Almost two years ago I went to the funeral of a medical school classmate.  A little more than three weeks before he had jumped from a parking garage after finishing his clinic.  He had a loving wife and three young children. He had the respect of his colleagues and the love of his patients. There was nothing out of the ordinary in his financial or personal life. It didn’t make sense, but it rarely does. Something broke inside the mind of someone I have always known to be a happy, easygoing person.

I don’t know why he committed suicide. It seemed to be related to a recent period of intense, severe depression.  I don’t know if the pressures of being a physician were a factor, but I do know that physicians have one of the highest, if not the highest suicide rate of any profession; nearly twice the rate of suicide compared to the general population.  It may actually be higher. There is tremendous social and institutional pressure to label a death an accident instead of a suicide when ambiguous. If any cohort of people could make suicide look like an accident or death from natural causes, it would be someone in the medical profession.

Of my medical school class of about one hundred, two have been lost to suicide before my 41st birthday. The first was before we even finished medical school. Why do we lose so many physicians to suicide and how many more will be lost?

There are pressures to being a physician that are unseen by most people not working in the medical field.  Rates of burnout and major depression are higher in medical students and physicians, and we tend to not seek treatment.  Why would we? There is a stigma to mental health problems. Many people view them as a weakness rather than a serious and very real disease. We would never view one of our patients this way, but sometimes we do treat our peers and ourselves this way. Physicians are often afraid to seek help because of fear of losing their medical license, hospital privileges or malpractice insurance.  The inconsistency of treatments prescribed by medical boards and physician ‘help’ programs discourages those who need help the most to seek it. If you know a colleague who has gone through this process you know exactly what I mean. Some of these programs cause more economic stress, guilt, shame and depression than they cure. They are a blunt instrument.

Many medical schools and residency programs teach us to “suck it up” and “tough it out,” not to seek help.  Maybe not always explicitly, but this is the culture. Residency is a time of being constantly sleep deprived, stressed out and living a very unbalanced life.  Work-life balance, whatever that means, is an abstract concept. It is not hard to imagine why a resident would have a higher rate of suicide, but my friend was a decade into his practice.

In some ways, life and practice are easier after residency but in other ways, they are much more difficult. The time commitments are generally less with fewer sleepless nights on-call, but the pace increases and the stress never really goes away. The administrative and bureaucratic realities of practicing medicine weave their way into daily life. These facts surprised me my first few years of practice, and medicine has seemed only to increase in complexity over the last decade.

I became good at managing the stress, though, and by this, I mean suppressing the negative feelings. Physicians are good at delayed gratification. We are good at telling ourselves we are living “normal” lives when anyone living outside of medicine would never consider our existence normal.  We tell ourselves it is normal because compared to residency, it kind of is in a perverse way. It works for a while, and many are able to do it their whole careers, but some can’t. I was good at it right up until the point that I wasn’t.

Being a doctor can feel very confining at times. There is an upfront investment of time and money that is greater than most professions.  The “real job” often doesn’t start until your early 30s (if you have gone straight through college, medical school, and residency) and at the end of training, you have walked so far down the path it’s all you know. What if it’s not what you expected? What if you hate it? What if it’s no longer fulfilling? The chronic stress of being a physician can manifest itself as depression, anxiety, failed relationships, substance abuse or even suicide. I’ve seen all of these scenarios up close either in myself or others.

Every step of the way for me was different than I expected.

Being a physician is a huge piece of your identity. Walking away is like your ego jumping on a hand grenade. Some can do it, but it takes a certain amount of inner strength and self-knowledge. It can be a very lonely place with a mountain of student loan debt and a stressful job that you hate. I can’t know for sure, but I’m guessing a large percentage of physician suicides are due to these factors. When trapped like this suicide seems like the only way out of the cage for some.

I don’t know how much of a factor my friend’s job was in his suicide. I think he loved this profession or, at least, significant parts of it. All evidence would point to this — but there is something dark in being a physician that breaks some of us. Something we don’t like to talk about. Something we cover up. I don’t think he was looking for an escape from medicine, but it’s impossible to know for sure.

Another doctor will take his place, and his patients will find the care they need. His family and friends will mourn and eventually find a way to cope with the loss, but at what cost? There has been and will continue to be great suffering and unimaginable pain along the way.

I recently spoke to my friend’s wife about the suicide, the depression and all the events surrounding this tragedy. It took me a year and a half to even do that. Time has healed some of the wounds, but I could feel the deep underlying sadness behind the conversation, scars that would always be there. It was palpable, and I hated it, but needed to feel it at the same time. It exposed my own grief; something that almost two years later I am still trying to figure out how to deal with. A wife lost her husband, children lost their father, and I lost my friend. It seems so unfair.

Behind my grief though is fear and guilt. Fear that I’m not so different than my friend. Fear that this could happen to someone else I love. Fear that this could have been me under different circumstances. Guilt that I blindly stumble along in a system I know to be broken. A system I know will destroy the lives and families of other physicians. Guilt of knowing I’m doing nothing to help fix it.

I don’t know if I should cry or scream in anger, but I do know that nearly two years later I still think about this. This changed me. For better or worse I am different now.

Statistics are an abstraction, not real. My medical school classmates were the most real thing in my life for four years. Our shared experience and consciousness was unique, and we formed a tribe unseen by the rest of society. Losing anyone to suicide is a tragedy, but losing one of my own is real. It hurts. It’s terrible.

I felt nothing the day I heard the news. Nothing. I suppressed it because deep down I lost a part of myself that day. I pushed it away like all the other negative things in my life. I buried the emotions and only now am I facing them. I wish I could go back and change something, but I can’t.

I f*cking hate that fact.

I miss my friend, and I’m sorry I failed him.

I hope he found peace.

Note: It took me nearly two years to write this essay. Even after thinking and reading about this topic for all this time I still have more questions than answers. Thank you for reading.

The author is an anonymous radiologist who blogs at the Happy Philosopher.

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