On December 3rd, 1999, Dr. Loice Swisher’s life changed forever when doctors diagnosed her five-year-old daughter with a pediatric brain tumor. Dr. Swisher describes, in a piece for Emergency Medicine News, that her daughter went into surgery yelling, ‘It’s my tumor, I want to keep it!’ “She came back to me blind, mute, and totally paralyzed, and to make the situation exquisitely painful, she could hear and think like a normal 5-year-old. She was totally locked in. I was locked out.” Dr. Swisher began dedicating her time and effort toward pediatric brain tumors, rehabilitation, and education, not only focusing on how to make her daughter better but also helping similarly situated families. Simultaneously, she felt unrelenting, soul-crushing guilt, believing she’d failed her daughter, both as a mother and a physician. Dr. Swisher had been vigilant, asking the doctor two years before to check for leukemia and Lyme disease when her daughter complained of joint pain. After her daughter had five episodes of unexplained vomiting in a single month, Dr. Swisher contacted the pediatrician to rule out a brain tumor, resulting in the MRI that showed a large mass in her daughter’s brain. “Even though I’m the one who diagnosed it, I didn’t believe she had a tumor. I just thought I was a paranoid emergency medicine mom who suspected her daughter of having a fatal disease every year or two. It made me question how many clues I blew off or just thought I was making up. How late was I taking her to the pediatrician? The self-blame never stopped.”
During this time, when colleagues asked Dr. Swisher, an emergency medicine clinical associate professor at Mercy Philadelphia Hospital, how she was doing, she’d respond, “Nothing is going on today that 100 units of insulin wouldn’t cure.” The trouble is that her colleagues didn’t know what to say or thought she was joking, so no one responded. “I said it many times, and in some ways I wanted it to be a red flag because I was in pain, but at the same time, if you tell people, ‘I’m thinking about killing myself,’ you might wind up in the crisis unit in your hospital, and I didn’t want that either.” Dr. Swisher says, instead, she began to consider herself dead: she continued to attend work, help others, and make sure her daughter had a good life but would let go of emotions and not hold onto threads of hope, passions, or dreams. “If emotion crept in, I’d remind myself that I wasn’t allowed to do that, telling myself, ‘Remember, you made this deal.’”
Dr. Swisher says physicians often don’t talk about suicide but have a high occupational risk. Doctors in the emergency department often work in environments where their patients teeter between life and death. They aid patients in severe medical distress, where the likelihood of loss of life is higher but no less easy to accept. Their intervention, if successful, is life-saving. If it fails, they often self-blame. Dr. Swisher says what compounds the guilt and pain is the high bar doctors put on themselves. “We simply aren’t allowed to make mistakes.” While suicide is a public health risk among the general population, ranking as the 10th overall cause of death in the United States, it’s even higher for doctors. Women physicians have a relative ratio risk of 2.27, and men physicians have one of 1.41. Roughly 300-400 medical students and physicians die of suicide each year. Part of the reason why, says Dr. Swisher, is the stigma associated with depression and suicidal ideation among physicians, which decreases the likelihood of self-reporting. “We need a shift in our professional culture to support doctors in need and must acknowledge the power of compassion and strength that comes from sharing our stories. Doing so is necessary to combat the power of shame and self-judgment.”
Cultural norms are hard to break, and Dr. Swisher didn’t let go of them overnight. In fact, she kept her end of the deal with herself, remaining silent for 16 years until she read a letter by Chris Doty, MD, to his emergency medicine colleagues in January 2016. In the letter, he shared the tragic loss of one of his residents who died of suicide. Dr. Swisher says she had a visceral reaction because she felt complicit in the stigma that prevented this young man from getting help. “If we, as physicians, had been more open with our stories, making it normalized, perhaps there would have been a different outcome. I made a promise, from that point forward, to shine a light on our occupational risk and focus on suicide prevention every day for 2,000 days. If you don’t make it a habit, you stop.”
On September 17th, 2018, Dr. Swisher pioneered the first annual National Physician Suicide Awareness (NPSA) Day in the United States to counter stigma, increasing awareness of the occupational risk, and giving doctors a day to share stories on how their lives have been impacted by suicide. She worked alongside the American Association of Suicidology (AAS) and the Council of Emergency Medicine Residency Directors (CORD), setting up a series of interviews on Facebook for doctors to access. (The videos continue to be available to anyone who wants to watch them.) “People shared their own experiences or that of someone who they worked with or went to school alongside. It’s vital to create a safe space for doctors to tell their stories as it’s hard for them to find the appropriate time to talk about suicide.”
Awareness of occupational suicide risk isn’t enough, says Dr. Swisher. Physicians must also learn what they can do as leaders in healthcare to make a difference in this increasing public health epidemic in the United States. “Many doctors continue to use stigmatizing language like ‘commit suicide.’ That term is like nails on a chalkboard for me: it separates people who died of suicide from every other way people die. There is no other committed death out there.” She says all it takes is some forethought to change the language to died of suicide. “It’s such a small difference but changes everything in meaning and costs nothing.”
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