Losing Balance: How to Address High Rates of Suicide among Orthopaedic Surgeons

Mental illness and suicide have long been cloaked in shame. Sadly, a suicide or suicide attempt will touch most people indirectly or directly: an acquaintance, friend, or, perhaps most painfully, a family member. The suicide of an orthopaedic surgeon can be a tragic mirror for others in the profession.

Shining light on the topic removes stigma, which may help encourage surgeons (or anyone) to seek treatment that could avert a tragedy. Over the past 5 years, robust writing in both the lay press and orthopaedic literature has explored burnout and mental illness. The number of articles on suicide risk has grown in the orthopaedic literature following the 2020 publication of a sobering article in the Annals of Surgery that noted that suicide rates among orthopaedic surgeons led all other surgical specialties.

Risk factors
Underlying mental illness contributes to suicide risk. Multiple studies have demonstrated high rates of depression, anxiety, and even suicidal ideation among medical students, residents, and surgeons. Use of alcohol or other drugs may emerge as a coping mechanism for stress or mental illness, further contributing to a risk for suicide. A study found that 61 percent of orthopaedic residents met criteria for alcohol or drug abuse.

Lifestyle factors impact suicide risk as well. Long work hours contribute to social isolation, identified as one of the strongest predictors of suicidal ideation and attempt. Working long hours during training also creates vulnerability for surgeons at that stage, with suicidal ideation reported by roughly 10 percent of medical students and 16.6 percent of interns. Once a person is in practice, stressors may change but they do not disappear; one survey demonstrated a suicidal ideation rate of one in 16 surgeons. Work hours continue to be lengthy and demands of chart and message completion—even from home—create further isolation from family and friends. Call duties restrict time available to participate in hobbies or activities that can nurture relationships. There is robust literature supporting the positive impact of exercise to ameliorate symptoms of depression, but the time constraints engendering social isolation also limit access to physical activity.

Among surgeons, some nonmodifiable factors impact suicide risk. The surgeon survey identified middle-aged, white males as the majority of surgeons who died by suicide, matching the demographic makeup of orthopaedic surgeons at large. Black surgeons were 56 percent less likely to die by suicide, but surgeons who were Asian or Pacific Islander were 438 percent more likely to die by suicide. Suicide deaths are 250 to 400 percent higher among female physicians relative to other professions. Among practicing orthopaedic surgeons, women have the greatest lifetime rate of suicidal ideation, at 32.8 percent.

Although cognitively surgeons recognize that adverse outcomes will occur, most retain a personal expectation of perfection. When a case goes poorly or a patient has a complication, guilt and self-recrimination may torture a surgeon. Certainly, when litigation follows, burnout, depression, and suicidal ideation can all ensue, contributing to the finding of an odds ratio of 3.89 for civil/legal issues among surgeon suicide victims.

Beyond the stressors from direct patient care, other professional work demands have been associated with increased suicide risk. Orthopaedic literature now abounds with articles addressing the high prevalence of burnout in the profession, detailing the factors which contribute and the impact on surgeons, the healthcare system, and patients. The relationship between suicide risk and burnout has varied among studies, but potential contributing factors should be considered, such as workload, lack of control, and documentation/electronic health record demands.

Finally, although mental illness and personal stressors lead many to attempt suicide, an attempt is more likely to be successful among physicians. They have knowledge of and access to self-destructive means, so a cry for help in a nonphysician can become a markedly elevated suicide rate among physicians relative to the general population.

Barriers to seeking help
Physicians may be vulnerable due to a professional culture that values stoicism and strength. Studies demonstrate that medical students and residents continue to feel a strong stigma against accessing mental health services.

A recent survey of practicing physicians demonstrated that 52 percent of respondents with suicidal ideation failed to seek any treatment, claiming, “[I] can deal with this without a professional.” For surgeons, the estimated rate of failure to seek treatment is even higher, at 60 percent.

Even for physicians recognizing an issue, admission of a mental health challenge carries not only social stigma but also potential professional repercussions. Historically, most state medical boards have required disclosure of any mental illness, even if there is no reported functional impairment associated with the diagnosis. The Federation of State Medical Boards does not require mental health questions and encourages state licensing boards, hospitals, and insurers to focus on current impairments rather than diagnosis and to avoid public disclosure, as that could discourage physicians from seeking treatment.

The Dr. Lorna Breen Heroes’ Foundation and the Dr. Lorna Breen Health Care Provider Protection Act facilitate reduction and prevention of suicide, including working with medical boards. As of May 2023, 21 states had eliminated broad questions regarding mental health or substance abuse.

Interventions
How do you raise a topic no one wants to discuss? For individuals and institutions, this requires recognizing that suicide is a real threat for surgeons and destigmatizing it.

Heal (or at least diagnosis) thyself. Table 1 lists individual and institutional interventions that can be used to address risk factors of suicide. The value of screening tools for mental health and substance abuse is taught in medical school, but surgeons often struggle to perceive themselves as patients. Fig. 1 lists some common self-assessment tools to aid in the diagnosis of depression or substance use issues. The Patient Health Questionnaire 9 screening provides an objective way to assess depression in a patient—or a friend, a colleague, or oneself.

Other self-assessment tools, such as the CAGE (Concern, Annoyed, Guilty, Eyeopener) assessment, AUDIT (Alcohol Use Disorders Identification Test), and TAPS (Tobacco, Alcohol, Prescription medication, and other Substance use tool) can be used for diagnosis of substance use disorders. Making the diagnosis is the vital first step in any treatment.

Seek therapy. As the stigma against mental illness including depression and anxiety fades, there are encouraging signs that more physicians are sharing suicidal ideation with therapists. When mental health professionals may be colleagues, accessing help through routine channels may feel daunting.

hysicians dying by suicide have been found less likely to be receiving treatment for depression compared to nonphysician suicide victims. In crisis situations, phone, text, and online services are available, including those directed at physicians and healthcare professionals. Fig. 2 has several phone and online resources for physicians.

Make connections. Prioritize time with your partner, family, or close friends. Recognize that even loved ones may not understand the pressures of patient care that bring a surgeon to the point of suicidal ideation. Consider a trusted colleague, perhaps from another institution or city. Some of the resources listed in Fig. 2 connect physicians with other physicians who can offer a shared perspective.

For institutions, use any of the recent AAOS Now articles on burnout or mental health, including those that specifically mention suicide, for journal clubs (some are provided in the references in the online version of this article). Departments can also open discussions about suicide risk, establish peer groups to address work stressors and enhance personal connections, and provide information on confidential programs for mental health intervention.

Orthopaedic surgeons save limbs and lifestyles. Lifting the shame from mental illness and suicide can save a life.

Alexandra E. Page, MD, FAAOS, is a foot and ankle specialist in private practice in San Diego and the deputy editor of AAOS Now.

References

1. McKenna J: Doctors’ Burden: Medscape Physician Suicide Report 2023. Available at https://www.medscape.com/slideshow/2023-physician-suicide-report-6016243?0=reg=1.
2. American Foundation for Suicide Prevention: Facts about Mental Health and Suicide Among Physicians. Available at https://www.datocms-assets.com/12810/1578319045-physician-mental-health-suicide-one-pager.pdf.
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9. Pearl A, Saleh K, Quick JC: Identifying and addressing burnout in the orthopaedic surgeon. J Am Acad Orthop Surg 2023;31(5):229-38.