The Value of Vulnerability

Physician suicide is a public health crisis and has been for many years. According to a study by Center et al¹ , an estimated 300 physicians commit suicide in the United States every year. Many of these might be related to depression that is ignored and left untreated. Despite the urgency of this epidemic, news of physician suicides and depression often gets buried on public forums because it represents a failure of the many stakeholders involved. This forces one to wonder how many doctors will have to die until someone takes notice. As a part of this system and as an honor to the many colleagues we have lost to this day, today I want to advocate for the value of vulnerability.

How do you define vulnerability? Derived from the Latin word for wound, “vulnus,” it defines the state of being open to injury, and of being open to hurt, sadness, error, and emotional and physical turmoil. As doctors, we are often not comfortable with talking about the above-mentioned things, nor are we not allowed to by those in charge. As part of the medical community, there is an unsaid expectation for us to be the ultimate pillars of strength. Writing the word “vulnerable” next to a physician’s name seems like a huge stigma in our world of perfectionism in medicine. How does that relate to physician suicide?

Two physicians whom I knew distantly recently committed suicide. Pictures that were taken 2 days before their deaths were shared. They were smiling and representing a persona of living normal lives. Peers and family were unaware of the mental turmoil they had been experiencing. Their deaths came as a complete shock to many. How can an always-smiling, joyful individual like Dr So-and-So take his life? What did people around him fail to see and recognize?

As a colleague, I questioned what were those physicians thinking? What made them feel so hopeless that they felt they could talk to no one? Why did they come to this conclusion that taking their life was the only option to end the pain? Was it related to a patient they had lost? Was it a medical error? Was it the fear of losing their career if their well-hidden depression became common knowledge? Why could they not talk?

And then it dawned on me. How many times have I failed or almost made a mistake and tried my best to cover it up so that no one found out? How many times have my colleagues and I faltered and spent sleepless nights thinking about patients but on the outside, painted the most stoic exterior? How many physicians are scared to seek mental health resources, fearful that their colleagues or supervisors would find out, affecting their reputation? How petrified are we to show 1 moment of weakness or vulnerability? We are all going through this together, but we are also hiding from each other. How did we become like this?

When we enrolled into medical school, we never assumed that there may be some darkness that surrounds the profession that we are indulging in. We were bright eyed and cheerful and believed in the optimism and hope of bringing peace and health to other humans’ lives. We believed that we were in the noblest profession of all and that over time, our compassion and love for humanity was what would keep us going. We had confidence that we would give it our best and that the rewards and gratification would follow. Nobody told us the truth.

What we did not know yet was that this is a job in which often our best efforts will not be enough. Death and loss will stare at us straight in our eyes, following us to sleep, and present when we wake up the next morning. Our compassion and love for humanity will often break our hearts. We will often have to ignore our personal lives, miss our children’s school recitals, miss our fathers’ doctor’s appointments, and ignore our own health issues. Our days will often be consumed by piles of documentation and interactions with insurance companies. In this “business” of human lives, there will often be no second chances. We might miss 1 small thing and lose a patient forever. And that alone is terrifying. And among all these things, we will not be allowed to flinch. Being tough is the only option. We will never see someone above us in the hierarchy cry or admit to making a mistake. Supervisors will often tell us to “be tough” or tell us how it was harder in their times. We will be provided with a list of mental health resources on a brochure, but we will never see anyone use it. Hence, we are left with no choice but to hold ourselves to the same pedestal.

As we progress through our years of training and practicing, much of the above facts reveal themselves on us. And often we try to power through them. We smile and build up a façade of a perfection that is expected of us. We are often scared, but we are resistant to admit it. We experience sadness but are fearful to show it because it will often be mistaken for frailty. We try to suppress any humane feeling that we have for ourselves and instead channel it into taking care of patients. And maybe some feel so trapped in this cage that they have created that they think about ending their lives. In his novel, Verghese²  describes the attitude in medicine as “a silent but terrible collusion to cover up pain, to cover up depression; there is a fear of blushing, a machismo that destroys us.”

Clearly, the practice of hiding the news of physician suicides by hospitals stems from the same deep-rooted malignant culture in which vulnerability is seen as a sign of weakness. The death of a physician by suicide is not a personal failure, it is a failure of this system that venerates physicians. It is a failure of the system that makes physicians fearful of seeking help. A study in 2015 revealed that almost 1 in 4 of resident physicians experience a major depressive episode during their training years.³  This ratio is higher than that of similarly aged individuals in the general US population.

What will it take for physician leaders to speak this ugly truth? What will it take for hospitals to humanize physicians? Hospital leadership needs to take urgent steps to remove the stigma from the careers of physicians willing to pursue help. Clearly, we cannot afford to lose anymore.

Today, as your colleague, I want to admit that I have numerous moments of weakness; I hope you all can find the strength to do the same. I want to emphasize the strength of sadness and of exposing our true selves to the world. In our own small to large work environments, I aim that we give each other room for imperfection. I hope that we can snap out of the idealism that we hold for ourselves and others. I hope that we can cry and not feel weak. I hope that we can share and not feel judged. And I hope that when things get tough for us, we let go of that pressured smile and do not feel ashamed to ask for help. I hope that we remember that we are more important to others than how we would be described in our obituaries.