ED docs at high risk for suicide

Many are reluctant to seek help

The bad news: Nearly three-quarters of ED physicians may experience depression at some point in their careers, and nearly half consider harming themselves. The worse news: Nearly half of those with such problems do not seek treatment.

These are some of the sobering statistics revealed in an article in the March 2006 issue of Emergency Physicians Monthly (www.epmonthly.com). In a survey of 108 emergency physicians, 73% of the respondents reported having experienced depression, and 41% of them did not seek treatment. In addition, 48% considered harming themselves in the course of the condition, and 85% did not report the illness to regulatory authorities, with several noting privately that to do so might jeopardize their ability to continue to practice.

Physicians are uniquely unwilling to seek help, says Louise B. Andrew, MD, JD, an emergency physician and a medical-legal consultant in Victoria, British Columbia, and the article's author. "There is a very real concern that medical boards might jump on us and say we shouldn't be practicing," she says. "You can't blame anyone for not wanting to be forthcoming if it could immediately cost them their livelihood."

Another impediment to seeking help is the "physician mentality," asserts Jack Turner, MD, PhD, FACEP, an emergency physician with Team Health, an organization in Knoxville, TN, that provides ED administrative and staffing services to hospitals. Turner also chairs his organization's Committee on Physician Well-Being and sits on the wellness committee of the American College of Emergency Physicians.

"Physicians think they can do everything," he says. "It's almost a strike against us to admit we are fallible somehow." Also, emergency medicine in general is more a lonely specialty, Turner reports. "We do not have the collegial support mechanisms most other specialties have — the conversations around the doctor's lounge, sitting in our offices around lunch and chatting — and we often do not see other colleagues in the hospital," Turner adds.

Options appear limited

There are some options that may provide confidentiality, notes Andrew.

Some organizations offer employee assistance programs (EAPs) available to physicians, although the number of such programs she is aware of is "vanishingly small." And indeed, Andrew adds, physicians still may be reluctant to visit an in-house EAP "because they fear the licensing board or the employing entity will be notified." This fear exists despite that fact that EAPs are designed to maintain confidentiality, because even such a program may treat physicians differently for fear of liability in the event of patient injury.

Another option is your state's physician health program, she says. "A doctor can go to that organization without reporting directly to the licensure board, but the majority of physicians don't understand or don't trust this as an arm's-length arrangement," Andrew notes. "If you do go to a physician health program, and if they agree with you that you are depressed and that your patients' care might be jeopardized, they can force you into treatment or threaten to report you to the board if you do not comply."

Remember that any person who is depressed may not be thinking very clearly and may need some direction about their options, she says. "[The state's physician health program] actually would be a good place to go, because the doctors they refer to are used to treating doctors," she says. "Many doctors are reluctant to provide care to other doctors or to recognize illness, especially mental illness, in this population."

An ED director who suspects any kind of illness in a staff member should say, "You don't look so good. What's the problem? Is there anything I can do?'" he advises. "Let them know you're asking because you care about them, that you're there to help, and that they can be open with you," Turner says.

This approach may release the physician's reluctance to talk, says Andrew. "It's so unusual for people to show they care about doctors," she notes. "Sometimes the surprise brings a sense of relief, and they think: 'Oh my God, someone really cares!' and let down their defenses."

Creating more opportunity for dialogue between doctors would also help, Turner suggests. "Rather than just having meetings to discuss business, have meetings to discuss the experiential things they do: the difficult cases, those that affected them emotionally," he says. "It may help relieve the cumulative stress."

Turner suggests that a topic a month be selected, such as what to do if you find a colleague who is impaired. "Then, maybe next month, 'What happens if one of us becomes depressed? What do we do? How we help?'" he says.

"You could have a general inservice: education about the signs and symptoms of depression, or other illnesses in physicians," Andrew suggests. "It may not be the least bit unreasonable to have one session of CME a year on impairment."

Where do you get facilitators for such sessions? A good resource is the American College of Emergency Physicians' (ACEP's) practice management department, says Andrew. "There is a superb speakers' bureau on wellness topics," he adds.