Manitoba suicides force consideration of stresses facing medical residents
Lynne Sears Williams
CMAJ 1997;156:1599-1602
[ en bref ]
Lynne Sears Williams, a writer married to a Canadian physician, lives in Wisconsin.
© 1997 Lynne Sears Williams
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In brief
The suicides of 3 Winnipeg medical residents within 15 months shocked Manitoba physicians and raised concerns among interns and residents across Canada. The cluster of self-inflicted deaths has observers wondering if the stress of residency programs was a contributing factor in the tragedies.
En bref
Le suicide de 3 résidents en médecine de Winnipeg en 15 mois a bouleversé la communauté médicale du Manitoba et soulevé des préoccupations au sujet des internes et des résidents partout au Canada. Cette grappe de suicides incite les observateurs à se demander si le stress imposé par le programme de résidence en médecine a contribué aux tragédies.
The suicides of 3 Winnipeg medical residents within 15 months have shocked Manitoba's medical community and sparked national concern among interns and residents.
Dr. Stephen Brown, president of the Canadian Association of Internes and Residents (CAIR), says the deaths -- in October 1995, November 1995 and January 1997 -- have generated worry and speculation that intense working conditions may have contributed to the doctors' decisions to take their lives. The residents were all enrolled in specialty programs; 2 died by lethal injection, 1 by gun shot. Two committed suicide in the hospitals where they worked. The cluster of self-inflicted deaths has observers wondering whether the deaths should be considered a commentary on residency programs in general, or are simply a statistical anomaly.
"We have to get the facts and the numbers and seek expert resource people for input on this situation," Brown said in an interview. "Is this statistic higher than would be expected in a normal population? If so, are there any common themes? Even if there are additional factors involved, we know that a common denominator is stress from working conditions."
Dr. Bill Jacyk, chair of the National Conference on Physician Impairment, says the fact that 2 of the suicides occurred in hospitals is disturbing. Studies suggest that victims may choose where to die for a variety of reasons, but a predominant one is the choice of "home" as the location.
"We are talking about the concept that 'this is my most familiar place or the place where I live the most,' " said Jacyk. Sometimes the location can be linked to a desire to shock survivors. Another possibility is that the 2 who died in hospital were hoping for an 11th-hour reprieve and believed their chances for successful rescue were best in a hospital.
Availability of means
A Calgary institute that studies suicide says that choosing a hospital could also mean that the victims felt they had the best opportunity and means to take their lives there. A spokesperson said the "availability of means" often affects the suicide equation. "Means is sometimes the determining factor, although at other times, where a person commits suicide is indicative of the person's state of mind. If it is in the home, it may be seen as a means of striking back at people."
The unresolved questions are whether the residents considered the hospitals to be their "homes" and whether the institutions could have taken any action to prevent the deaths.
Jacyk, who is coordinator of the Manitoba Medical Association's (MMA) Physicians at Risk Program, said the suicides make him wonder if institutional safeguards failed. "Was there anything in place that could have headed this off?"
He noted that the MMA's program is designed to assist doctors who are under stress but may be afraid to access assistance programs at their hospitals. "Residents in particular don't want to be perceived as being vulnerable," Jacyk said. "Often, residency programs will have an internal system in place to help doctors, but residents are too afraid to access it for fear of reprisal."
Dr. Peter Markesteyn, Winnipeg's chief medical examiner, says high workload and associated stress definitely affect residents' lives. "But it is a quantum leap to go from analysing the abuse of residents that may go on in the hospital system and suggesting that that has caused the suicides."
While Markesteyn said work-related stress can exacerbate suicidal ideation, the 3 Winnipeg residents had psychosocial factors in common that went beyond the stresses of their residency program. Two left notes, but Markesteyn said neither attributed their decision to die to their residency programs.
"Suicide is a very complex matter, and while stress makes pre-existing things worse, it very seldom causes things," he noted. "If people have domestic problems, generally they can better work that out while they're on a vacation in Mexico, and it's very difficult to do that while you're working your guts out. But overwork is not a cause in my opinion."
Common denominator
He said the major common denominator for most suicides may be any combination involving a history of mental illness, drug or alcohol abuse, and domestic problems.
If Winnipeg's Medical Examiner's Office uncovers evidence that the suicides were related to medical residency, an inquiry will be ordered. "I have a responsibility as the coroner," said Markesteyn. "If I feel that there is a problem in the medical community that leads people to their death, we could call an inquest to determine the cause of death. So far we have not done so. I agree this [cluster of suicides] is a statistical anomaly but not that it [necessarily indicates] some systemic problem."
He agreed that the stumbling block for residents under stress is a fear that if they do not pull their weight on the medical floor, future opportunities may be compromised. "Doctors are reluctant to seek help because if it's found out, you become tainted."
Jacyk stressed that residents shouldn't expect that medical staff will be unresponsive to their problems. He has advocated on behalf of residents who knew they had severe problems and needed time away from the program to obtain help.
"I have always found the residency directors to be very supportive. Their universal reaction was 'he should have asked us himself.' I have never been turned down on a request for medical leave and I have found all the programs to be very accommodating. Some of the fear on residents' parts can be seen as just maturing and realizing, 'I really did make it and I really do belong.' "
Jacyk pointed out that residents may receive conflicting messages from the doctors in charge of residency programs. "The main message is that we're all human and you've got to look after yourself. Unfortunately, there's also [the thinking from] the previous generation that says you have to be top notch, you have to be top gun. Not only are we as senior physicians not consistent, there often aren't really good role models who can [exhibit vulnerability while] being on top of their fields.
"Many residents haven't crossed over to see themselves as being colleagues with the medical staff who supervise them. They still see themselves as students and perceive staff as being taskmasters. Perhaps that is one of our problems. We don't treat them as colleagues . . . and let them know we'll take care of them."
An associate professor in the University of Alberta's Department of Family Medicine says one of the hardest things for physicians to do is put themselves in the hands of another medical professional. Among all professionals, says Dr. Fraser Brenneis, physicians may do the poorest job of looking after themselves.
"Physicians often don't have family doctors, which tends to lead to fragmented medical care. It's easier for them to do it themselves. You can always talk to your friend the cardiologist or your friend the surgeon if you think you have a problem. I think the access issue is there and that doctors tend to find it hard to trust someone else to do that for them. It's hard for us to put ourselves in the hands of others."
Brenneis agreed that residency program directors are probably more approachable than residents believe. "I think it very much depends on the program directors and their own personal philosophy. They're often very much easier to deal with than the residents think." ß
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