By: Jessica Gold
Today is National Physician Suicide Awareness Day. To honor this day, we could talk about how 300-400 physicians die each year due to suicide, or the fact that women physicians die by suicide at rates over two to four times the rate of women in the general population. We could also discuss the barriers to care in physicians and why so many suffer in silence in the first place. But, instead it felt important to tell a different story and one that we hear less often: one of survival.
Dr. Justin Bullock is a resident physician in Medicine at University of California, San Francisco. He first experienced depressive symptoms at age 16, with his first suicide attempt in high school around the time he came out to his family. By the time he first arrived at medical school, he was well versed in the mental health system. He had even encountered stigma towards medication in his own family that prevented him from starting any medication in college for years until his track coach suggested it. But, even coming into medicine with a diagnosis and set up with providers, knowing that he had “lived [his] life for long enough to recognize that this is probably going to happen again,” he still was unaware of what it meant to be someone with a mental illness in medicine.
Halfway through his first year of school, Justin says he felt “gray,” which is a symptom he notices when he gets depressed. That was the start of the worst depression he has ever had, with intensifying suicidal thoughts and self-harm behaviors. Once he was put back on medication by a psychiatrist, he became activated, going from sleeping 6 hours a night to only 90 minutes, and not needing any more than that. Because of those symptoms, his doctors then brought up a new diagnosis with him: Bipolar Disorder, a diagnosis that his father had, and looking back, made sense to him. Yet, his “up” periods were episodes of what is called hypomania, or less severe symptoms and shorter episodes of mania. In him, they had always seemed like a good thing as he was very productive, remained generally risk averse as a person and good with money, and his impulsivity, when worsened, was “probably more like what normal people do,” as he did not drink until age 21, for example.
Still, Justin struggled with his mental health for the next year and had a severe suicide attempt in his second year of medical school requiring an intensive care unit admission. When discussing the misconceptions of suicidality, he highlighted that many people think people with suicidal thoughts are irrational, and they can’t make reasonable decisions. But, in actuality, there are people who live their lives every day with suicidal thoughts and, as he points out, “that does not mean they’re not exceptional at whatever they do. It just means that they are struggling and suffering in a very profound way…I’ve used suicidality as a marker of suffering and not as a marker of competence.”
After his attempt and hospitalizations, he had difficulty going back to medical school, but his school was very supportive. He says he was lucky, though, that his struggles happened when he was in pass/fail courses and he could simply come back, do well on his rotations, and go where he wanted for residency.
Still, despite the support he received from his school and peers, even when he spoke out year after year on days that his medical school had to highlight mental illness narratives in medical students and normalize them, people repeatedly warned him of the repercussions of his honesty. They told him about questions on licensing boards and Fitness for Duty evaluations. But, he had learned not to be ashamed. To him, his Bipolar is both a gift and a curse. He says, “if you’re ashamed of it, then you end up missing the beautiful ways that it actually makes your life better.”
Open and ready for the next step, before Medicine residency began, he disclosed his diagnosis to his program, making sure he had accommodations for appointments, and “that everyone knows that there’s like a thing about Justin.” Yet, like he expected it to eventually, “the thing” caught up to him again. When he was switching between nights and days as an intern, as many people warned him it would, he suddenly became really activated from not sleeping. Then, as is classic with Bipolar, afterwards he crashed, and became depressed again.
Though sleep shifting was the trigger this time, it really could have been anything. He emphasizes that in medicine you work so hard there is little left in your reserves. He explains, “at any point in your life, you’re okay, but if one little tiny thing falls out, then it just collapses. It’s like Jenga, but you have one block that you can pull and no matter what that block is, it’s the one block that’s going to make everything fall.” And, fall he did. He had another suicide attempt, only this time when he called 9-1-1, he was brought to the hospital where he trained. This part, he said, “ended up being very very problematic.”
After recovery and a month long treatment program and despite having clearance to return to work by a therapist and psychiatrist, Justin was referred to the Well Being Committee at his institution and told he needed to go through the Fitness for Duty process. He felt this decision for him to undergo this particular type of evaluation made no sense as those evaluations were typically for providers for whom there are concerns about impairment while practicing medicine. Though he had obviously been ill, he felt that he had actually shown considerable insight into his disease, always taking off work before his symptoms worsened, and having clinical evaluations with no performance issues. He believed, instead, he was referred for evaluation because he was always so open about his mental illness, and had even written about a previous voluntary hospitalization earlier in the year in the New England Journal of Medicine. Subsequently, everyone knew he had a serious mental illness.
Bipolar, Justin says, is often much more stigmatized, than Depression alone. This is, in part, due to the symptom of impulsivity. He said, “The manic side is viewed as very dangerous. I think that a lot of people really have a very specific sort of image in their mind of what a person with Bipolar looks like.” As a result of that image, he felt his judgement was questioned, even if he was not a person who was typically impulsive when he was manic. He adds, while he had never before felt ashamed of who he was or his illness, he felt the process of the evaluation and how invasive it was, made him ashamed.
Justin emphasized,“People deserve to be treated like humans…if this was my first time dealing with Bipolar and my first time being diagnosed I would live the rest of my life in shame because of this process, because of how terrible it was and how harmful it was.” He adds that he feels the evaluation for him reversed years of therapy and caused significant damage, even if he is still proud and open about his disorder.
Among the many issues that he had with the process itself, he felt many of the things he had to do, like talk about all of his childhood trauma, did not feel relevant to his job, his work, or his performance. He also felt like the process itself was not transparent or racially sensitive, and in the end, when they told him he needed to do dialectical behavioral therapy for the remainder of his residency, he felt “very strongly that is completely inappropriate for my job to dictate my medical treatment, especially when I had no performance concerns.” He added that anyone with medical illnesses would not be treated in the same way.
UCSF Health’s Physician Mental Health Services emphasized in an e-mail that it has prioritized the mental health of physicians for years, and even more so over the Covid-19 pandemic, and is continuously working to improve the support it provides. It emphasized that the Physician Well Being Committee, which it has just like every hospital accredited by The Joint Commission, provides resources for staff members who may need help with chemical dependency or mental illness. The program is entirely voluntary and it’s goal is “always, first, to provide the compassion and assistance our physicians need to address the issues they face and continue to pursue their careers.” The committee is made up of “a diverse group of medical and administrative leaders at UCSF, including broad representation from the LGBTQ community, as well as members from diverse ethnic and socioeconomic backgrounds.”
To protect confidentiality, the program is bound by state and federal statutes and for each evaluation, it brings in outside experts with specific subject matter expertise relevant to the individual involved to diagnose and recommend the appropriate treatment. If the participant does not agree with the expert recommendations, the committee will then thoughtfully assess the expert’s conclusions based on “what we believe will enable the physician to make a successful rehabilitation.” The participant, then, has “every right to decline this assistance.” Most importantly, the e-mail emphasized, that for the committee it is important that “first and foremost – no one is harmed by the situation, including the participant.”
The good news is that because Justin has always been vocal about his story, his experience is leading to real change. 600 residents at his institution signed a petition in support of him and he is optimistic that changes will be made to the Fitness for Duty process overall (at his institution but ideally more broadly). To him, evaluations make sense and he should have been evaluated, but there needs to be transparency about the process and what the process looks like needs to change. He adds, “How do we create a system in which people are, you know, prized for coming forward, and getting help. As opposed to penalized.” According to UCSF Health’s Physician Mental Health Services, “UCSF Health has initiated an internal review of the committee to review the Physician Well Being Committee process, including its members, to assess ways to enhance it further and better support our physicians.”
Justin’s story is just one story, at one institution, but he is far from alone. Each time he has spoken out publicly, online or written about it, Justin says that people come up to him and share their stories or write to him and explain how his experience resonated. He thinks people can relate because, “I’m pretty realistic about mental illness and it’s not like ‘oh I defeated suicidality and I never have to deal with it again,’ that’s not how it is for me. And, it’s not how it is for most people.” He knows there are more stories of suicide survival in medicine, we just don’t talk about them. Today seems like a good day to start.
If you or someone you know needs help, call 1-800-273-8255 for the National Suicide Prevention Lifeline. You can also text HOME to 741-741 for free, 24-hour support from the Crisis Text Line. If you are a physician in need of free and confidential help, you can call the Physician Support Line, 1-888-409-0401, 7 days a week from 8 am to 1 am EST. Outside of the U.S., please visit the International Association for Suicide Prevention for a database of resources.
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