Ghosts and Grief: Physician Suicide in the Age of COVID-19
The Parable of the River, a tale popularized nearly 100 years ago, can help us begin to understand what it feels like to fight against physician suicide. The story goes like this:
When it began, a group of villagers was working in the fields, next to a river. A cry roused them from their work—someone had spotted a baby floating downstream. A woman rushed to the banks, plunged herself into the water, and brought the infant ashore. The villagers returned to their work.
Over the next several days, however, more babies were spotted bobbing in the waters, prompting several villagers to jump in and rescue them, too. And the babies kept appearing.
Before long, the villagers abandoned their field work and organized themselves into a company to rescue as many babies as they could. Each villager had a role: One jumped into the river and plucked the baby from the water. Another waited on shore with blankets, while yet another ensured the baby was fed. The next villager in the chain found a new home for the baby, and so on. Village life soon became defined by this rescue operation, and the stream of babies struggling in the river became constant.
So many babies emerged in the water that it was impossible to save them all. But the villagers felt they were doing well to save as many as they could.
As time passed, many of the villagers became exhausted by the relentless task. Concern grew over the fields that now lay fallow. Eventually, one villager made a suggestion.
“Why don’t we go upstream and see how all these babies end up in the river?”
The question led to a villagewide debate. Some argued that sending a party up the river would mean fewer people would be on hand to help bring babies ashore. Others objected, arguing that if they could find out why the babies were in the water, they might save more lives.
“Don’t you see?” cried some. “By going upstream, we can eliminate the cause of the problem.”
“But it’s too risky,” the village elders responded. “What if you fail? What if you don’t return? We’re rescuing so many of the babies through the method we’ve set up. It’s not for us to change the system. And besides, how would we occupy ourselves if we no longer had this to do?”
When we talk about physician suicide, burnout, and their consequences, it can feel like we’re not going upstream. Solutions often involve advising doctors to practice self-care or take some time off work. While these can be useful strategies, the root causes of physician suicide and burnout remain in place. The babies keep floating downriver, and not all of them are rescued.
Life After Death
Every year, more than 45,000 people are reported to die by suicide in the US. In their wake, they typically leave at least six “suicide survivors”—friends and family members who find themselves battling grief and struggling with questions for which there are no answers. Physicians and their families go through this horrible process more than many people. According to a 2019 article co-authored by Jessica Gold, MD, the suicide rate for physicians is roughly twice that of the general population and may be on the rise.
Meanwhile, for those who are left behind, life after losing a loved one can be almost intolerable. There are physiological reasons behind this: Part of this is a process called the selfish brain theory. During times of acute psychological stress, it’s hypothesized that the brain prioritizes its energy requirements over the rest of the body, favoring glucose allocation to the brain at the expense of other organs and tissues.
This theory was put to the test in a 2017 study conducted at the University of Cambridge, which saw rowing crews completing two tasks: A three-minute memory test and a three-minute power test on a rowing machine. Participants then completed both tasks at the same time. During the simultaneous challenge, researchers found that both physical and mental performance were diminished—but, significantly, their recall ability was impacted far less than their rowing. The reduction in physical power was on average 30% greater than the drop in cognitive function.
This preferential allocation of energy is thought to be an evolutionary trait, which allowed our ancestors to think quickly during times of stress, helping our species to survive. In a sense, the brain is designed to keep itself ticking, possibly to the detriment of our bodies. For those going through grief, this can result in fatigue, weight loss, disrupted sleep, and other physical symptoms. We may feel like one of the villagers in the Parable of the River, exhausted and unsure whether you can continue.
At the same time, the mind keeps whirring. Those who’ve lost a loved one to suicide may experience recurring thoughts of the death. They could find themselves replaying moments in their head again and again. It might feel like they can’t shake the image of the baby they couldn’t rescue, forever watching it drift further out of reach, down the river.
Ghost Stories
A grieving brain can do unexpected things to us. A rarely discussed but surprisingly common experience for the bereaved is hallucinations. People who’ve lost loved ones don’t typically talk about this, for fear of being labelled mentally unstable, but many see or even communicate with the “ghosts” of those who’ve passed.
In fact, these visitations are common enough to be considered the norm rather than the exception. According to research published in 2017 in Frontiers in Psychology, more than 80% of elderly people report experiencing hallucinations following the loss of a partner. People often experience “sensing the presence” of their dead spouse or feel them “watching out for or protecting them.” Some even report being touched by their dead partner, hearing their voice, or smelling their presence. These don’t tend to be passing visions—they are veritably vivid evocations of a life no longer lived.
Scientists think the brain causes these hallucinations in its attempt to mitigate the impacts of social isolation, affective deprivation disorder, and despair, all of which can arise when a person is in mourning. Depending on the kind of death, these ghosts can be a distressing presence or a comforting one. It’s telling that the intensity of the grief, as well as the happiness of the marriage, are found to correlate with how pleasant the hallucinations are. These ghosts don’t arrive to haunt those who remain. They come to provide a shoulder to cry on, to lend an ear, to remind their partner of the love that’s still very much alive.
COVID-19 and Grief
The COVID-19 pandemic has already left millions of ghosts in its wake, and not all of them died of the virus.
Physician burnout was already reaching epidemic levels prior to the start of the pandemic. According to a national survey conducted by Medscape in the months before COVID, 42% of physicians reported feeling symptoms of burnout. Even more concerning were the responses to a question on how physicians are coping with this: The top answer was “isolate myself from others.”
And while the factors contributing most to burnout (too many bureaucratic tasks, long working hours, lack of support in the workplace) have remained the same, the pandemic has added a plethora of new fears and stresses to the mix. Over the past year, doctors have reported not having adequate access to personal protective equipment. Their working hours have become longer. They’ve reported significant anxieties over their chances of catching the virus themselves, and passing it on to family members or other loved ones. They’ve watched half a million people die, often in slow, painful ways—and often alone.
In a Twitter thread, pulmonary and critical care physician Dr. Lakshman Swamy described how significantly the pandemic has intensified the trauma experienced regularly by those who work in ICUs. Swamy recently had a nurse tell him “I’ve had someone die in every one of these rooms.”
“Every single ICU room carries the trauma of so many COVID deaths,” Swamy wrote. “There were so many bad deaths, and we carry them all.”
The trauma of all of this was epitomized in a tweet from one physician, who described a recurring COVID-related nightmare: “O2 sats dipping... 40%... 29%... 10%... 3%... and the 3% keeps flashing. Saw it in real life and it kept playing over in my nightmares.”
As a result of this, Sharp Index has seen a marked increase in responses to a survey on burnout and mental health, as well as a dip in the number of people who want to be contacted for a follow-up.
Medscape’s 2021 Physician Burnout & Suicide Report, findings of which were published last month, also illuminated the impacts of the pandemic. The survey, completed by over 12,000 physicians in 29 specialties from August to November, 2020, found that roughly 42% of doctors are experiencing burnout and that a fifth of those physicians felt that their burnout symptoms were a direct result of the pandemic. It’s estimated that roughly 300 physicians die by suicide every year, but Medscape’s survey indicated that the number of physicians who have attempted suicide could be far higher than this. 1% of respondents reported an attempt and 13% reported having suicidal ideation.
This impact can be seen across the general populous too. Various studies have found that COVID-19 has caused significant psychological distress and those that used models to estimate the effect of the pandemic on suicide rates predicted increases ranging from 1% to 145%.
While vaccine rollouts across the globe have demonstrated that we’re willing to go upstream to solve the problem of the virus, efforts to combat physician suicide and burnout still feel like rescuing babies from the river. Health systems that only launch the much-mocked yoga class or focus on resilience over systemic change are not in search of the root cause.
Studies have suggested that some of this “upstream work” is feasible. In the COVID-19 pandemic, proper access to PPE is an easy one. Daily check-ins with frontline healthcare workers have been shown to reduce anxiety. More broadly, providing childcare options to physicians, supporting them in seeking mental health care, and redesigning work schedules could improve the function of the US healthcare system at large.
But the fact remains that, once the COVID dust has settled, the babies will still be flowing downriver. Sending a party upstream will still be the only way to stem the tide.
