Doctor Suicides: Intention, Failure, and Self-Worth

Why We Have to Change Our Terms to Beat the Pandemic and Where to Begin

A valued emergency medicine physician committed suicide this week. I have thought a lot about her and the few details shared about the last weeks of her life.  There is no way that we can—or should—know everything about her.  Even so, a few things have stayed with me from her story.  She worked in a Coronavirus Pandemic hotspot in New York City. Then she became infected but was back at work in 10 days.  Her family recognized she wasn't doing well and brought her to their home where she took her life. What happened?  Did her work in the pandemic tip her into despair that was ordinarily offset by successes at work? Did it unmask a crushing sense of futility that abruptly drained the joy and meaning out of life? Did she experience an overwhelming sense of horror? 

These are unanswerable questions for her but deserve our consideration in her memory and because she is not alone. It is beautiful to see the sacred intention of physicians and other healthcare workers in action responding to COVID-19, but we need to reconsider our strategy for treating patients during the pandemic and take a closer look at how and why we work the way we do. The epidemic is being run as a sprint by clinicians when it's really a marathon that should be run as a relay race with all hands on deck. The Pandemic Prescription I am writing arose directly from introspection about physician sacred intention and common confusion about failure and our self-worth.

Intention

The soul-nourishing part of having a sacred intention as a doctor is that it points the way for our service and creates a sense of meaning and purpose.  That internal guide inspires us to lean into hard problems, assume personal risk, and make sacrifices to serve patients, but it can also be the source of despair when it is either suppressed or we believe we have failed to deliver on it.  Our intention is suppressed when we neglect it or trade it in for something of less value, like money. I do not believe the sacred intention ever goes away, but in ordinary life, it is cheated more often than we like to acknowledge.  

Each doctor knows her or his one and only sacred intention, the one that resides in the privacy of our own heart and addresses one patient at a time—not a health care system or a population, and each of us can feel when we have abandoned it.  It doesn't feel good.  Over time, the boat of intention can become unmoored and drift farther from the dock.  When our intention is untethered from our performance, our work becomes a drag.  That gap is one place where compassion fatigue gets a toehold.  When the untethering happens due to pressure from an employer or our colleagues, we become angry or resentful and, eventually, furious.  This is moral outrage.  We feel sick, sick at heart.  We may even begin to despise ourselves for our complicity and weakness. A revelation of the Coronavirus pandemic is the direct call to and reconnection with our sacred intention, and right now, everyone in the world can see it and celebrates it.

Failure

By definition, it is impossible to fail to deliver on the sacred intention that is held true.  The holding is the delivery as it guides our actions.  Failure is something different. It is an assessment of our performance and of the result of our performance. The determination of failure is measured against our expectations and treatment outcomes. The expectations of doctors can be our own, those we generate as a profession, and those that other people have of us. Sometimes these are realistic, and sometimes they are not.  Right now, most of the world is cheering HCWs at change of shift because we show up and try—they know we don't have the answers, which makes it all the more meaningful that we do our best anyway.  Really only we could judge ourselves as failing right now, and that would come from holding an unreasonable expectation or standard for this situation.

While the outcome might often seem to be the final arbiter of performance, it's actually not. As in Olympic figure skating where the base score depends on completing all the compulsory elements of a routine without falling, the distinguishing points in skating and in medicine are given for style and technical performance. In medicine, there is always room for improvement of technical performance because the pinnacle keeps moving as technology advances.  With respect to outcomes, we can apply ourselves to improving a patient's chance of healing and living a longer, fuller life, but the result is ultimately not in our control. It is not possible for us to stand between people and every bad thing. We are not that wall no matter how much we wish we could be, and sometimes our only role is to stand with people and the really bad thing, to accompany them as they deal with it. This can be especially hard if it activates our own sense of inadequacy by reminding us what we don’t control.

Self-Worth

When we judge our adequacy based on the outcomes of our care or use our sacrifice as a gauge of our intention, we put ourselves on very thin ice. Even in normal circumstances, these are unbeatable odds. Play long enough, and the house always wins.  We can never achieve a perfect technical score, and we aren't even the winner or loser of the battles: patients are. We throw our skills and knowledge about their disease into the fight to give them a leg up and a better chance of surviving. We get confused.  Our biggest, strongest secret weapon is our intention.  It's what makes us care enough to show up and do our best.

This common mistake of confusing our value as doctors with our patients' outcomes makes dealing with the pandemic particularly hazardous. The sheer volume of incoming patients, the number of deaths, the urgency at the time of presentation, the poor prognosis, the abrupt deterioration of condition, and the lack of a vaccine and knowledge about this infection and how to optimally treat it, all challenge the treating clinician intellectually, physically, and emotionally.  Feeling outmatched, we might try harder and make bigger personal sacrifices, like coming to work sick and tired or sleeping in our cars.  There is nothing about being on that bleeding edge internally or externally that fortifies the perspective we so desperately need to weather this storm. One of my surgeon colleagues often says, “Just about perfect will do.”  It would be typical for us to ward off feelings of inadequacy or futility by trying even harder, which in turn pushes us farther onto the bleeding edge.  

Prescription

Here's my prescription.  We should do exactly the opposite of what our habit is for as long as that is possible.  We should put in half our usual work hours, not more or even the same. To preserve the health and sanity of physicians and other healthcare workers and remind us that our depletion does not make us more worthy, shifts should be ridiculously small: 6 hours, 4 times per week.  Call in the reinforcements. Right now, even as there are a lot of people working extraordinary hours under tremendous pressure on the front lines, there are a lot more medical personnel on furlough or underutilized because of the disruption of regular services who could be helping.  I am a subspecialty surgeon, but I bet I could cross-cover a respiratory therapist if I were told what to do.  We can all draw blood, bathe and turn patients, start IV's, wheel patients to their rooms, and talk with families.  Then, when we go home from our intense, short shifts, we should take a hot shower, wash off the day, take a nap, and curl up with a partner or a good book for a few hours.  Once we have rested and regained our sense of ourself and understand the impossibility of solving the pandemic alone, we are ready to return and relieve the staff on duty.  Most critically, we should remember our sacred intention and what a gift it is to be allowed the privilege of caring, for ourselves as well as each other.