From the Editor

“We talk about the toll suicide takes on families… We talk about the tragedy for the people who’ve died… What we don’t openly talk about is suicide’s toll on the doctors who have treated these patients.”

So writes Dr. Dinah Miller, a psychiatrist affiliated with Johns Hopkins Medicine. She discusses the death of a patient and the impact on her life.

Dr. Miller’s essay is one of three selections in this week’s Reading.

The papers are different and look at different issues. The one common thread: they were all published in The New England Journal of Medicine.

And they all ask important, thought-provoking questions:

How to cope with a patient’s suicide?

What to do when nudges don’t work?

Can technology bring physicians together?

p17Dr. Dinah Miller



Suicide and Physicians

“When a Patient Dies by Suicide –  The Physician’s Silent Sorrow”

Dinah Miller

The New England Journal of Medicine, 24 January 2019


The news came by text as we drove home from brunch. My patient had died that morning by suicide. I read the text and wailed. My husband was driving, and our adult children happened to be away, traveling together on an exotic journey. I struggled to gather words, and my husband held control of the car through those excruciating moments when he thought something horrible had happened to our kids. I calmed down enough to tell him that the tragedy involved a patient. He was relieved. I was not.

Dr. Miller, a psychiatrist, writes about loss and psychiatric practice.

She notes some statistics:

  • “U.S. suicide rates increased by 25.4% between 1999 and 2016.”
  • “It’s been estimated that at least half of psychiatrists will lose at least one patient to suicide during their career.”
  • “There are no estimates on how many primary care physicians will have the same experience, though they often treat psychiatric disorders.”

She talks about the impact of suicide:

We talk about the toll suicide takes on families. They experience grief, guilt, regret, anguish, anger, and stigma, and they often face significant financial and logistic consequences. We talk about the tragedy for the people who’ve died — the years of life lost, the graduations and weddings they won’t attend, the grandchildren they’ll never hold. Since suicide is considered preventable, these deaths inflict an added injury on the survivors, who may face the lingering pain of believing that there was something more they might have done.

What we don’t openly talk about is suicide’s toll on the doctors who have treated these patients. Death is part of life, and for many physicians it becomes a routine element of the job. Oncology patients die, trauma patients die, geriatric patients die — indeed, everybody eventually dies. In psychiatry, however, death is not a usual or expected outcome, and suicide induces the sharpest feelings of failure. We may grieve the loss of patients when they die of cancer, but when they die by suicide, it leaves us changed, sometimes even devastated.

Dr. Miller describes the challenge of coming to terms with the death of this patient, complicated by the fact that “we have no systematized way of coming together to learn from these cases, and no set rituals of our own to mark a death and find a path toward healing.” She herself describes a period of bereavement complicated perhaps by professional failing: “I am still figuring out how to quiet my haunting emotions. For quite some time, I would wake up with my dead patient front and center in my mind, and we traveled together through the days.”

This paper resonates with me, as I’ve lost more patients than I would like to acknowledge over the years. Dr. Miller is very honest in her account. I also appreciate the courage it takes to write about a patient suicide (and for The New England Journal of Medicine, no less).

The paper can be found here:


Nudges and Assertiveness

“Beyond Nudges — When Improving Health Calls for Greater Assertiveness”

Peter A. Ubel and Meredith B. Rosenthal

The New England Journal of Medicine, 24 January 2019


Behavioural economics is very popular. The idea that we can gently push people to better decisions, popularized by economist Cass Sunstein. In this paper, Dr. Ubel and Ms. Rosenthal wonder what works when nudges don’t.

They describe the popularity of nudges in health care:

Nudges are popular because they offer new ways to address persistently problematic behaviors, including those that traditional economic interventions have failed to influence. Proponents of nudging reason that if standard incentive-based approaches for changing behavior — such as pay-for-performance schemes — have failed, then perhaps a different approach will have more success. Nudges are also favored for being relatively hands-off, preserving choice rather than forcing people to behave in a specific manner.

But while they acknowledge a role for nudging, they also note its limitations:

  • “First, some health-related behaviors harm not only the people engaging in them but also other members of the public, creating what economists call externalities.”
  • “Second, some health care choices are not solely in the hands of patients.”
  • “Third, financial interests often influence health care decisions in ways that harm patients or society more broadly.”

Picking up on that first point: the authors note that secondhand smoke from cigarettes affects non-smokers. “If nudges fail to substantially reduce engagement in behaviors that create harmful externalities, we believe that health care leaders should consider interventions that go beyond nudging.”

They note that behavioural interventions are something of a continuum.

In fact, it’s often difficult to know when we’ve progressed from a nudge to something more forceful: a $5 penalty for engaging in an unhealthy behavior might be a nudge, but what about a $25 penalty? Or a $250 one? Requiring a couple of extra mouse clicks could nudge physicians away from ordering unnecessary tests, but would requiring half a dozen clicks count as a nudge? Or requiring multiple phone calls? The harmfulness of behaviors also varies along a continuum, from behaviors that have a small effect on the person engaging in the behavior (e.g., eating one additional donut per day) to behaviors that have a potentially large effect on third parties (e.g., not taking precautions to avoid exposing people to active tuberculosis).

In the end, they argue:

When nudges fail, or when there are serious societal consequences associated with suboptimal behaviors, we believe health and health care decision makers should consider going beyond nudges and adopting more forceful policies that maximize the chances of changing health-related behaviors.

This paper is well argued, and provides a more nuanced view of nudging than is often presented.

The piece can be found here:

Nudging has been considered in past Readings. Here’s one that looked at smoking cessation and nudging:


Technology and Loneliness

“Navigating Loneliness in the Era of Virtual Care”

Ameya Kulkarni

The New England Journal of Medicine, 24 January 2019


Dr. Kulkarni, who is affiliated with the Mid-Atlantic Permanente Medical Group, writes about the loneliness of work as a physician. After noting a challenging case, he describes how he found refuge in the resident’s lounge. But life post-residency “can feel much lonelier.”

Midnights in the ED are solitary affairs. Painful moments are no longer eased by shared experience. The burden of losing a patient, once made lighter by the shoulders of co-residents, now lies heavier on a single set of shoulders.

He also notes that the isolation of practice is unlikely to disappear, especially with technology changing our delivery of care:

The realities of modern health care are such that many current drivers of loneliness are not likely to disappear anytime soon. Virtual care is an important attribute of the medical village in the 21st century — unlike periodic appointments, it connects patients and their care teams in ways more in sync with the dynamic needs of managing a clinical condition. The model of a team of doctors on night float, a great support system in what might otherwise be the most isolating of moments, cannot feasibly exist outside the training setting. Moreover, the draws on physicians’ time also change as we move out of training and into practice. My primary social circle surrounds my children now, not necessarily the team of doctors I work with.

How to address loneliness. In this essay, Dr. Kulkarni discusses his own experience using technology to connect with other physicians:

About 2 years ago, I became more active on Twitter, right around the time that cardiologists from around the world began tweeting about new techniques, new data, and new challenges. Some of these cardiologists were prominent in our field, but others were practicing physicians who had figured out novel solutions to their everyday problems. Initially, the chatter surrounded the mechanics of care. But as in the resident lounge of the past, the power of shared experience brought us together in surprising ways. One group (#dropandgiveme20) provided encouragement for physicians interested in exercise. Another offered words of support at moments, especially during the holidays, when the demands of our jobs often meant missing out on family celebrations. Still other groups shared stories, which led to surprising connections. In one case, a thread by a prominent cardiologist about his visit to his parents’ hometown in India led to connections with some colleagues who’d grown up in the same town in different generations.

21-doctor-twitter-w529-h352-2x280 characters and one remedy for loneliness?

He notes that his group also emails out autobiographical essays to each other (the program is called, “This is Me”), allowing doctors to share patient stories, but also about their shared non-clinical interest. And he finds other ways of connecting – including a more traditional approach: he and his colleagues regularly make time to discuss stories of clinical care.

Dr. Kulkarni’s essay is timely and relevant to all of us clinicians. For the record, Twitter changed my life, and introduced me to an international community of mental health professionals.

The piece can be found here:


Reading of the Week. Every week I pick articles and papers from the world of Psychiatry.