Putting It All Together

Putting It All Together

October 2018

The PBI approach encourages physicians to consider their situation and protect themselves

It’s important to know the warning signs for suicide (see below), but by the time they become visible, the risk of harm has often reached a dangerous level. And the warning signs themselves, designed to detect suicidal thoughts in others, do nothing to help an individual consider their own situation early on and make changes to avoid reaching the point of desperation.

There are numerous self-assessment tools available. The Stanford Medicine WellMd site provides links to questionnaires and quizzes that can help physicians determine their level of anxiety, stress, burnout, happiness, self-compassion and work-life balance, to name just a few. These tools are valuable, especially when they offer resources and referrals for those who need them.

The PBI Suicide Potential Formula (SPF) goes a step further. Modeled on the organization’s well-established Violation Potential Formula, SPF offers physicians a holistic way of thinking through their own unique situation. It is not meant to gauge how close someone is to suicide. Instead, it provides each practitioner with an easy-to-manage framework for considering how the various forces discussed in this issue are affecting them, so they can take steps to protect themselves.

Everyone has a suicide potential. Even the most well-adjusted energetic physician has personal vulnerabilities that can be triggered by pressures at work or home. They may not be causing a problem today, but it takes surprisingly little for them to become serious concerns. All it takes is a momentary lapse, a mistake or a complaint from a patient, and someone who has been happy working long hours and proud of their success as a physician suddenly feels they may lose everything that matters to them.

The basics of the formula are simple. External risk factors and internal vulnerabilities interact in ways that multiply their effect. A feeling of accountability helps reduce the combined stress. And a refusal to consider the power of these factors raises one’s suicide potential exponentially. In other words:

Suicide Potential formula

RISK FACTORS are external circumstances and conditions you find stressful. Examples include
• Pressure to see more patients per day
• Intrusive oversight by others (supervisors, insurance companies, etc.)
• Time-consuming record keeping
• Working long hours
• Lack of down time
• Isolation from family and friends
• Financial worries
• Marital stress

VULNERABILITIES are aspects of your inner life that make you susceptible to burnout and depression, such as:
• Anxiety
• Compulsiveness
• Difficulty saying no
• Needing to succeed or “win”
• Dread of failure

ACCOUNTABILITY. In this context, ac-countability is an awareness that others are keeping track of your welfare.

RESISTANCE is your refusal to confront these issues. Often it is grounded in concerns about admitting weakness either to yourself or to those who have power over your career.

The value of the Formula is that it allows physicians to think ahead about the various internal and external factors that are likely to affect them, and take steps to protect themselves. If a physician realizes ahead of time how important their success as a doctor is to their sense of self-worth, and how over-extended they are at work, they can start looking for ways to find meaning outside of work. By discussing their plans with colleagues and/or loved ones, they increase their accountability. With a more balanced view of themselves, and the help of others keeping an eye on them, they are far less likely to feel overwhelmed by any problems that arise at work.


THE FSMB’S WORKGROUP ON PHYSICIAN WELLNESS AND BURNOUT has published a long list of recommendations encompassing all facets of health care. Most directly, FSMB urges state medical boards to review their licensing and renewal policies that might dissuade physicians from seeking the help they need. In particular, the workgroup recommends that boards ask questions not about illness per se, but about whether or not illness impairs a physician’s current ability to practice safely and effectively. “Applications must not seek information about impairment that may have occurred in the distant past,” says FSMB, “and state medical boards should limit the time window for such historical questions to two years or less.”

has compiled “Tools and Resources for Resident and Faculty Member Well-Being,” including sections on Promoting Well-Being, Assessing and Addressing Emotional and Psychological Distress/Depression/Suicide, Improving the Learning and Working Environment, Coping with Tragedy.

THE MAYO CLINIC’S PROGRAM ON PHYSICIAN WELL-BEING. Launched in 2007, the Mayo program focuses on ways to improve physician well-being throughout their careers. The group conducts research into the causes and consequences of physician burnout, uses its findings to develop interventions, and rigorously evaluates the results to ensure “meaningful and substantive changes within the organization and for the profession of medicine.”

THE STANFORD MEDICINE WELLMD CENTER was created in late 2015 not simply to reduce burnout but also to “improve the health and professional fulfillment of physicians and the associated health of their patients, their students, and other members of the medical teams they lead.” The program focuses on three domains:

CULTURE OF WELLNESS: Organizational work environment, values and behaviors that promote self-care, personal and professional growth, and compassion for ourselves, our colleagues and our patients.
EFFICIENCY OF PRACTICE: Workplace systems, processes, and practices that promote safety, quality, effectiveness, positive patient and colleague interactions, and work-life balance.
PERSONAL RESILIENCE: Individual skills, behaviors, and attitudes that contribute to physical, emotional, and professional well-being.

AMA STEPS FORWARD: PREVENTING PHYSICIAN DISTRESS AND SUICIDE. This online module explains how to identify at-risk physicians and facilitate access to appropriate care. It also offers numerous downloadable tools.

THE HEALER EDUCATION ASSESSMENT AND REFERRAL (HEAR) PROGRAM at the University of California San Diego (UCSD) School of Medicine is offered as a practical example of the STEPS Forward approach in action. In addition to education about physician suicide, the program offers students and faculty an anonymous questionnaire to help them assess whether and how stress and depression may be affecting them. It also allows for confidential interaction with a counselor who can help the participant get the help they need. Launched in 2009, more than 2,600 individuals have completed the questionnaire, which was able to identify “a high proportion of currently untreated, at-risk and potentially suicidal individuals.”

Chart provides Warning Signs of Suicide