Dr. John Bradford remembers taking the block heater cable, the kind of cable that doesn’t stretch, into the house.
He had just returned home from visiting his daughter, his eldest girl, in Montreal. On the highway back to Ottawa, he thought about driving his car into an overpass. But he worried. “What happens if you survive?” he remembers thinking, “and you’re left paraplegic?”
Inside his house, he thought about where he could loop the cable. He wondered if he would leave a suicide note.
He was in the most lethal phase of post-traumatic stress disorder, a deadly dissociative state where nothing seems real “and you’re only thinking about one thing.”
Then, his daughter called from Montreal. “I’m worried about you,” she said softly.
Dr. John Bradford chose to speak openly about his depression to warn others in the medical field. (Wayne Cuddington / Postmedia News)
“I had been with her just two-and-a-half hours before. We went to a movie; we’d spent time together,” says Bradford, the world-renowned forensic psychiatrist who suffered an astonishing mental collapse in 2010 after watching horrific videos of sexual sadist Canadian Air Force Colonel Russell Williams raping and murdering two young women.
“She’s a clinical psychologist and she didn’t know how suicidal I was, but she was worried about me…. Intuitively, I think she felt something was wrong.”
The call, and another soon after from a family friend, broke the spell. Bradford “kicked out of it,” he says. “These were signs, good signs, that I should not be doing what I was planning to do.” He called two psychiatric colleagues. He returned to the doctor who first diagnosed him with PTSD nearly two years earlier, the doctor whose advice Bradford originally ignored.
Like most doctors, Bradford was a bad patient. “I didn’t follow what I was supposed to do.” This time, he wasn’t given any latitude. “He said, ‘this is what you’re going to do.” Bradford started on psychotherapy and anti-depressants. Since then, “I’ve been — touch wood — fine.”
Bradford chose several years ago to speak openly about his depression, and the demons of PTSD, to warn others in the medical field that what happened to him could happen to any of them. This is the first time he has publicly revealed the depth of it. “Everybody saw me as this tough forensic guy, that nothing would faze me. Well, that was bullshit, right? More than that, it nearly was the end of me.”
When Dr. Michael Myers read of Bradford’s struggles, he reached out. When doctors go public about their own struggle, Myers always sends an email or a card to thank them. “Because they make it easier for other doctors.”
“We’ve done pretty well with the general public in terms of reducing the stigma associated with going for help,” says Myers, an Ontario native and professor of clinical psychiatry at SUNY Downstate Medical Center in Brooklyn, NY.
“But we still have so far to go in the house of medicine.”
Statistics suggest doctors kill themselves at a higher rate than the rest of the population. Male physicians die by suicide at a rate nearly twice that for other men. For female doctors, the risk is two to three-fold higher. A random sample of more than 3,200 doctors from the 2007-08 Canadian Physician Health Survey found nearly a quarter reported a two-week period of depressed mood. “Anhedonia,” a kind of flattened emotional numbness, was reported by one-fifth. In Ontario today, 300 doctors are on disability — the majority for mental illness.
Myers, a past president of the Canadian Psychiatric Association, has dedicated his career to treating doctors in mental distress, to studying what he describes as “the tragedy and enigma” that is suicide among the healing profession.
He and others say the very personality traits that drive people to medicine — perfectionism, an obsession with detail — can make them vulnerable to depression and, in extreme cases, self-annihilation. Not helping matters is the heavy work demands, the stress, and the emotional aspects of dealing with patients — the burnout.
Yet doctors are notoriously bad at seeking help, because to declare any kind of mental illness, to admit to “anything less than perfection,” as one surgeon describes it, can be seen as a sign of weakness. Others fear risking their license, their hospital privileges or professional lives.
In his new book, Why Physicians Die By Suicide: Lessons Learned from their Families and Others Who Cared, Myers chronicles “the inner conflict and the irony of self-destruction and despair” among doctors. He describes doctors struggling to “uphold the demands of their professional persona,” working as if nothing is wrong — never late to the OR, answering pagers and cellphones, inserting breathing tubes or cutting into organs — while slowly coming undone.
“When I did this research,” Myers said, “and I saw there were these families where the (doctor) husband or wife went from well to ill, to death, without going to anyone, like a family doctor, an internist, a psychologist, a social worker, the clergy, a psychiatrist, none of that. They killed themselves. And I thought, this is unprecedented in medicine.”
It’s also a risk to patients. Untreated depression can put patients at risk of medical errors, of substandard or medically dangerous care, he and others say. “People who feel burned out feel overextended and tired, with nothing left to give,” Dr. Paul Garfinkel, professor emeritus at the University of Toronto writes in his book, A Life in Psychiatry: Looking out, Looking In. “They can become negative and cynical and lose feeling for other people, including patients.”
Myers once believed the myth that work is the last thing to go; that doctors are so driven they can work even when their life is in utter shambles. The reality is there are “subtle (and not so subtle) changes in precision and safety,” he writes. A near miss in the OR. A medication error. Sometimes coworkers enable the dysfunction, he says, covering up for the person, “making excuses and taking up the slack.”
Tragically, when doctors on the edge contemplate suicide, they are deadly strategic. They know which drugs produce rapid loss of consciousness and death, or which ones are exceptionally deadly in overdose. “They want to get it right; they want it to be fool-proof; they want to die quickly and completely,” Myers says.
In his book, he describes one female surgeon who, an hour after waking in an ICU after a near-fatal suicide attempt, told Myers, “What kind of surgeon can’t even kill herself properly?”
Canadian data is lacking. In the United States it’s estimated 400 doctors die by suicide every year. Myers believes those numbers are low. Some deaths are ruled “natural” or accidental. Or a physician or coroner may cover up the true cause when filling out the death certificate.
There have been tragedies in Canada: In 2000, Suzanne Killinger-Johnson, a family doctor and psychotherapist who specialized in depression, jumped in front of a Toronto subway train, her six-month-old son in her arms. The baby was crushed to death. His mother, who had been suffering untreated postpartum depression, died eight days later of her injuries.
More recently, in December, Montreal pediatrician Dr. Alain Sirard, under investigation by the Quebec College of Physicians for allegations he had falsely claimed some parents had abused their children, took his life inside his hospital.
Public humiliation and shame are among the leading triggers of suicide, Myers says. Licensure investigations can be even more traumatic than lawsuits, he says, “because they threaten the doctor’s identity so intimately associated with meaning and purpose in one’s life work.”
Doctors can be haunted by mistakes or failures, he adds. “It’s the price to pay for having set the bar so high.”
Arguably the biggest risk Dr. Mark Bernstein has taken in his career was admitting that he suffered from depression. (Peter J. Thompson / National Post)
Pure, natural adrenaline fuels Dr. Mark Bernstein, a neurosurgeon who specializes in brain cancer.
By his estimation, he has operated on more than 5,000 patients with brain tumours. Still, he worries before every one — the night before surgery, on the morning drive to the hospital. In the rarefied and high-stakes field of neurosurgery — and Bernstein is among its stars — there are always technical problems. Arteries in places where they shouldn’t be. Tumours right in the speech or motor part of the brain. Tumours with crucial blood vessels inside them or stuck to them.
“Some operations you go into knowing that you’re likely going to produce a neurological deficit for this patient,” says Bernstein, of Toronto Western Hospital, a pioneer of brain surgery on awake patients. “You do an excellent job; you do everything right. But despite that there’s a decent chance the patient is not going to be a perfectly happy camper at the end of the day. And, that weighs on you.”
But arguably the biggest risk Bernstein has taken in his career was a story he wrote about a brain surgeon in the advanced stages of burnout and depression. The creative, non-fiction piece, written for the Canadian Medical Association Journal, was stimulated by his own brief bout of depression.
Bernstein describes waking drenched in panic and sweat, struggling with feelings of “inadequacy and insecurity,” and sobbing like a baby after hanging up from a call from one of his daughters.
His wasn’t a serious depression. Bernstein didn’t miss any work, “although I’d have to be dead before missing work. But there was no question. It was clinical depression.”
By exposing himself, the risks weren’t just theoretical. “If all the family doctors and neurologists who send me brain tumour patients, if they all read this article and said, ‘this guy is depressed, I better not send him any more cases,’ I could have seen a drop in referrals.” It didn’t happen. Instead, “I had people reaching out,” he remembers.
His brief depression, in 2003, never progressed to the point it affected his medical judgment. While the stigma around mental illness isn’t as strong as it once was, with more attention being paid to burnout, depression and physician “wellness,” it lingers still, Bernstein says. “I think, underneath, covertly, it’s still there.”
The very nature of the work itself can sometimes be depressing. Bernstein recently operated on an 18-year-old girl with brain cancer. “So her parents, these lovely, lovely people, were there with their precious daughter, who they know is probably going to die of brain cancer before she sees her 20th birthday,” Bernstein says.
“If that doesn’t get you, then you’ve got to hang up your spurs and get another job. Because you can’t stop caring.”
Doctors do learn to compartmentalize. “I think the bigger piece is the workload, the bandwidth issue — the making patients wait, the not-having-enough-hours-in-the-day …. the administrative crap, the system imperfections, the constant worry that you’re not going to serve patients well enough… It’s that sensation of drowning all the time. And that’s the way a lot of doctors are functioning in our system,” says Bernstein. “It’s frightening and it’s exhausting and it leads to depression.”
In a recently published survey of more than 2,100 physician-mothers who belong to a closed Facebook page, half of them believed they met criteria for a mental illness at some point in their careers — but had never sought help. Only six per cent who received a formal diagnosis reported it to their licensing boards.
The survey’s lead author, Dr. Katherine Gold of the department of family medicine at the University of Michigan, was surprised how often the women would warn each other against seeking treatment. “Instead they would say, ‘if you need help, go to a different town or make sure you pay cash for your prescriptions.’”
Many confessed to writing their own scripts for tranquilizers or antidepressants, or asking a trusted colleague, “I’m going through a rough time, could you write me for some Zoloft?”
“We just really need to make it normative for physicians to get help if there’s a problem,” Gold says. “We need to help them realize it doesn’t make them a worse physician or a worse person.”
When Dr. John Bradford realized he was in serious trouble, he contacted the Ontario Medical Association’s Physician Health Program, which refers doctors for assessment and treatment of problems related to stress, burnout, mental health, addiction and other issues. The program monitors about 140 doctors at any given time, 90 per cent of them ending in “satisfactory completion.”
“They jumped on it immediately, they did everything right,” Bradford recalls, adding his hospital’s CEO was also supportive.
“But to take that first step was anxiety-provoking. I was just in such bad shape at that point, I didn’t have a choice.”
Myers, in his research, found some physicians are dressed as doctors when they take their lives. One of his patients changed out of her street clothes and into her surgical scrubs before injecting herself with a lethal overdose. Another male doctor was found on his examination table, his wrist tethered to an IV pole with his belt.
“Could the means of death or setting of death have medical meaning?” Myers writes. “That in the moment of time, the individual is really in the role of physician?
“We can only hope the doctor has found some good memories and comfort in those lonely final moments of life.”
Dr. Michael Myers was a first year medical student at Western University in London, Ont., in the early 1960s, when his roommate killed himself. His body was found in his parked car on a deserted stretch of a Lake Huron beach. The experience influenced Myers’ own career as a doctor. Myers recently published Why Physicians Die By Suicide: Lessons Learned from their Families and Others Who Cared. The following is an edited transcript of an interview with the National Post’s Sharon Kirkey.
The loss of my roommate to suicide when I was a first year medical student, I think, was really pivotal. I buried that; I didn’t really pay attention to it. There was such a stigma associated with suicide.
I was the last one, I think, to see him alive from our class. We were both saying goodbye for the weekend. It was superficial talk, “see you after the weekend.” And when I went back he had killed himself. I tried to talk to my roommates about it, but I guess they were awkward about it, and we heard nothing from the dean’s office or the medical school. It was as if he never existed.
It wasn’t until I finished medical school, when I was interning in Los Angeles, I began to see and look after more and more people who had made very serious suicide attempts. I worked in Detroit for a year as an emergency doc, and I saw the maiming that occurs with suicide attempts — by gunshot injury or jumping from heights or severe overdoses that really damage the body. I went back to Los Angeles to do internal medicine and saw more of that. That really kind of directed me into psychiatry. During my psychiatry residency, I just happened to look after physicians and their family members. I began to get more and more doctor referrals.
When your roommate died, you said no one really talked about it, that it just “sat there.” How has that culture changed?
It’s changed tremendously. When the cause of death is known to be suicide, there’s always a response now. If it’s a medical student, it emanates from the dean’s office. They have grief counsellors or so-called critical incident debriefing. They meet with the medical school class. You walk a fine line between acknowledging the person died by their own hands and and not sensationalizing it.
(When there is a physician suicide in smaller communities) that’s when there are a lot of very raw and very painful emotions in doctors. Because not only are they grieving the loss of a colleague or friend, but there’s a great deal of blame and self-responsibility as well. They feel often they missed clues or didn’t reach out enough. Or sometimes they worry about who might be next. Because if it’s a stressed community with a shortage of doctors, so many of them will say, ‘of all of us, he seemed really to be coping the best.’
I mention in the book that some people feel that there’s an ethical problem — that we physicians shouldn’t be allowed to kill ourselves. That we just have to suck it up if we get depressed and suicidal. That we’ve got a responsibility to our patients.
Why was it important to interview family members — the spouses and children of doctors who died by suicide?
I’ve felt for so long their voices really needed to be heard. These people have on-the-ground observations. You’re entering the world of grieving people, and yet they want to talk, because there’s a lot they want to say.
The one thing I uncovered most was stigma. Either that (the doctors) really, really delayed going for help so they were very sick when they first knocked on someone’s door, or they didn’t go for help at all. That was what I found most disturbing.
Many managed to go into work even when they were quite symptomatic — that’s the other thing I heard from families: “I don’t know how my wife did it. She was not functioning at home at all for the last six months of her life. But she kept going into work; she kept delivering babies. And one day, she just didn’t come home.”