Mental illness doesnt always show itself superficially

He was the go-to sports guy in Washington, D.C. A masterful surgeon with countless academic publications, he trained orthopedic surgeons across the world and was the top physician for professional sports teams and Olympians.

Dr. Benjamin Shaffer had it all.

Yet Ben was more than a stellar surgeon. He was a kind, sweet, brilliant, and sensitive soul who could relate to anyone -- from inner-city children to Supreme Court justices. He was gorgeous and magnetic with a sense of humor and a zest for life that was contagious. Most of all, he loved helping people. Patients came to him in pain and left his office laughing. They called him "Dr. Smiles."

Ben was at the top of his game when he ended his life. So why did he die?

Underneath his irresistible smile, Ben hid a lifetime of anxiety amid his professional achievements. He had recently been weaned off anxiolytics and was suffering from rebound anxiety and insomnia -- sleeping just a few hours per night and trying to operate and treat patients each day. Then his psychiatrist retired and passed him on to a new one.

Eight days before he died, his psychiatrist prescribed two new drugs that worsened his insomnia, increased his anxiety, and led to paranoia. He was told he would need medication for the rest of his life. Devastated, Ben feared he would never have a normal life. He told his sister it was "game over."

Ben admitted he was suicidal with a plan though he told his psychiatrist he wouldnt act on it. Ben knew he should check himself into a hospital, but was panicked. He was terrified he would lose his patients, his practice, his marriage, and that everyone in D.C. -- team owners, players, patients, colleagues -- would find out about his mental illness and he would be shunned.

The night before he died, Ben requested the remainder of the week off to rest. His colleagues were supportive, yet he was ashamed. He slept that night, but awoke wiped out on May 20, 2015. After driving his son to school, he came home and hanged himself on a bookcase. He left no note. He left behind his wife and two children.

I feel a kinship with Ben, partly because I used to suffer from chronic anxiety that I hid under academic achievements, but mostly because Im a cheerful doctor who was once a suicidal physician too. In 2004, I thought I was the only suicidal physician in the world -- until 2012 when I found myself at the memorial for our third doctor suicide in my small town. Despite his very public death, nobody uttered the word suicide aloud. Yet everyone kept whispering "Why?" I wanted to know why. So I started counting doctor suicides. Within a few minutes, I counted 10. Five years later, I had a list of 547. By January this year, I had 757 cases on my registry. As of today that number is 1,013.

High doctor suicide rates have been reported since 1858. Yet 160 years later the root causes of these suicides remain unaddressed. Physician suicide is a global public health crisis. More than one million Americans lose their doctors each year to suicide -- just in the U.S. Many doctors have lost several colleagues to suicide. One doctor told me he lost eight physicians during his career with no chance to grieve.

Of these 1,013 suicides, 888 are physicians and 125 are medical students. The majority (867) are in the U.S. and 146 are international. Surgeons have the greatest number of suicides on my registry, then anesthesiologists.

However, when accounting for numbers of active physicians per specialty, anesthesiologists are more than twice as likely to die by suicide than any other physician. Surgeons are number 2, then emergency medicine physicians, obstetrician/gynecologists, and psychiatrists.

For every woman who dies by suicide on my registry, we lose four men. Suicide methods vary by specialty, region, and gender. Women prefer overdose. In the U.S., men use firearms. Jumping is popular in New York City. In India, doctors are found hanging from ceiling fans. Male anesthesiologists are at highest risk among all physicians. Most anesthesiologists overdose. Many are found dead inside hospital call rooms.

Doctor suicides on the registry were submitted to me during a 6-year period (2012-2018) by families, friends, and colleagues who knew the deceased. After speaking to thousands of suicidal physicians since 2012 on my informal doctor suicide hotline and analyzing registry data, I discovered surprising themes -- many unique to physicians.

Public perception maintains that doctors are successful, intelligent, wealthy, and immune from the problems of the masses. To patients, it is inconceivable that doctors would have the highest suicide rate of any profession (see abstract 227 from the 2018 American Psychiatric Association meeting.)

Even more baffling, "happy" doctors are dying by suicide. Many doctors who kill themselves appear to be the most optimistic, upbeat, and confident people. Just back from Disneyland, just bought tickets for a family cruise, just gave a thumbs up to the team after a successful surgery -- and hours later they shoot themselves in the head.

Doctors are masters of disguise and compartmentalization.

Turns out some of the happiest people -- especially those who spend their days making other people happy -- may be masking their own despair. Reading this excerpt from the 1858 Manual of Psychological Medicine, Im reminded of so many brilliant doctors Ive lost to suicide:

"Carlini, a French actor of reputation, consulted a physician to whom he was unknown, on account of the attacks of profound melancholy to which he was subject. The doctor, among other things, recommended the diversion of the Italian comedy; for, said he, your distemper must be rooted indeed, if the acting of the lively Carlini does not remove it. Alas! ejaculated the miserable patient, I am the very Carlini whom you recommend me to see; and, while I am capable of filling Paris with mirth and laughter, I am myself the dejected victim of melancholy and chagrin."

Many of our most inspiring and visionary leaders -- artists, actors, even doctors -- suffer from mental illness.

Yet students enter medical school with their mental health on par with or better than their peers. Suicide is an occupational hazard in medicine. Doctors develop on-the-job PTSD -- especially in emergency medicine. Patient deaths -- even with no medical error -- may lead to self-loathing. Suicide is the ultimate self-punishment. Humans make mistakes. When doctors make mistakes, they are publicly shamed in court, on television, and in newspapers (that live online forever). As doctors, we suffer the agony of harming someone else -- unintentionally -- for the rest of our lives.

Blaming doctors increases suicides. Words like "burnout" and "resilience" are employed by medical institutions to blame and shame doctors while deflecting their own accountability for inhumane working conditions in failing health systems. When doctors are punished for occupationally induced mental health wounds, they become even more desperate.

If physicians do seek help, they risk being disciplined. Doctors rightfully fear lack of confidentiality when receiving mental health care as private conversations with therapists could be turned over to medical boards and illegally accessed by their supervisors via electronic medical records at their institutions. So physicians drive out of town, pay cash, and use fake names in paper charts to hide from state boards, hospitals, and insurance plans that interrogate doctors about their mental health and may prevent or delay state licensure, hospital privileges, and health plan participation.

With a great work ethic until their last breath, doctors are often checking in on patients, reviewing test results, and dictating charts minutes before orchestrating their own suicides. Many leave apologetic heartfelt letters detailing the reasons for their suicide for friends, family, and staff. One orthopedic surgeon simply wrote: "Im sorry I couldnt fix everyone."

Doctors choose suicide to end their pain (not because they want to die). Suicide is preventable if we stop the secrecy, stigma, and punishment. In absence of support, doctors make impulsive decisions to end their pain permanently. I asked several male physicians who survived their suicides, "How long after you decided to kill yourself did you take action -- overdose on pills or pull the trigger?" The answer: 3 to 5 minutes.

Ignoring doctor suicides leads to more doctor suicides. Lets not wait until the last few minutes of a doctors life when heroic interventions are required. Most physician suicides are multifactorial involving a cascade of events that unfold months to years prior. So reach out to "happy" doctors today -- especially male anesthesiologists and surgeons who are least likely to cry or ask for help.

Pamela Wible, MD, pioneered the community-designed ideal medical clinic and blogs at Ideal Medical Care. She is the author of Physician Suicide Letters -- Answered and Pet Goats and Pap Smears. Watch her TEDx talk, How to Get Naked with Your Doctor. She hosts the physician retreat, Live Your Dream, to help her colleagues heal from grief and reclaim their lives and careers.

This post originally appeared on Ideal Medical Care.