By Steve Adelman, MD

Last month I wrote about the MMWR’s report of an alarming increase in overall suicide rates when comparing 1999 with 2010. The demographic breakdown of the data did not include an analysis of employment or professional status.

It is well-known that physicians have an especially high suicide rate. Over the years, various studies suggest that physicians kill themselves at a rate that is about double that of the general population. Approximately one U.S. physician per day commits suicide. This represents an annual physician suicide rate that is the equivalent of 3 graduating medical school classes. If these high suicide rates are sustained, more than 2% of all medical school graduates will take their own lives.

The suicide rate of female physicians is particularly high. Women account for almost one half of all physician suicides, and they kill themselves almost four times as often as female non-physicians.

Time will tell whether or not the overall increase in completed suicides reported in 2010 continues to be sustained. It may be related to the economic downturn that led to high unemployment and the glut of home foreclosures.

We also do not know if the already high rate of physician suicides is increasing. The information on physicians cited above is based on data collected intermittently over the past 40 years. However, in 2013 the medical profession is rife with reports of physician stress and burnout. Few of us would be surprised to learn that suicide remains a significant occupational hazard in our profession.

There has been much speculation as to the causes of the heightened physician suicide rate. There are many reasons to believe that the current environment may be increasingly hazardous to the health of physicians. To wit:

• We are victims of our own success. The explosion of medical knowledge and therapeutics has increased longevity, and as people live longer, their medical care becomes more complex and demanding. Concurrently, there is growing pressure on the health care dollar. In this environment, many doctors are called upon to do more with less.
• Technology and regulatory requirements add new layers of complexity to the practice of medicine, and the pressures to be a productive physician have never been greater. There is less time available for the sustaining human connection that is at the heart of the doctor-patient encounter, and this frustrates every physician I know.
• The demanding health care world we live in makes it more difficult than ever to balance the demands of work with the pleasures of family and community, and many of us find it increasingly difficult to take good care of ourselves.

It is incumbent upon us, as a profession, as members of health care teams and organizations, and as individuals, to meet these challenges effectively in order to improve the quality of physician life in our society. I am hopeful that we in the physician community will use our wits, our energy, and a spirit of self-help to establish successful strategies to counter the occupational stresses and pressures that may contribute to our unusually and unacceptably high suicide rate.

On October 3, 2013, the Massachusetts Medical Society and Physician Health Services are jointly sponsoring a one-day “Caring for the Caregivers” CME event that will focus on peer support, mindfulness, compassionate care and resiliency training as strategies that can be utilized to improve the work life of practicing physicians. Stay tuned.

Dr. Adelman is director of Physician Health Services, Inc., a corporation of the Massachusetts Medical Society. For more information, visit www.physicianhealth.org. Opinions expressed here are his own, and do not necessarily reflect those of the Massachusetts Medical Society or Physician Health Services.

The medical community’s response to the bombings, generally regarded as a model example of emergency response, provides the starting point for a discussion of emergency preparedness and the specialty of disaster medicine in the June edition of Physician Focus.

Paul Biddinger, M.D.,  (right, photo) Chief of the Division of Emergency Preparedness and Medical Director of Emergency Department Operations at Massachusetts General Hospital in Boston, and Mary-Elise Manuell, M.D., (center) Director of the Division of Disaster Medicine and Emergency Management at UMass Memorial Medical Center in Worcester, join host James Kenealy, M.D. (left) in describing the key elements to emergency preparedness and how disaster medicine is practiced.

Among a number of topics of conversation are the critical phase of planning and using a “whole community” approach to preparedness, the unique aspects of Boston that contributed to a successful response, how medical personnel and citizens can participate in response efforts, the contributions that battlefield experience in wars and cooperation with other countries have made to improved planning and response, and what smaller communities should consider in preparing for emergencies.

Physician Focus is available for viewing on public access television stations throughout Massachusetts and also available online at www.massmed.org/physicianfocus, www.physicianfocus.org and on iTunes at www.massmed.org/itunes.

By Steve Adelman, MD

Earlier this month, the CDC’s Morbidity and Mortality Weekly Report (MMWR) presented alarming data comparing age-adjusted suicide rates between 1999 and 2010.

Historically, the two major causes of death of younger people have been motor vehicle accidents and suicide. As motor vehicle accident deaths have gone down, suicides have gone up: 2009 was the first year in which the number of people who put an end to their lives themselves was greater than the number who lost their lives in car accidents.

Overall, the suicide rate jumped by 28.4% among persons aged 35-64. The rate of increase was even greater for whites, American Indian/Alaska Natives, older women (60-64), and people living in the West. As usual, in most successful suicides the cause of death is firearms.

To put the numbers in perspective, let’s think about a busy, multispecialty ambulatory adult primary care practice that employs a group of 4 internists, 2 nurse practitioners and a physician assistant. In the course of a year, perhaps 12,000 unique patients are seen in the office. A practice of this sort in Massachusetts, New York or New Jersey is likely to see one patient die by suicide per year. In Midwestern practices of this size, a second patient suicide would be predicted.

Suicide, not murder, is the most prevalent form of firearm death in this country. What is the role of primary care physicians in addressing this worrisome, growing public health problem?

Provide an opening: Give patients in the office enough time and space to talk about the things that worry them and weigh on them. A question like, “Is there anything else going on that you’d like to share with me? “ may give permission for a suicidal person to open up. A comment like, “Sometimes the most important stuff is the hardest to talk about….I’m all ears,” followed by enough time for the patient to think and open up, can make a difference.

Know your patient’s psychiatric history: Many elements in a patient’s history elevate the risk of suicide: a history of previous suicide attempts, a known mood disorder, a history of a substance use disorder, recent losses, and family history of suicide. Take the time to know your patients, and get help from mental professionals, as appropriate.

Clarify access to firearms: As firearms are the commonest proximate cause of violent deaths, physicians should understand whether or not their patients have access to firearms. It is appropriate to be worrying about high-risk patients with access to firearms, and to address this risk factor with the help of the patient’s family, mental health professionals, and, in some cases, the police.

Let patients know that the channels of communication are always open: People who know that they can always call and reach a health care professional have a place to turn when all else fails. Make sure that your practice has accessible 24/7 coverage, and that those covering know what to do when somebody suicidal calls for help.

In my next  post, I plan to discuss an important related topic: physician suicide. We have always been a high risk group, and this is especially worrisome in view of the recent overall increase in suicide.

Dr. Adelman is director of Physician Health Services, Inc., a corporation of the Massachusetts Medical Society. For more information, visit www.physicianhealth.org. Opinions expressed here are his own, and do not necessarily reflect those of the Massachusetts Medical Society or Physician Health Services.

Regular website content and member email services will not be affected by this brief outage.

By Steve Adelman, MD

Nobody has asked me to write these words; they are mine, and mine alone.

I should have realized, before the fact, that my speculative blog post on a possible marijuana-marathon connection had the potential to offend many good people. In retrospect, I regret the fact that I linked a painful and horrific public tragedy to the alleged perpetrator’s reported use of marijuana. I didn’t intend to upset, provoke and irritate, but that is exactly what my blog posting has done. I feel bad that my words and ideas were offensive to others, and I have asked that the post be removed.

I see little point in attempting to explain what I was trying to accomplish with my speculative posting. Going forward, I plan to focus on topics concerning the health of physicians. With stress and burnout growing in the medical profession, there is much work to be done in this area. Physicians who take really good care of themselves are best able to help their patients. I plan to do my best to promote the health of caregivers and the public.

Dr. Adelman is director of Physician Health Services, Inc., a corporation of the Massachusetts Medical Society. For more information, visit www.physicianhealth.org. Opinions expressed here are his own, and do not necessarily reflect those of the Massachusetts Medical Society or Physician Health Services.

Infectious diseases have plagued the globe for hundreds of years, and through those years, medicine has had its victories: the eradication of smallpox, vaccines for polio and other once-debilitating diseases, and the change from conditions originally thought to be killers, like AIDS and TB, to manageable chronic conditions.

Yet the battle against chronic infectious disease continues, and says the renowned Dr. Paul Farmer, the biggest problem we face today is one of health care delivery to treat – and possibly cure – those conditions.

Dr. Farmer, Kolokotrones University Professor at Harvard University and Chair of the Department of Global Health and Social Medicine at Harvard Medical School, provided a glimpse of the pitfalls and progress in combating infectious disease around the world in delivering the 123^rd Shattuck Lecture presented by the MMS Committee on Publications as part of the MMS Annual Meeting on Friday, May 10.

Well known as the founding director of the nonprofit international agency Partners in Health that works in poor environments around the globe, Dr. Farmer suggested that medicine’s view of fatalism from infectious diseases has being undermined with dramatic improvements in life expectancy and new therapies to treat disease.

While he noted that global life expectancy depends on a variety of factors, among them nutrition, sanitation, delivery of medical services, preventions, and cures, he pinpointed health care delivery as key to sustained improvement. “Health care delivery is the “least well studied,” he said, “and the bias against serious scrutiny of delivery needs to be overcome.”

Recounting his experience in fighting chronic infectious disease in countries around the world such as Haiti and Rwanda – and noting the successes in those nations – he said that the best delivery in poor areas includes community-based health workers who compliment doctors and nurses and hospitals and clinics.

From his vast experience, Dr. Farmer offered five lessons learned in fighting chronic disease:

• Drug resistance is here to stay, but its rate of emergence and spread can be slowed.
• Even the tardy introduction of robust delivery platforms leads, in settings of poverty, to improved outcomes as long as what is delivered is clinically effective.
• A shift from hospital- and clinic-based to community-based care should occur for tuberculosis patients who do not need inpatient or laboratory services.
• Therapeutic innovations need to be linked more rapidly to equitable delivery mechanisms (the “equity plan”).
• It’s not clear that any disease is helpfully termed “untreatable.”

Dr. Farmer concluded his address on a positive note, saying “we have every reason to be optimistic, with new agents being developed, and the growing activity to build integrated health systems.”

Dr. Farmer’s presentation, and biographical information, may be viewed here.

In introducing the 2013 Annual Education Program, Navigating the Currents of Change: Integrating Innovative Technologies Into Your Clinical Practice, MMS President Richard Aghababian, M.D. said “Incorporating technology into our approaches to patient care is one of the biggest challenges we face as physicians today. The tools and data we now have at our disposal are truly amazing. But we must balance the machines with the humans side of medicine.”

The educational program on Friday, May 10 included four distinguished clinicians and scientists who addressed concrete examples of how the latest technologies have made advances in the surveillance, diagnosis and management of disease, and how those technologies are being incorporated into patient care.

Dr. Robert L. Jesse, Principal Under Secretary of Health at the Department of Veterans Administration, discussed health information technology and how it affects patient care.

Dr. Marc Semigran, Medical Director of the Massachusetts General Hospital Heart Failure and Cardiac Transplant Program, talked about how technology and the latest medical devices are improving and extending the lives of patients with heart disease.

Dr. Suzanne  Topalian, Professor of Surgery and Oncology at Johns Hopkins School of Medicine, examined how nanotechnology and targeted immunotherapy are making progress in the battle against various forms of cancer.

Dr. John Moore, of MIT’s Media Lab, discussed the application of technology for patient empowerment within the medical home model.

The participants’ presentations, along with their biographical information, are available for viewing here.

These resources include:

• Crisis counseling and support
• Federal disaster distress helpline
• In-person counseling support
• Assistance to businesses or organizations
• Home modification assistance
• Assistance for veterans
• Assistance for tax filers

Visit the Commonwealth’s website here.

These workshops are co-sponsored by the Massachusetts Department of Mental Health (DMH) and Department of Public Health (DPH) in collaboration with the Executive Office of Health and Human Services (EOHHS).

Psychological First Aid & Resilience in the Aftermath of Terrorism (Workshop #1)

Workshop Summary: This workshop will discuss the impacts of disaster on individuals and communities, techniques for working with impacted populations, and when to triage individuals to additional support.  Attendees will also learn the importance of self care and the importance of resilience both individually and for a community.  The Israel Trauma Coalition will incorporate their own response experience into the training.

Target Group: Licensed mental health clinicians or individuals who have served as crisis counselors in emergencies

Dates: May 7th or 10th (9am – 3pm)

May 7 – Location & Registration

• Talbot Conference Room, Hadley Building, 167 Lyman Street, Westborough Mass.
• Register for May 7th at: http://psychologicalresilience1.eventbrite.com

May 10 – Location & Registration

•  Boston Medical Intelligence Center.  This is located within Boston EMS Headquarters, Miranda-Creamer Building, 35 Northampton Street, Boston MA.  As you enter the garage there will be a large blue sign that reads Miranda-Creamer Elevators and a blue door on your far right. Exit the garage through that door and take elevator to the 6th floor. Once off the elevators, go through the double doors to your right. The Lawlor Regional Medical Intelligence Center is the fourth door on the right.
• Register for May 10th at: http://psychologicalresilience2.eventbrite.com

Introduction to Disaster Behavioral Health & the Impact Of Disaster On Communities (Workshop #2)

Workshop Summary: This workshop will provide an introduction to the psychological impacts of disaster on the community and how community members can assist individuals who have been impacted. A particular focus of the workshop will be the impact of terrorist events on immigrant communities.

Target Group: Social service employees, healthcare professionals, clergy and other natural helpers and community leaders

Date: May 9th (1 – 4pm)

• Location: Boston Room, Eric Lindeman Mental Health Center, 25 Staniford Street, Boston MA
• Register for May 9th at: http://impactofdisasteroncommunities.eventbrite.com

Please Note:

• Though registration is required, trainings are free and open.
• Lunch will not be provided at these events.
• CME credit will not be offered.
• Free on site parking is available at the Westborough workshop.  $5 garage parking is available at the Boston Medical Intelligence Center.  Attendees to the Lindeman Center trainings are strongly encouraged to take public transportation.  Paid parking and limited on street metered parking is available.

For further information contact Liam Seward (Director of Program Implementation and Emergency Management, DMH): Liam.Seward@State.MA.US (617) 626-8170

About ITC

The Israel Trauma Coalition (ITC) was created in 2001, on the initiative of the UJA-Federation of New York. Expanding from Direct Care to encompass Professional Training, Community-wide Interventions and emergency preparedness, ITC has consistently evolved its scope to address broader issues and needs.

The mission of the Israel Trauma Coalition (ITC) is to create a continuum of care in the trauma field, response and preparedness, by leveraging diverse resources to initiate, prioritize, and optimize services. The ITC provides a comprehensive view of the trauma field, whilst working towards strengthening community resilience and ensuring national emergency preparedness. The ITC harnesses the collective knowledge, expertise and experience of Israel’s leading NGO’s and government organizations- as no organization can do this work alone.

Joint replacement is booming in health care, with more than a million people getting new joints every year, usually hips or knees.  And the numbers are expected
to increase as baby boomers approach their mid-sixties. Among the causes are normal wear and tear over decades of use, injuries, genetics, conditions such as arthritis, and high rates of obesity.

The May edition of Physician Focus provides an introduction into joint replacements with R. Scott Oliver, M.D., (photo, right) a board-certified orthopedic surgeon at Plymouth Bay Orthopedic Associates in Duxbury and Chief of Orthopedic Surgery at Jordan Hospital in Plymouth.  Hosting this edition is Bruce Karlin, M.D., (left) a primary care physician in Worcester.

Among the topics of conversation are why more people are getting joint replacements, how they are done, and what patients need to know before, during, and after surgery.  With models of a hip and knees, Dr. Oliver also provides viewers with a visual tour of replacement surgery.

Physician Focus is available for viewing on public access television stations throughout Massachusetts and also available online at www.massmed.org/physicianfocus, www.physicianfocus.org  and on iTunes at www.massmed.org/itunes.