Causes of death among residents

What is the leading cause of death among residents in all specialties?

A. Accidents
B. Neoplasms
C. Suicide
D. Miscellaneous diseases

If you answered C, you were wrong. The correct answer is B, neoplasms. Suicide was the second most common cause, followed by accidents and miscellaneous diseases.

A study in Academic Medicine looked at resident deaths over a 15 year period and found that of the 381,614 individual physicians in ACGME training programs, 66 died of suicide. For the over 1.6 million person-years studied, the suicide rate for residents was 4.07 per 100,000 person-years—well below the figure of 13.07 per 100,000 years in the general population of people aged 25-34.

Residents in age groups 35-44 and 45-54 had suicide rates higher than the 25-34 group and higher than the rates of those in comparable general population age groups.

More suicides occurred during the first and second years of training and during the months of July through September and January through March. In my opinion, the months that deaths occurred in can be explained as follows. In the first three months of the academic year, residents in the first and second years may feel overwhelmed and subject to self-doubt—the so-called "impostor syndrome." By the time January and February roll around, it is mid-winter, and it seems like the year will never end.

Residents had a much lower rate of death from accidents, including those related to automobile crashes, than the general population.

The overall death rate from all causes was also lower for residents than the rate of the general population at 16.91 per 100,000 person-years and 105.4 per 100,000 person-years, respectively.

The authors were surprised that resident rates of suicide were lower than age- and gender-matched populations especially because suicide rates for medical students and practicing physicians are higher.

They concluded that suicide was probably the only area in which prevention strategies, such as a supportive environment and medical and mental health services, could reduce the death toll.

Program directors, faculty, and residents themselves should probably show heightened vigilance in the first and third quarters of the academic year particularly for first and second year trainees.

Hospital politics, patient care and a doctor's suicide

What causes a doctor to commit suicide? A tweet from Helen Haskell (@hask) linking to a story about a radiation oncologist from Springfield, IL brought this strange case to my attention. Dr. Thomas G. Shanahan committed suicide by cutting his throat in November of 2011. He was respected in his field, having published many research papers and traveled the world helping to set up brachytherapy clinics in several countries. He also had been an acting alderman in his home city. He left his wife and three daughters.

Why did he do it? He had a history of depression. But an event occurred the year before his death that apparently significantly affected his personal and professional life.

Perhaps this story will puzzle you as much as it did me.

A patient with a diagnosis of advanced lung cancer was transferred to Memorial Medical Center where Shanahan worked. She had fallen and broken her leg and developed massive distension of the colon. She was having difficulty breathing. All of her doctors assumed she was terminally ill and advised the family to place her on a comfort care only status. Dr. Shanahan had received a request to see her and did so the next day. After evaluating her and her biopsy results from the first hospital, he felt that she was not necessarily terminally ill and should have a colonoscopy to decompress her colon. The other physicians declined to do so although inexplicably, a colorectal surgeon agreed to colonoscope her and ruled out obstruction but felt decompressing the colon would have been futile.

Shanahan then instructed a nurse to insert a rectal tube which evacuated all the gas and promptly resolved the breathing difficulty. The patient survived for seven more months with some diminished mental capacity thought to be related to the relative lack of oxygen when she was getting only comfort measures. She and her family were pleased with Dr. Shanahan’s efforts on her behalf.

The patient had Ogilvie’s syndrome, also known as pseudo-obstruction of the colon. It occurs in bedridden patients and those with recent orthopedic problems who receive large doses of narcotic pain medication. The treatment Shanahan ordered was correct.

But Dr. Shanahan admitted he had "ruffled the feathers" of some colleagues. He was called a “disruptive physician.” Memorial Medical Center conducted “an inquiry” to investigate his conduct. It was eventually dropped without any formal action being taken.

The chief medical officer at Memorial said, “Shanahan portrayed himself as ‘somewhat heroic’ to Reindl's family and was unnecessarily abrasive toward Springfield Clinic doctors and Memorial employees.”

Another account reported the following. Shanahan moved his office earlier this year from Memorial to St. John’s Hospital, telling friends and colleagues in an email June 28: “The last six months have been hard on me, deciding to defend a patient or turn my head and follow the herd. … I have received over 500 letters and emails supporting my decision.”

We will never know how deeply this situation affected Dr. Shanahan. He left no note.

Having learned all I can about this tragedy, I have some questions. Why was a radiation oncologist able to correctly diagnose and treat this patient while several more clinically oriented specialists could not? How is it that the doctor who made the right call over the objections of several colleagues is the one who is subjected to an inquiry and feels the need to move to another hospital? Is it OK to be “abrasive” when you are the only one who got the diagnosis right? Wasn’t he in fact a “hero” for refusing to back down and saving the patient’s life?

[This post used material from three newspaper reports (here, here, and here) and other sources.]