeks; however, my condition seemed to improve on its own. I called Dr. Keller the day before surgery. He said the phenomenon of lumbar disc herniation resorption is well recognized, and he surmised it explained my improvement. “Let’s cancel surgery for now, start physical therapy, and give it more time,” he recommended. I recovered without surgery.

A Great Surgeon

I’ve been told that the difference between a good surgeon and a great one is that the latter knows when not to operate. Dr. Keller certainly fulfilled that criterion. However, a year later, I was unable to escape the fate of surgery. My disc had reherniated. Neither of us believed another spontaneous remission was likely, and I did not want to endure more pain. Dr. Keller performed a microdiscectomy with good results. I was walking within two weeks relatively pain-free. Dr. Keller saw me in follow-up and discharged me from his care in early 2017.

In late 2018, I phoned his office for an appointment to discuss additional back and leg symptoms resulting from progressive degenerative disc disease and spinal stenosis, as revealed on a recent lumbar MRI. The receptionist told me Dr. Keller was on “indefinite medical leave.” Would I like to see his physician assistant, she asked?

I met with the physician assistant in February of 2019. He suggested I try physical therapy before considering surgery for spinal stenosis. “What can you tell me about Dr. Keller?” I asked. The physician assistant replied it was confidential, but that Dr. Keller’s medical leave was for a family member and not for himself. His return-to-work status was uncertain. I reluctantly sought consultation from several other neurosurgeons, each recommending different surgical procedures. It was not until May of 2019, shortly after Dr. Keller’s death, that I learned through the grapevine that he had died by suicide.

Standing Room Only

Dr. Michael F. Myers, Professor of Clinical Psychiatry in the Department of Psychiatry and Behavioral Sciences at SUNY-Downstate Medical Center in Brooklyn, New York, is one of the world’s leading authorities on physician suicide. In 2016, Dr. Myers and I, along with psychiatrist H. Steven Moffic, conducted a standing-room-only workshop at the annual meeting of the American Psychiatric Association. The topic of the workshop was post-traumatic stress disorder (PTSD) in physicians, which we considered a hidden epidemic.(3)

Physicians are burning out at record high numbers, and medicine now has the highest rate of suicide of any profession.

The progression from PTSD to burnout to depression and suicide is not inevitable, but it is certainly possible. Much of physician burnout is related to “administrative creep”(4)—the piling on of excessive tasks to physicians who can’t, and won’t, say no, in essence taking advantage of their good will. In addition, practicing with limited resources combined with the burden of electronic health systems, prior-authorization requests, and the omnipresent threat of litigation, contribute to burnout. Physicians are burning out at record high numbers,(5) and medicine now has the highest rate of suicide of any profession, considerably higher than that of the general population.

Prevention

Whether or not Dr. Keller’s suicide was due to burnout or depression is unknown. However, it is clear that some suicides could be prevented if more physicians were inclined to seek treatment, and if barriers to seeking treatment were removed, especially the stigma attached to mental health treatment. Questions related to mental health treatment are asked on licensing and credentialing applications and frighten physicians who have sought treatment in the past or are contemplating it in the future. Regulators may have concerns that psychiatric treatment might jeopardize physicians’ ability to practice medicine. Public disclosure of psychiatric treatment may lead to shame and guilt, igniting the development of PTSD and depression.

Understanding physician suicide is complex, because the dynamics underlying it are many and varied.

According to Dr. Myers, understanding physician suicide is complex, because the dynamics underlying it are many and varied—a perfect storm of biopsychosocial factors. New research, however, suggests that information on just a few key risk factors may help predict future suicide attempts with a high degree of accuracy.(6) Still, there will always be a small percentage of physicians who die unpredictably by suicide and the reason remains a mystery to everyone. “They have taken the answer(s) with them,” remarks Dr. Myers. “Even a psychological autopsy does not yield much clarity.”(7)

Physicians like Dr. Keller who complete suicide for unknown reasons leave behind grieving family, friends, colleagues, and patients, but also unresolved and unsettling feelings and memories, which makes it difficult for loved ones to find closure. The inability to backtrack and piece together warning signs and know for sure what pushed physicians to the brink impedes emotional healing and accommodation to the loss. Painful endings such as Dr. Keller’s highlight more than ever that physician wellness is indeed the missing quality indicator in medicine today.(8)

References

1. Rotenstein LS, Ramos MA, Torre M, et al. Prevalence of depression, depressive symptoms, and suicidal ideation among medical students: a systemic review and meta-analysis. JAMA. 2016;316:2214-2236.

2. Zisook S, Young I, Doran N, et al. Suicidal ideation among students and physicians at a U.S. medical school: a healer education, assessment and referral (HEAR) program report. Omega–Journal of Death and Dying. 2016;74(1):35-61.

3. Lazarus A. Traumatized by practice: PTSD in physicians. J Med Pract Manage. 2014;30:131-134.

4. Ofri D. The business of health care depends on exploiting doctors and nurses. The New York Times. June 8, 2019. www.nytimes.com/2019/06/08/opinion/sunday/hospitals-doctors-nurses-burnout.html .

5. 2018 Survey of America’s Physicians: Practice Patterns & Perspective. Survey conducted on behalf of The Physicians Foundation by Merritt-Hawkins. https://physiciansfoundation.org/wp-content/uploads/2018/09/physicians-survey-results-final-2018.pdf .

6. Zuromski KL, Bernecker SL, Gutierrez PM, et al. Assessment of a risk index for suicide attempts among US Army soldiers with suicide ideation: analysis of data from the Army Study to Assess Risk and Resilience in Servicemembers (Army STARRS). JAMA Netw Open. 2019;2(3):e190766. doi: 10.1001/jamanetworkopen.2019.0766.

7. Myers MF. The complexity of physician suicide. The BMJ Opinion. August 31, 2018. https://blogs.bmj.com/bmj/2018/08/31/michael-myers-the-complexity-of-physician-suicide .

8. Wallace JE, Lemaire JB, Ghali WA. Physician wellness: a missing quality indicator. Lancet. 2009;374:1714-1721.