Physicians have the highest rate of suicide of any profession in the U.S., including military service. We lose about one doctor per day in the U.S. to suicide. The high levels of stress, lack of sleep, ease of self-medication, and reluctance to seek mental health treatment are among the reasons for these high numbers. But those are not the only reasons.

If you’re like me, you’ve been hearing about how physicians need to do more “self-care” to prevent burnout. This is being touted by administrators as something we have a responsibility to do to prevent our own burnout. As if there were not enough demands on our time in a broken system that requires ever more paperwork, charting, RVU counting, MOC hoops, QI projects, and more. Physicians are beginning to push back, as they should, at being told to do yoga rather than having hospital administration participate in a meaningful conversation about how health care in our country has fallen off track. I’d like to make sure that, as we push back against the “self- care” talk, we don’t forget about secondary post-traumatic stress.

Secondary post-traumatic stress is something most of us encounter and do psychological battle with every day in our jobs and training. This is the stress response that happens in your body when you hear the story or read the chart of someone who has been through a horrible tragedy. You can’t help but imagine what that was like, and then wade into the situation to provide support to the patient. This happens to law enforcement, first responders, counselors, clergy, and … yes, doctors and nurses.

One silent, dark morning as I walked into the hospital in the wee hours, preparing for rounds as a medical student, I heard someone screaming, “My baby! My baby!” in the ambulance bay outside the ER. It was a gut-wrenching sound, and I could only imagine what had happened. I’m sure my heart rate quickened, and I had an emotional response. Someone’s child was dying. Should this make me cry in empathy? Or should I shut off my emotions and keep walking as if nothing had happened. I had to consciously bottle my emotions and keep going.

I have also worked in a long-term care hospital for children, where many of the children were admitted because of abuse or a terrible accident. One child had a heavy gate in a pasture fall on him. He laid there and was suffocated by the weight on his chest before he was found. Another baby was suffocated when her mother fell asleep while breastfeeding. When you hear stories like this every day and can’t help but imagine it happening to your family, you have a physical response to that knowledge, and you need to do something to bring your stress level back down.

Ironically, “self-care” is something we can do to keep our own stress responses, or cortisol levels, from becoming chronically high due to this constant exposure to stressful situations. Anything that helps reduce your cortisol response can help reduce or prevent secondary post-traumatic stress.

Below are some examples of coping strategies:

1. Exercise
2. Mindfulness/meditation: apps like Calm, Headspace, and Abide
3. Grounding exercises
4. Tactical breathing
5. Spending time with family
6. Spending time with pets or animals
7. Hobbies
8. Gardening, hiking, time in nature
9. Journaling: If you don’t like to write, you can write three things you are grateful for and three things you are looking forward to tomorrow.
10. Prayer
11. Connecting with a faith community or church
12. Talking to a colleague who understands
13. Humor, comedy

Another great way to think about it is to make a daily coping plan:

• Every day: exercise, prayer
• At work: talk to a colleague
• After work: spend time with pets or family, watch a comedy on TV
• On days off: spend time in nature, church, or hobby

Psychiatrists have one of the highest suicide rates among physicians. That makes sense to me when I think about secondary post-traumatic stress. It is the nature of their job to listen to stories of personal trauma. But there are many other specialties or job situations that are also high risk. Those of us in helping professions are sometimes more likely to have survived adverse childhood events or ACEs, which can have long term mental and physical health effects.

Physicians are more at-risk during times of life transition — near the end of medical school, near the end of residency, near retirement, when adding children to the family, etc. When a physician decides to work part-time, especially those who are caregivers for young children or family members, we need to act as a support system. We cannot support each other when we encourage systems of punishing a part-time colleague, or a mother or father who uses their FMLA.

Let’s step up and look out for each other. Let’s encourage stress-relieving activities as a cultural norm. Be aware of the resources available to access confidential mental health services and be ready to connect your friends to help when needed. This is a really common problem, so a physician seeking mental health services should also be common. Funny story: I once had to be evaluated for depression in residency just because I am not a morning person. Apparently, someone thought I looked grumpy in the NICU at 6 a.m., and rather than ask me if I was doing OK, they referred me to the residency director who had to have me evaluated! But really, 15 to 30 percent of residents do suffer from clinical depression at some time during their training. Let’s help each other and not be afraid to reach out.

Laura Shamblin is a pediatrician.

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