I put it on one night among tears and grief. It slid onto my skin like butter, like it was meant for me. It hugged my torso and clung to all the wrong places. The truth is, I had worn it before. I am unsure exactly when I last stopped wearing it. Unlike the donning of the letter, the removal is much quieter. I probably did not realize exactly when I shed it, but one day, I realized it was gone. Glad of its departure, I did not question what had prompted its dismissal lest I jinx my freedom.

The problem with the Scarlet Letter is that you never know how long you will have to wear it. In fact, it is not clear who placed the letter. In truth, I put it there. I did not put up a defense, anyway. Readily accepting the red letter of shame, I felt I deserved it. It did not matter that I had practiced medicine as well as I could. It did not matter that my peers thought I was doing a good job or the accolades and thanks I had received from patients. None of that matters with the scarlet letter of psychiatry or any specialty of medicine, for that matter, donned. I felt like a modern-day Hester Prynn of the hospital. I know you are thinking, “Dramatic much?” I wish it felt like dramatics, but to me, it felt like a thousand cuts. That is why there was no protest when I put it on.

I am confident that many facets of medicine, nursing, and psychology have these letters. Psychiatry is the only field in which I can write knowledgeably. I think the field that probably struggles the most closely with mine regarding the donning of red letters may be obstetrics and gynecology. You see, almost everyone knows someone who has had a baby or dealt with depression and suicide. These topics, frequently mentioned on TV and in movies, often generate diverse opinions. If a vascular surgeon has a bad outcome in a popliteal bypass, the layperson does not know what that is, so they do not have an opinion. Psychiatric or obstetric complications or loss carry significant emotional weight as they should. It is human nature to want to blame someone after a loss.

I know the data; I know I cannot predict suicide. When someone is gone, having practiced appropriately does not take the sting away. I think the extra layer with a psychiatrist’s red letter is like so much of psychiatry, where subjective factors come into play. In the early days, with the scarlet letter on my chest, I assumed everyone knew I had it on. When I entered a room, I knew everyone saw the shame dripping off my skin. But work is not the worst of it. For me at least, the worst is when I am at home alone at night. Of course, I considered quitting, walking away. But if I want to have a frank discussion about what it is like to wear the scarlet letter, I must admit to thinking about a more severe punishment. Perhaps I deserve to cease being; maybe I do not deserve to live. There, I said it; I felt it.

I am seasoned, and I knew that thought would pop up. I have worn the letter before, and I know that with it comes a myriad of irrational thoughts and feelings. The thought comes and goes. What scares me more is the thought that a young psychiatrist dealing with their first time wearing the letter could be catastrophic. As physicians, our risk of suicide is higher than that of the general population. Female physicians have a 2.5 times higher risk of dying by suicide. Since I was twenty years old when I received the notification of my admission to medical school, I defined myself as a future doctor. Before I knew true love or could legally drink, I was inextricably bound to my future profession. Without that identity, I feared I might become unmoored. If I were not a good doctor, was I good at anything?

Words from coworkers, friends, and peers helped me forget the letter. Continuing to decide about treatment and care, as I had before, and boring days all helped. At some point, I became less sure that everyone could see my scarlet letter. I could still feel it. I am my harshest judge, and with only myself on the jury, there can be no easy sentence. In fact, the sentence is unclear as there are no clear guidelines for when I can remove the letter. There are no criteria really, other than feeling like I have paid enough, hurt enough, and questioned myself enough. I know it will eventually come off, as it did when I wore it before. That brings me comfort.

I also know that I will always call my colleagues and reassure them when I hear something that makes me wonder if they slipped their own letter on. They will not listen when I tell them in coded words they can take their letter off, but maybe they will hurt less knowing a fellow letter wearer is beside them. I know I have felt the relief of a peer’s reassurance many times over. For now, I wear my letter mostly in silence and bide my time. It helps to talk about it, so thanks for listening.

Epilogue

This piece was written many years ago, and the letter has since come off, and I am doing fine. The longer I practice, the more likely I will wear the letter again, and sometimes that keeps me up at night.

Courtney Markham-Abedi is a psychiatrist.