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Who Cares for the Caregivers? Reaching the Limits of Public Policy

The views expressed are those of the author and do not necessarily reflect the views of ASPA as an organization.

By Burden Lundgren
August 20, 2018

This summer, the Centers for Disease Control and Prevention (CDC) issued a stunning report on the incidence of suicide in the United States. From 1999 to 2016, suicide rates increased more than 25 percent to 45,000 deaths per year. That is more than from breast cancer, and twice the number from homicides. Some of these are certainly what have been labeled “deaths of despair”—suicide coupled with poverty and alcohol or drug abuse—but there is no clear pattern. Suicide is increasing in all areas of the country, across all races, ages and social classes.

Dr. Thomas Insel, former director of the National Institute of Mental Health (NIMH), has identified a frustrating lack of accountability for the rising number of deaths by suicide. “In contrast to homicide and traffic safety and other public health issues, there’s no one accountable, no one whose job it is to prevent these deaths – no one who gets fired if these numbers go from 45,000 to 50,000… It’s shameful. We would never tolerate that in other areas of public health and medicine.” Actually, we tolerate it within the discipline of medicine itself. Those caregivers who themselves might help stem the tide of suicide are themselves disproportionately part of it.

Doctors commit suicide at more than double the rate of the general population and at the highest rate of any profession. In a recent poll, 65 percent of physicians said they have known a doctor who tried or completed a suicidal act. At first thought, it might be supposed that the daily stress of making life or death decisions might be a driver of suicidal behavior. In my experience, that’s not the hardest part of the job. Health care exists largely in a toxic workplace environment. There is a substantial literature on bullying in health care because bullying is so common. Education is often by intimidation and humiliation. Fear of punishment for making a mistake is ever-present. John-Henry Pfifferling, PhD, an anthropologist who spent six years studying medical residents called the culture “brutal”.

Dr. Rosalind Kaplan, who left practice after 30 years, described the prevailing ingrained mindset as being driven to do one’s very best, punishing both individual physicians and others, being good soldiers no matter what the cost, sacrificing one’s self to the profession. Physicians complain of a number of stressors: being forced into a mold that may not fit, chronic lack of sleep, the need to justify treatments to insurers, social isolation (one in three doctors report feeling lonely within the past week), the unrelenting requirements of completing electronic health records, and demands for “productivity” by employers and practice managers (fewer than half of physicians own their own practices and a third are employed by hospitals). Then too, there may be an issue of self-selection. Those who go into medicine are high-achievers, competitive, often perfectionistic. Would those qualities predispose them to suicide no matter what their profession?

In the past two years, news about physician burnout has arrived on my screen more and more often. Like physician suicide, it is difficult to discern whether burnout rates are increasing or simply coming under more scrutiny. Burnout is described in Merriam Webster as “exhaustion of physical or emotional strength or motivation usually as a result of prolonged stress or frustration”. Surveys indicate that more than half of physicians report at least one symptom of burnout with 30 percent reporting suicidal thoughts, twice the rate of the general population.

It would seem simple to draw a through line from burnout to depression to suicide, but that line may not exist. Depression rates are the same for physicians as for the general population, though the rates are higher for medical students and residents. Ironically, psychiatrists have one of the highest suicide rates.

There is considerably more bemoaning the problem than suggestions to help. The notion of offering more mental health services often comes up, but that is little use to those in a culture where using them is not only stigmatized, but presents a real threat to licensure. Physicians may also leave clinical practice and put their skills to use in other areas – a move that to many looks like giving up.

Here again, there is no accountable body to address the problem. Most health professions regulation is in the hands of state boards, the members of which are physicians steeped in the “brutal” culture themselves. Medical schools might be expected to address the issue, but they are ruled by the same social mores. The suicides of hundreds of physicians each year leave thousands of patients abandoned. In an ideal world, demands to address the problem would come from them, but patients have almost no voice in the health care system. I prefer to think there are solutions for problems like this, but here we have a reified system that creates an endless loop of suffering leading to an endless supply of casualties. The next time you go for a check-up, please be kind. The doctor you save may be your own.


Author: Burden S. Lundgren, MPH, PhD, RN practiced as a registered nurse, specializing in acute and critical care. After leaving clinical practice, she worked as an analyst at the Centers for Medicare and Medicaid Services and later taught at Old Dominion University in Norfolk, Virginia. She has served as a consultant to a number of nonprofit groups. Presently, she divides her time between Virginia and Pennsylvania. She can be reached at [email protected]

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The American Society for Public Administration is the largest and most prominent professional association for public administration. It is dedicated to advancing the art, science, teaching and practice of public and non-profit administration.

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