Who are the doctors who end their own lives? [PODCAST]

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“Recently, a fellow physician mom ended her life. While outwardly, a very vibrant, lively, and happy woman, she fought her own internal demons for some time. From what we know, she struggled with depression but was still committed to being a good mom, physician, and wife. Sadly, a few days before her birthday, she could no longer bear her sadness and decided to end her agony. I know many physicians’ lives follow these patterns. What shook me this time, though, was a discussion I had with a very close group of friends. These are all very highly educated professionals whom I love, respect, and admire. But, none are physicians.”

Fariha Shafi is an internal medicine physician.

She shares her story and discusses her KevinMD article, “Who are the doctors who end their own lives?”

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Hosted by Kevin Pho, MD, The Podcast by KevinMD shares the stories of the many who intersect with our health care system but are rarely heard from.

Transcript

Kevin Pho: Hi, and welcome to the show, where we share the stories of the many who intersect with our health care system but are rarely heard from. My name is Kevin Pho, founder and editor of KevinMD. Today on the show, we have Fariha Shafi. She’s an internal medicine physician, and she wrote the KevinMD article “Who are the doctors who end their own lives?” Fariha, welcome to the show.

Fariha Shafi: Thank you so much, Kevin. It’s a pleasure being here.

Kevin Pho: So we’ll get into your article a little bit, but first off, can you share your story and your journey to where you are today?

Fariha Shafi: Yes, absolutely. I was born in the beautiful valley of Kashmir, which is the northernmost part of India, and it’s kind of a disputed territory. Growing up, I grew up between the Middle East and my hometown. My dad is an internist, and he worked in the Middle East. After finishing high school, I actually landed in the Caribbean and finished my medical school there, in the Dominican Republic. I came back and did my residency at the State University of New York at Buffalo, and after finishing up there, I moved to Kansas City, to the University of Missouri-Kansas City, for my first and so far my only job for the past 15 years as an academician.

I’m currently an associate professor there. I chair the diversity, equity, and inclusion council, I’m a docent mentor at our six-year BA/MD combined program, which is the joy of my career, and I lead the women in medicine group at that school. I’m very privileged to be taking care of a very diverse set of patients at Truman Medical Centers, which is our main teaching hospital, and I’m also the medical director for our medical assistant program there.

So when you ask me about my journey to where I am today, I think a lot of it stemmed from being an attending four to five years into my job and feeling that I was stuck. I felt that I wasn’t seeing my career progress the way that I wanted to. I was more tired, I was more irritable, I felt like I had lost my motivation, and I felt that I wasn’t really accomplishing much. I didn’t realize that a lot of my peers, my colleagues, my friends, and my mentors had gone through it or were in certain stages of it, and that it was burnout that I was experiencing. I just wanted to try to fix these feelings.

When we were at a council meeting at the American College of Physicians (I belong to the Missouri chapter), I happened to have a conversation with the governor, telling him how I felt and how I wanted to do something about it. Before I knew it, I was flying to San Francisco for a wellness champions certification workshop, and that really changed my perspective, what I wanted to do, and my approach to what I was feeling. So from there, today I’m a certified wellness champion, I’m the co-chair of our wellness committee at the Missouri ACP, and I also chair the women in medicine group for our Missouri chapter. In between there, I also got married. I’ve been married to a physician for the past 20 years, and we have two beautiful kids. They’re the ones who keep me real and keep me honest.

Kevin Pho: So the picture that you’re describing: Even before the pandemic, 50 percent of physicians experienced symptoms of burnout, and that’s only exacerbated during COVID-19. What are a few tips that you could recommend, just off the top of your head, to help these physicians out?

Fariha Shafi: The first thing is to understand what is happening to you and acknowledge it. There is no harm in accepting that things are not going well, or that something is out of the norm. The other thing that I would say is that we have to get out of this whole perpetuated practice where we feel we have to fix it all, we have to know it all, and we have to do it all. During COVID times, it’s even gotten worse, I feel, to some degree, because it’s a virus that we’re still learning about. You feel even more frustrated, and you feel more out of control.

What I want to make sure people understand is that it’s OK to feel like that. Build your community around that, right? Try to find ways to connect with other people and figure out what you can do, but understand that if you’re not able to deliver what you set out to do, it is OK. I think as physicians, one of the problems (I call it a problem) that a lot of us have is that most of us have that perfectionist, go-getter, gunner personality where we feel like failure is not an option. If you can’t be 110 percent, if you can’t be right all the time, you will be frowned upon, or you’ll be looked down upon.

I think if anything, COVID has taught us that it is OK not to know, but then to try to do your level best, to try to do the best that you can at that point in time. The one thing that I want everybody to get into the habit of telling themselves is that you are enough at this point in time, with what you have and what you are able to do. You are giving it your best shot, and that is enough.

Kevin Pho: Now, just from hearing your story, it sounds like you’re fulfilled by doing so many committees, being part of the medical school, and doing so many things outside of your job in clinical medicine. How did you know that all those things were right for you? I guess my question is, when you’re a physician who is burned out and you’re looking for avenues outside of clinical medicine, how can they find what’s right for them?

Fariha Shafi: That realization came after I went to the well-being workshop. People were very honest, and it was almost like finding your safe space, because I felt like one of the biggest things that we struggled with is: Is it OK to talk about your vulnerability, your imperfections, your stressors, the fact that you’re not feeling great or you’re feeling depressed? I think that for me, finding that safe space, finding that camaraderie, and finding that community is what changed my outlook and helped me figure out what I wanted to do. Of course, a lot of what we learned during the process is how to build resilience and how to overcome all these things.

They all come with time, and it’s not like I picked the first thing that I wanted to do, it worked out really well, and I was really excited about it. It was a lot of trial and error, figuring out what it was that gave me fulfillment and where I wanted to find that. I thought that I would come back and start this job of a well-being champion at my place of work, and that would be what I would do for the rest of my career. I realized that wasn’t what I wanted to do. I wanted to do things differently; I wanted to have a different platform. So I think, again, getting out of your comfort zone, trying different things, and figuring out what works for you is what really helped me. It definitely was not the first committee I joined. I had to try different avenues and find what I call my tribe, which helped me propel my message.

Kevin Pho: So let’s transition into your KevinMD article, “Who are the doctors who end their own lives?” Now, for those who haven’t read that article, can you just walk my audience through it and share the story of why you decided to write it?

Fariha Shafi: The article actually came after we had a dinner party get-together with some of my very closest friends. Within that week, a few days prior to that, a physician, a mom within the community, had committed suicide. So one thing led to the other, and the conversation dwelled on what could have happened. One of my friends actually said, “But she was a physician. Why would a physician do that? They have it made. They have everything.” Somebody else said something like, “Irrespective of whatever it is, I don’t agree with that. She had kids to think of. Why would you do that? I mean, what kind of a doctor does that?” It was sort of an aha moment for me that the general non-physician population, or the non-doctor population, does not really get what our lives are like.

One of the things that happened during that time was that my husband was sensing the angst that was being created within me, and that I wanted to shed light on what physician lives are like. So he actually kind of paved the way, and we had a very long conversation on what our lives looked like. I felt that this was my safe space. These were people that are very close to me, and I felt like I could tell them what it is to come back from work day in and day out, or to have to be the face of medicine when you have very little control over what medication your insurance carrier wants to pay for, and to be shouted at. When your patient is upset, you’re the face that they’re angry with.

Or sometimes we have to listen to our patients’ stories, which break our hearts, and sometimes we can’t do a whole lot about it, but we do internalize a lot of their grief and a lot of their struggles, and then you kind of have to live with that. Some of us do have it easier; maybe work is not that hard. But a lot of us, I would say the majority of us, are struggling to find that fine line and balance between being the most amazing doctors and being the most amazing dads, partners, moms, brothers, sons, and daughters, right? So it is very difficult for a lot of us to find that balance. You’re constantly juggling; you’re constantly having this fight.

And the kind of people we are, and the kind of people who want to go to med school, like I said before, are your overachievers, or your people who have a lot of empathy and really want to change the world, people who really take this job seriously. It’s not a normal person who’s going to sacrifice 12 to 15, maybe 16 years of their life to actually get to an attending physician’s position. The majority of us do not do it for the money, and it kind of irks me sometimes when people say, “But you’re a doctor.” People don’t understand the amount of financial burdens that we have.

That was the background of how it all started. A lot of what I blog about comes up at our dinner table, and so we were sitting there having this conversation, and my son said, “Why don’t you just write about it?” My husband said, “I think it’s a really great idea. See where you can publish it.” I said, “I’m not creating a blog.” Then KevinMD came up, because I follow you, and so I said, “All right, I’m going to try to pitch it and see if I can get this across.” So that was the background of that article.

Kevin Pho: I have a lot of non-physicians who read my blog and listen to this podcast. We talk about physician burnout a lot, and one of the responses I get is that there is a lot of stress in other professions outside of medicine as well. What makes physician burnout different from burnout in other professions? I know you alluded to some of this previously, but go into more detail. What makes medicine different?

Fariha Shafi: There are a lot of non-physician lifestyles that have burnout. What makes medicine different is the amount of emotionality and humanity that is tied to it. The stressors in some professions are definitely related to maybe all the finances, and stressors with the kind of people you’re working for. Medicine, especially in this country, is so unique, because between the patient and you and the way that you’re delivering health care, there are so many things that are not within your control, whether it’s the middleman, the electronic medical record, the insurance company, or all the other durable medical equipment companies, and so on and so forth, that you have to deal with. So it’s definitely not like a lot of the eight-to-five, nine-to-five jobs.

And again, there’s that human connection that comes in, which also bogs you down, right? I wouldn’t say it bogs you down in a negative way, but our jobs are designed to help and care for people, right? We are habitual empaths. We are habitual fixers. When we can’t fix a problem, when we can’t deliver what we promised to do when we went into medical school, it eats us up, right? So when I talk about how layer by layer we’re shredded and broken apart, that’s what happens, because you feel like, “I should be able to do this,” but there’s a lot of loss of control that does not allow us to do that.

During the COVID pandemic, for example, you see so many physicians who, again, succumbed to physician suicide. I was reading an article about this very wonderful physician who basically, on her last thing, had written, “I just couldn’t help them anymore.” I think the biggest problem in our profession is that we have this need to give empathy, to understand, and to try to help, yet we are often put in situations where we feel like that is not reciprocated or given to us, right? An example, again, during the pandemic, is that within months we went from being heroes to being the evil people who labeled everybody with that diagnosis because we wanted to make a few extra bucks. This constant fear that we have, that we have to explain to people that that is not who we are, is the additional stressor and the burnout that is difficult for a lot of us to deal with.

We try to deal with it at work, but think about when you come back home to your families. We have jobs that are now putting our families at risk, and you’re trying to find that balance and trying to protect your family. I mean, how many doctors did we read about who had camped out in their garages or their backyards? I don’t think that there are a lot of professions that end up doing that, because you’re trying to find that balance on how to do right by your profession and your patient, and then how to balance it out for your family. So I think that’s the different part.

There are lots of professions where there are, I would say, finance is one big one, lawyers are one big one. But there aren’t a lot of professions where they tell you that the one big risk you’re going to take on is the depression and everything you’re going to develop. I think a big part of it is the amount of time that we put into it. I mean, four years of undergrad, med school, residency, fellowship: You’re in it for the long haul, and there’s not a big rate of return right at the outset. Being able to reconcile with that makes it a lot harder.

Kevin Pho: Now, a lot of medical institutions and hospitals are recognizing burnout, to their credit, and they’re responding by offering things like resilience classes, meditation, and yoga. What are your thoughts on that response?

Fariha Shafi: I think it’s wonderful that there is an acknowledgment of it. I mean, look at Dr. Shanafelt, who’s been writing about this for decades, and then you would have people who’d say it’s not a real thing. I think even within the past 15 years that I have been in this profession, people have come a long way to acknowledge that, and I don’t think there’s any other way out, right? When 25 percent of the surveyed population tells you that they are depressed within the first two years of medical school, you realize you need to do something differently. That number doesn’t change a whole lot.

But there were so many studies that actually showed that, within those residents, for example, who were surveyed and had depression, if you made an intervention, if you did something as simple as cognitive behavioral therapy, whether that was just allowing people to talk to someone and unburden themselves, or having Balint groups, or having yoga, or having these wellness opportunities, the risk of perpetuation of that depression in that cohort actually dropped by 50 percent. So I think every little bit counts. Having these things available is excellent, but making sure that you are supporting your physicians so they are able to take the time off to partake in them is the next step. I think it’s very important to have wellness initiatives, but taking the next step and making sure that there’s time carved out where those initiatives can be utilized and made to function, for every establishment, is important.

Kevin Pho: We’re talking to Fariha Shafi. She is an internal medicine physician, and she wrote the KevinMD article “Who are the doctors who end their own lives?” I read an article saying that the equivalent of a medical school class of physicians commits suicide every single year. Now, obviously, we don’t want it to get to that point. What are some red flags that physicians should look out for, and perhaps turn to professional help after recognizing them?

Fariha Shafi: I think it’s the red flags of depression. Again, for physicians, we all know that we screen our patients with the PHQ-8, so I think those would be the major ones. You ask people, or check in with each other, and notice whether the people around you, or you yourself, are losing any interest in the hobbies that you had. You’re losing interest in activities, you’re getting angrier, you’re feeling frustrated, you’re feeling stuck, you’re making mistakes, you’re not able to put in your best effort, and you’re feeling tired. All of those things are not that different than all the signs that we screen for in depression and anxiety, but those are all important.

Are you rested enough? Are you sleeping enough? Are you able to shut your mind off when you need to? Are you able to take out time for yourself, feel happy, and partake in things that gave you joy? If you feel that that is not you, there is something seriously wrong. Again, if you are somebody who’s an excellent student, an excellent physician, who’s never had trouble concentrating, and now suddenly you can’t seem to pass a class that should be really easy for you, and suddenly your performance has gone from an A-level student to a C-level student, and it’s not the difficulty of the course, something is wrong.

So at every level, having those check-ins, asking ourselves those questions, doing our internal screens, and doing screens for each other is important. There are so many establishments that have started programs like “check in one, check in two”: Check in with yourself, and then check in with another friend, and make sure that you’re doing that consistently and often enough. I think those are the things that we can do to figure out where we are.

Kevin Pho: Now, can you share some resources that physicians can look for online if they’re feeling some of these symptoms of burnout?

Fariha Shafi: I would say every major organization has its own wellness website. I can tell you about the American College of Physicians. They have their own wellness hub, they have their own wellness page, and that’s an easy one to go to. The American Academy of Pediatrics and the emergency physician cohorts all have excellent resources. Even if we’re just trying to find mindfulness resources, things that are cheap and easy, people are happy to share them. You have so many apps, like the mindfulness apps, like Calm, etc., so we can definitely go to those resources.

But even within our own establishments, I would say Google it. I mean, put “wellness” in your search. I would be surprised if there’s any organization or establishment left in the country that has not made that a priority for its workforce, and I’m not just talking about physicians, hospitals, and health care-related professions. I’m talking about professions all across the country. I think that it would be something that would be very easily available.

Kevin Pho: Now, if you’re a physician who is burnt out, and you’ve gone through all these recommendations and it’s not improving, at what point does it become more about the job itself? At what point should that physician consider either cutting down or maybe looking for a new position?

Fariha Shafi: Being aware, sifting through, and figuring out if it is their job that’s doing it. Again, that can be done with counseling, that can be done by finding peer mentoring groups, and that can be done by having Balint groups where you’re able to find your safe space and talk about it. You realize that it is your job that’s really bogging you down to the point where you’re not productive, so you’re there, but you’re not present. Mindfulness is a big gauge of it. If you’re just doing stuff robotically, you’re starting to make mistakes, and you’re not really present in the moment, that to me is a big reason to step away from what we’re doing.

It doesn’t mean that you have to step away completely. It means you have to figure out what part of that job is leading to this. For me, I would say some part of it was the autonomy, the ability to have my schedule where I had more control over my life. Sometimes it’s a simple step, like going up and asking your superior, “Can I make this change? Because this is what I’m experiencing, and I cannot be functional without that.” So sometimes, for me, it was as simple as that.

The other thing is, if you’re feeling you’re at that point, a lot of our state organizations actually have physicians, and I would say psychiatrists specifically, who deal with physicians in distress. That would be a time to go ahead and seek that out and move away from your clinical practice, or from what is burning you out, for a short period of time to kind of reset, and I think that is really important to do. One of my very close friends does this for the state of Missouri and for the state of Kansas, and what gives him fulfillment in his job is the number of physicians who have been able to step away and then go back to their practice with fulfillment, of course, making changes in the things that had actually led to the burnout.

Kevin Pho: And my final question: What is your take-home message that you want to leave with the KevinMD audience?

Fariha Shafi: I would say the most important thing is that it is OK to say no. In our profession, we get asked to do so many things, sometimes simultaneously, and we feel like we have to do this to fix it. It’s OK to say no. I would also say the other takeaways are: It is OK to be vulnerable. It is OK not to be perfect. It is completely OK to fail and then rise from that. Failure is an option, and I think in our profession we are constantly told that it’s not, and I think we need to get away from that.

It is also important to realize that you have to keep telling yourself that you are enough. You need to focus on yourself and your well-being, and it is OK to prioritize me. That’s the other problem we in the physician world experience: We take care of everyone else, we develop caregiver fatigue, which is another thing that leads to a lot of depression, and we don’t prioritize ourselves. It is OK to ask for help. It is OK to be a voice for what you believe in.

And the most important takeaway for the physician community, and especially for the medical students, the residents who are out there, and the people who are starting out their career, is to remember that medicine is a part of your life. It is not your entire life. That’s the most important thing that I can say: Find joy in other things, and I think you’ll have a much, much longer career in medicine.

Kevin Pho: Well, thank you so much for sharing your insight and time, and thanks again for being on the show.

Fariha Shafi: Thank you so much, Kevin. I really appreciate you.

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