A sense of angst was rattling students at the University of Southern California's Keck School of Medicine. One of their peers had taken his life days before.
Professor Mikel Snow felt the dark undercurrent and knew he had to speak up. So, for the first time, he told his students about his decades-long struggle with depression. As word spread, students across the campus started contacting him to discuss the suicide — and to share their own psychological distress.
"The reaction has been astounding," Snow said. "It crystallized that this is a much bigger issue than any of us really realized."
Suicide among medical students and doctors has been a largely unacknowledged phenomenon for decades, obscured by secrecy and shame.
Now, it's beginning to emerge from the shadows.
More than 62,000 people — many of them medical professionals and their families — signed a petition this year calling on medical associations to track physician suicides, provide confidential counseling, and require doctor training programs to address a "culture of abuse" too often characterized by bullying, harassment, and humiliation.
Those groups are responding. The Association of American Medical Colleges convened a meeting to address an escalating crisis of depression, burnout, and suicide among physicians. Among the ideas under consideration: encouraging medical students to join clubs so they feel less isolated; ensuring that counseling is more accessible and private; and more actively tracking the mental health of students and doctors.
"This is something that the profession as a whole needs to come together around and deal with as a shared concern," said Dr. Darrell Kirch, president of the AAMC.
He knows the pain firsthand: He lost two students to suicide during his tenure as dean at medical schools in Pennsylvania and Georgia.
The Accreditation Council for Graduate Medical Education, which oversees the doctor training programs known as residencies, is also focusing on the issue. Officials are studying residents' deaths to determine which might have been preventable, and how to respond. The group sets standards for residencies and is looking at how to strengthen them to protect young doctors' mental health.
Hospitals, too, are racing to launch support groups, peer counseling, and sessions to teach doctors to manage stress by meditating or keeping journals.
The new attention to physicians' mental health comes too late for Cheryl Collier, who had no inkling that her 25-year-old son, Sean Petro, had plunged into despair during his third year at USC's medical school.
"If only he'd said, 'I'm depressed, I'm unhappy, I don't know what to do.' Perhaps I could have helped him," said Collier, weeping with grief and frustration.
In the weeks after Sean's death in May, someone mentioned to Collier that medical students and physicians have a high suicide rate. "I had no idea that was even a possibility," she said.
An epidemic of depression
The starkest sign of the crisis gripping medicine is the number of physicians who commit suicide every year — 300 to 400, about the size of three average medical school classes. Male doctors are 1.4 times more likely to kill themselves than men in the general population; female physicians, 2.3 times more likely.
The grim tally is probably an under-count, since many suicides aren't listed as such on death certificates. And it doesn't include suicides among medical students, which aren't tracked systematically in the United States.
In one study of six medical schools, nearly 1 in 4 students reported clinically significant symptoms of depression. Almost 7 percent said they had thought of ending their lives in the last two weeks.
In another, more recent study, 29 percent of residents suffered from significant symptoms of depression. And those symptoms escalated within a year of starting training — a sign that residency programs themselves were contributing to the problem.
The stress starts in medical school, where students face pressure to master an overwhelming amount of material. Competition with peers can be brutal. Sleep deprivation is common. And students can face withering criticism from faculty who have little tolerance for ignorance, signs of weakness, or emotional displays.
Once they're practicing, physicians face additional stresses: An immersion in human suffering. Long work hours. High expectations. A dread of making mistakes. They're often profoundly uncomfortable with acknowledging vulnerability. And they must adapt to a rapidly changing health care environment.
Medical education and training are "a profoundly dehumanizing experience and it's drilled into you: Do not show your heart or tears to anyone, ever again," said Dr. Pamela Wible, a family doctor in Eugene, Ore., who has grappled with profound depression, written a book about physician suicide, and given a popular TEDMed talk on the topic.
By necessity, Wible said, doctors become "masters of disguise," expert at concealing their emotions.
'I never saw this coming'
Sean Petro must have learned to conceal despair and hopelessness at some point.
In an emotional interview, his mother described Sean, her only child, as caring, generous, smart, and sensitive. She used to run a small day care out of her house; Sean helped her feed the children and gave them toys he'd outgrown. "He treated them like brothers and sisters," she said.
That love of children inspired Sean to declare in second grade that he wanted to be a pediatrician. He changed his preference to oncology after his father died of stomach cancer when Sean was 15.
When it came time to go to college, Sean decided to keep living at home in San Diego with his mother. Collier understood that he saw himself as her protector.
Sean did well in medical school at the University of Southern California; he had friends and he seemed well-adjusted. Though Collier didn't hear from him often, she wasn't concerned. He was living on his own for the first time, and he wasn't a big talker.
Unexpectedly, though, Sean started calling regularly — and talking to his mom for an hour or more — during a month-long training Navy officer program in Rhode Island this past April. She thought he might be lonely.
He flew home after finishing the program on May 6 and spent the day with friends, hanging out in the hot tub and talking about his interest in becoming a Navy flight surgeon. "We had a wonderful, wonderful day," said Dr. Roneet Lev, the mother of Sean's best friend.
The following day was Mother's Day. Sean was quiet but brushed off his mom's concerns and gave her a warm hug before driving home to Los Angeles.
As promised, Sean texted his mother to tell her he'd arrived home safely. But he didn't return texts she sent the next day. On Tuesday morning, USC police entered his apartment and found him hanging from an exercise bar at the top of his closet. There was no note.
"He never said anything," Collier said. "I never saw this coming."
'My career is over'
By contrast, John and Michele Dietl knew that their son, Kevin, needed help.
But they didn't know how to interact with the medical school he was attending when his life began to unravel.
Kevin took his life on April 23, 2015, near the end of his fourth year at A.T. Still Kirksville College of Osteopathic Medicine in Kirksville, Mo.
"He was always stressed. He'd call and say, 'We had this test and I missed the grade I wanted by one question,'" John recalled. "And he'd say, 'I have no social skills any more because I'm studying all the time.'"
The Dietls urged Kevin to get help, but he told them he couldn't risk seeking counseling because it could appear on his record and compromise his future. So the family decided to pay cash for therapy, off-campus.
In the middle of his fourth year, crisis struck. Kevin became agitated after questioning his decision to go into psychiatry. A few days after Christmas vacation, he drove his car off the road. Sleep deprivation, he told police, but they didn't believe him and put him on a 96-hour psychiatric hold.
"My career is over," Kevin told his parents.
"We had no idea what to do," Michele said. Should they contact the school? Encourage Kevin to withdraw?
"As a parent, you're afraid to call and say you think something is wrong with your 26-year-old young adult. You don't know what your options are," Michele said.
A month later, John and Michele decided to organize an intervention. Before they could do so, Kevin drove to a railroad crossing, intending to chain himself to the tracks. Again, police intervened. This time, he volunteered to go into inpatient treatment.
Kevin seemed "like a different person" after a three-week stay, John said. He called his dean and said he was ready to go back at the end of April. He told his parents, "I can do this." But they knew he was upset about not graduating with his classmates.
Toward the end of April, John went into Kevin's bedroom and sat down on the bed. "We know this is extremely hard," he told his son, "But you're taking responsibility for getting better and you are getting better. We just want you to know we love you and appreciate it."
Arriving home from work the next day, John smelled fumes coming from the garage. Kevin was inside the car with the engine running, his head covered with a shroud, so his parents wouldn't have to see where he'd shot himself.
The Dietls will appear in an upcoming documentary about physician suicide, Do No Harm, the first feature-length examination of the issue.
Robyn Symon, the director, came to the topic after two young doctors in New York City jumped to their deaths in 2014. She said she hoped the film will "break the code of silence around suicide that exists in the medical profession."
The Dietls have also begun to travel across the country, speaking out about the need for change in medical education and training.
"You can't just tell these students, 'Well, we're going to help you deal with stress and give you some resiliency training,'" John said. "The problem is bigger than that and something more needs to be done."
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