Supporting Behavioral Health and Preventing Suicide in Family Medicine

Being a family physician is not easy business. Taking care of people is a big job. Add to that the pace of patient care, administrative and patient workloads, EHR systems and requirements, regulatory burdens, documentation mandatories, and operational policies, you quickly can find yourself getting pulled in a multitude of directions every day. With all that said, you didn’t get into medicine because you thought it would be easy; you wanted to help people.

Admittedly, the day-to-day demands can sometimes wear the best of us down. Over the longer term, these and other pressures can lead to burnout and depression, two known risk factors for suicide. In addition, physicians may struggle with emotional and/or behavioral problems such as mental illness, substance misuse and grief, which also have been linked to self-harm. In the most extreme circumstances, some physicians have taken their own lives. With 300 to 400 physicians taking their lives each year, every health care practice needs to focus its efforts on taking care of its own, and every physician needs to make personal self-care and well-being priorities if they want to help their patients.

With everything else on your plate, it is easy to fall back on the expectation that the levels of stress will ease up or improve in the next week, month or year. But things will not improve without you mindfully advocating for your own well-being.

^{Signs a Fellow Physician May Be Struggling}

Change in appetite, weight, and/or energy level
Suspected alcohol or drug misuse
Errors in clinical care
Issues with patient record keeping
Shortness with colleagues
Disruptive behavior
Patient and colleague complaints
Disengaged from patients and colleagues

A physician who exhibits these behaviors may be struggling with mental illness, substance misuse, grief, burnout, etc., and needs support.

As family physicians, we need to do a better job of taking an active role in taking care of ourselves. Family medicine ranks as the fourth-highest specialty when it comes to burnout, tied with diabetes and endocrinology, radiology, Ob/Gyn, and rheumatology, according to the Medscape National Physician Burnout & Suicide Report 2020. The 2020 report also showed that women physicians (48%) report a greater proportion of burnout compared to men (37%). Plus, of the physicians who said they were burned out, baby boomers often replied they were severely affected by it.

While waiting and hoping for things to get better or resolve themselves, we could be running on fumes ourselves, which will only lead to further distress. Keep in mind, there is a fine line between physician burnout and depression, and both can have severe consequences. The misalignment of work environment and your schedule, which includes a heavy workload, onerous tasks, long hours, and work-life imbalance can lead to emotional and physical exhaustion. Left untended, serious burnout can lead to withdrawal, disengagement or even something worse.

Meanwhile, depression is a common, yet serious, mood disorder that affects how you think, feel, and behave. Although burnout can resolve itself once work conditions become more favorable and you dedicate yourself to well-being strategies, depression is best addressed with the support of a mental health professional and your own physician.

Learn more about factors that contribute to depression and suicide, find out how to identify physicians and trainees most at risk, and become familiar with how to approach a colleague may be struggling in a video from the American Foundation for Suicide Prevention, Physician Mental Health: Preventing Distress and Enhancing Well-being.

Supportive practice steps for family physicians

Even as you work to address your own behavioral health, you can take steps to support your team and encourage a healthy work environment. Keep in mind, fighting the effects of stress and burnout is a continuous process, not a one-and-done solution.

Do not underestimate the emotional stress that you and your colleagues experience on a daily basis.
Make sure your team feels seen, heard, and valued.
Engage with your physicians. Learn what matters to them and what they need to do their best.
Provide physicians the time to undertake positive ways to cope with burnout, such as exercise and talking about concerns with colleagues, family, and friends.
If applicable, offer a workplace employee assistance program (EAP) to reduce stress.
Recommend and/or provide regularly scheduled “safe harbor” team meetings to talk about improving the stress of administrative challenges and practice inefficiencies. Encourage a participatory management style in which physicians focus on long-term sustainability for what can be done to create a healthy happy, engaged, and productive workplace.
Take pulse surveys to gauge physician sentiment.
Remind physicians of available wellness programs and support.
Take defined steps to address concerns, breaking it down into what can be done immediately, in the short term and then in the longer term. Identify ways to measure effectiveness, putting aside those ideas that do not help and seeking new ones to improve the work environment.

^{Ask the Tough Questions}

In 2008, Jennifer L. Middleton, MD, MPH, penned “Today, I’m Grieving a Physician Suicide,” an open letter in the Annals of Family Medicine to a colleague who had died by suicide. She described the shock, grief and guilt she felt following the death of her colleague.

“All of us as physicians also have a responsibility to contribute to a professional culture that, instead of stigmatizing and isolating, is instead affirming and supportive,” she opined.

A colleague who exhibits one or more of the signs listed above may be grappling with extreme, even disabling, distress and needs your help and support. If you suspect a colleague is struggling, consider taking these steps.

Ask them the tough question: "Are you thinking about killing yourself?"
Keep them safe. Ask if they have thought about how they would do it and separate them from anything they could use to hurt themselves.
Be there for them. Listen to their reasons for feeling hopeless and in pain.
Help them connect to a support system. The Suicide Prevention Lifeline is free and confidential: (800) 273-8255.
Follow up with them. Check in with them on a regular basis, especially in the days and weeks after a crisis.