Stress and professionalism: the history of physician suicide
By Alannah Tomkins
Medical practitioners have historically been regarded as particularly at risk of suicide. From the first investigations of British suicides by occupation, conducted by William Ogle in 1886, to the most recent analyses by the Office for National Statistics, suicide has been a prominent cause of death for doctors, at a markedly higher rate than for the general population. In the present day, the British Medical Association is making ever-greater efforts to support practitioners by identifying the causes of stress and offering ‘doctors for doctors’. We know relatively little, however, about this phenomenon in the past.
I have been working on the issue of physician suicide for the last three years, via reports of relevant coroners’ inquests in the press. The focus of my research is 1800–90 (in line with my larger project considering all forms of career turbulence for medical practitioners); these decades generate reports of over 280 medical men who killed themselves. This is likely to be a significant underestimate, given the probability of ‘accidental’ causes being ascribed in some cases to conceal the brutal truth, a phenomenon already noticed by historian Robert Woods.
My first opportunity to share this research with current practitioners came in March 2011, when I gave a seminar to north Staffordshire psychiatrists at the Harplands Hospital in Newcastle- under-Lyme. I discussed reports of methods and alleged motives, provided case studies from the lay press and observed the terse or highly muted reception of medical suicide by the contemporary medical journals.
Medical practitioners in their 30s were most at risk, and the most dangerous half of the year was during the months May to October. There were never more than ten reports of physician suicide in a year, but the methods and motives were notably resistant to change. Sixty per cent of the men (all instances were male in these decades) poisoned themselves, with a marked preference for prussic acid (also called hydrocyanic acid – or cyanide). This was assumed at the time to arise from ready access to poisons, and from the swiftness and certainty of cyanide as a means of self-destruction, but the coroners’ reports also reveal another possibility. Medical men needed to respond to patient demand at all hours of the day and night, even after occasions entailing alcohol consumption. This encouraged some of them to attempt an artificial ‘sobering- up’, which seems to have involved consumption of a diluted draught of prussic acid – a practice that was in itself replete with risk. A practitioner inured to consuming poison with a temporary purpose may have been more readily reconciled to using the same substance for a permanent outcome.
Not all reports ascribed a motive for suicide: around 30 per cent of instances either said that none could be determined or failed to give one. Stated motives for suicide varied, and were sometimes in line with background, non-professional causes, such as disappointment in love, but financial and career anxieties topped the list. One unfortunate (or hazardous) London practice lost three doctors in four years (1848–51).
Reporting of doctors’ suicides was typically very sympathetic and often brief in the lay press, but on one occasion the tragedy became a matter of national obsession. In the final days of 1882, William Whitfield Edwardes, a practitioner in Hounslow, ran into problems that he could not solve. He was accused of assault by a female patient and, when he appealed for professional support, he found none; his partner, Michael Whitmarsh, assumed he was guilty and offered to buy him out of their joint practice for a fraction of its value. Edwardes, in despair, took prussic acid. He also wrote a suicide note addressed directly to the coroner, ensuring maximum exposure for his case. The result was a public outcry in his favour. There were riotous scenes in Hounslow, and Whitmarsh’s house was burned down. The events of the inquest were memorialised in verse, and generated over 300 reports in the London and provincial press over the course of January 1883 (including in two Welsh-language publications).
The medical press, in contrast, were unsure what stance to take: to defend the wronged Edwardes or to contradict the execration of Whitmarsh, who remained very much alive. The Lancet and the British Medical Journal restrained their commentary to a few brief, neutral articles, the latter printing letters of support for both men. The Medical Times and Gazette was more reflective, but still endeavoured to resolve the dilemma by mourning Edwardes while provisionally defending Whitmarsh.
This case is particularly noteworthy for Edwardes’s assessment of his own situation. His letter said: “Such a charge against a medical man does not require substantiating. It is altogether enough to make it, and the man is lost forever, as far as this world is concerned.” He was acknowledging a situation which may have been relatively new for practitioners, that accusations of wrongdoing alone might be enough to secure indelible dishonour. Professional and personal respectability were entwined for Edwardes, and the one fatally jeopardised the other.
My seminar paper concluded that the expectations placed on doctors by their patients were high, but that pressure from within the profession (and self-expectation) was probably higher. I speculated that the increasing professionalisation of medicine meant that, from the 1860s if not earlier, doctors tended to be valorised or condemned outright, meaning that it was becoming more difficult to be both a doctor and an ordinary, flawed human being.
The seminar was very well received, and generated much reflection on the pressures for medical professionals in the past being echoed by stresses today. Examination procedures for medical students and trainees, alongside the ongoing stigma adhering to doctors who reveal mental health problems, were flagged for closer scrutiny. The audience also raised the issue of revalidation as a potential source of additional professional strain. Feedback after the session included, among other comments, “More topics like this would be good”.
The seminar was organised by Dr Lisetta Lovett, a consultant psychiatrist and medical humanities lead for the Keele University medical school. My collaboration with Lisetta over the years has been very fruitful; we have written a book together, Medical History for Health Professionals, to be published by Radcliffe Publishing in 2013. It does, of course, include a section on fatality and the coroner’s court.
Dr Alannah Tomkins is a Senior Lecturer in History at Keele University (E email@example.com). Her project ‘Doctors in difficulty: turbulent medical careers in an age of professionalisation’ will treat the issue of physician suicide at more length, alongside other barriers to successful practice. She is keen to hear from anyone with an interest in the project or with reflections on the potential for comparisons with medical careers today.