According to the American Foundation for Suicide Prevention, suicide is the tenth leading cause of death in the United States. In 2017 alone, 47,173 Americans, including popular music icons Chris Cornell and Chester Bennington, died by suicide.
On January 1, 2019, the Journal of the American Veterinary Medical Association (“JAVMA”) released a study assessing suicide rates for veterinarians. The sample for the study was obtained by the American Veterinary Medical Association (“AVMA”) obituary and life insurance databases as well as internet searches for deceased veterinarians. The authors of the study were three veterinarians and two medical doctors associated with the Centers for Disease Control and Prevention (“CDC”). The overall sample was reviewed by the three veterinarian authors for inclusion within the study. Out of the 11,620 veterinarians included, 398 veterinarians were determined to have died from suicide between 1979 and 2015.
The study cites several limitations, including information on non-decedent veterinarian populations from 1979 through 2015 was unknown. Lack of denominator data prevents the calculation of standardized mortality ratios, which are statistically stronger than the proportionate mortality ratios (“PMRs”), the methodology used. The study cites PMRs may be skewed by the high ratio of suicide within the sample population or by the low cause of death by other causes. For example, if fewer veterinarians in the sample die from heart disease than the general population, then the suicide rate for veterinarians may reflect higher rates. The study noted that for females, deaths by suicide was stable from 2000 through 2015 but the number of suicides “subjectively” increased with each 5-year period.
The purpose of the study was to conduct an updated assessment of PMRs for suicide among male U.S. veterinarians and to investigate PMRs for suicide among female U.S. veterinarians for the first time. Demographics within the profession has changed significantly over the past three decades. The study notes the profession has moved away from the agricultural based practice to companion animal based practice and that since 2017, larger than 75% of veterinary practices focus care on companion animals. The study also notes that since 2017 the number of practicing female veterinarians surpass the number of practicing males. The authors propose success of incorporating suicide prevention strategies may be evaluated by future studies of PMRs.
In November 2018, prior to the JAVMA publication of the veterinary specific study, the CDC released its analysis of suicide within occupations in one of its Morbidity and Mortality Weekly Reports (“MMWR”). The MMWR report noted during 2000-2016, the suicide rate among the U.S. working age population increased from 12.9 to 17.3 per 100,000. The CDC analyzed suicide deaths by Standard Occupational Classification major groups for decedents aged 16-64 years from 17 states participating in both a 2012 and 2015 National Violent Death Reporting System (“NVDRS”). The purpose of the analysis was to better understand suicide among different occupational groups in order to inform suicide prevention efforts.
According to the MMWR report, In both 2012 and 2015, the occupational groups with the highest suicide rates for males and females remained consistent. More males commit suicide than females, however, the highest percentage for suicide of 29% for both years was for females who were in unpaid occupations. The largest percentage of male suicides (19-20% of decedents) were in the Construction and Extraction group. The largest percentage of females among classifiable occupations was in the Office and Administrative Support group (15%). The highest male suicide rate was Construction and Extraction (43.6 and 53.2 per 100,000) and the highest female suicide rate was Arts, Design, Entertainment, Sports, and Media (11.7 and 15.6 per 100,000). The largest rate increase for males was in Arts, Design, Entertainment, Sports, and Media (from 26.9 to 39.7 per 100,000). The largest rate increase for females occurred in the Food Preparation and Serving Related group (from 6.1 to 9.4 per 100,000). None of these occupational groups include veterinarians.
The Health Care Practitioners and Technical Occupations group, which includes doctors, nurses, dentists, pharmacists, paramedics, veterinarians, and other medical and technical professionals, had a rate increase from 20.8 to 25.6 per 100,000 from 2012 to 2015. This group’s ratio in comparison to the total for all occupations for males remained consistent at 2%. The rate for females fell from 14% to 12% because even though suicides increased slightly for this occupational group (from 220 to 225), suicide rates have increased overall and at a higher rate for other occupational groups. The CDC has remarked there is limited data in determining veterinarian suicide rates in an earlier MMWR published February 13, 2015. Merck and the AVMA have also released a study in 2018 finding the veterinary profession did not have a higher rate of mental illness in comparison to the general public, but did have a lower sense of wellbeing.
The CDC noted in the November 2018 MMWR the etiology of suicide is multifactorial and identifying occupational factors that contribute to suicide is complicated. Both work and nonwork factors are associated with psychological distress and the relationship between occupation and suicide may be influenced by access to lethal means on the job. For example, law enforcement has easy access to firearms while doctors, nurses, and pharmacists have access to lethal drugs. The CDC’s veterinary specific report published in JAVMA attributed veterinarian suicide rates to a specific combination of factors unique to the veterinary profession that highlight a need for comprehensive suicide prevention strategies. Some of those factors included recognizing veterinary students are selected with certain personality traits, such as perfectionism, which has been associated with higher risk of mental illness such as anxiety and depression. The authors theorize occupational stressors, such as long working hours, client expectations, unexpected outcomes, communicating bad news, poor work-life balance, high workloads, rising veterinary care costs, professional isolation, student debt and lack of senior support may contribute to veterinarian suicide rates. The study recognizes the knowledge and acceptance of euthanasia as an acceptable means of ending suffering may influence veterinarians’ perceptions of suicide. In addition, the authors acknowledge veterinarians have easy access to lethal pharmaceutical products.
The authors suggest incorporating a subset of suicide prevention strategies recommended by the CDC in Preventing suicide: a technical package of policies, programs, and practices by Stone DM, Holland KM, Bartholow B, et al such as creating protective environments, teaching coping and problem-solving skills, and identifying and supporting people at risk. The authors propose incorporating healthy work design and well-being concepts in the clinical environment to address compassion fatigue and occupational stress and offering continuing education on managing occupational stressors might help to reduce the number of suicides among veterinarians.
A number of media outlets have covered the JAVMA report. In my opinion, the focus on veterinarian suicides has been disproportionately covered. In light of the #MeToo movement, where are the articles discussing the suicide rates for unpaid women, the group with the consistently highest suicide rate across all other groups? While some articles covering suicide by veterinary professionals have been responsible, like this article published by Alex Johnson of NBC News and this article published by Katelyn Newman of U.S. News and World Reports, others have published articles blaming “misguided” clients and social media for an increased rate of suicide by veterinarians. While one might expect an inferior level of journalism from a website called cracked.com, I was surprised to see it in reputable publications such as the Washington Post in an article written by David Leffler and in a similar article written by Sy Montgomery published by the Boston Globe in 2016. The CDC studies do not support the conclusion clients are misguided or that cyberbullying has directly impacted the suicide rates of veterinarians. In fact, since suicide rates peaked prior to and remained stable throughout the evolution of the internet, the studies suggest cyberbullying is not a factor. I have heard the refrain clients are causing veterinarians to commit suicide for years now, I suspect there is a campaign to keep this narrative front and center.
The three articles attributing veterinary suicide to disgruntled clients and social media heavily feature the story of Dr. Shirley Koshi. Dr. Koshi committed suicide in 2014 during a custody dispute over a cat named Karl. The authors rely on an anecdotal story sympathetic to Dr. Koshi. The authors point out Dr. Koshi was subjected to internet scorn, but neglect to mention Dr. Koshi’s supporters also engaged in cyberbullying. The absurdity can be fairly summarized by an example of one of Dr. Koshi’s supporters wishing for pack of feral dogs to eat Dr. Koshi’s detractors. The comments directed at Gwen Jurmark, the woman on the other side of the controversy, on a YouTube interview are simply put, mean. The merits of the controversy was never decided as Dr. Koshi died prior to a hearing on the matter. There were no winners in the courts or on social media, yet, mainstream media is citing Dr. Koshi’s suicide as a talking point to undermine the credibility of those who would speak out on social media about their terrible experiences at the hands of veterinary professionals. Individuals like Corey Dafnis, who’s dog Milly bled to death after a receptionist at a veterinary practice botched a spay surgery, and Madeline Kayser, who’s dog Betsy died strangling herself after being left alone overnight after surgery after assurances Betsy would be supervised, are being discredited by national news organizations dismissing them as “misguided” clients.
Dr. Koshi’s suicide is tragic, as is Dr. Sophia Yin’s, or even Dr. Valerie McDaniel’s. I encourage the profession to incorporate some of the strategies recommended by the CDC to help mitigate suicide risk within the profession instead of projecting blame on clients. I also encourage the profession, in light of the evolution of the industry, to consider and revisit some positions, policies and practices contributing to rifts between veterinarians and clients, especially if the profession believes social media may contribute to veterinarian suicides. While maligning clients may have been effective in the past, in the age of social media, more and more clients will be able to set the record straight. The profession is quite lucrative, to the tune of $18 billion in revenue in 2018. Consumers and their companion animals deserve high quality and compassionate care at reasonable prices. It is time for the profession to be proactive, not only about suicide, but also quality care, affordability, and client relations.
I encourage news organizations like the Washington Post and the Boston Globe to refrain from discrediting consumers who have been victimized by the veterinary profession. I imagine if anyone did a study on victims of veterinary malpractice, it would yield pet owners who decided to end it all because they trusted the wrong professional to care for their beloved family member. There is nothing quite like the feeling of betrayal and guilt of entrusting your family member to the wrong practitioner, only to learn soon after the profession has successfully lobbied for extraordinary protections for veterinarians who harm pet after pet, family after family. Suicide is a serious matter impacting all demographics; it is not exclusive to veterinarians. Those who fall victim to its grip have lost hope. Please don’t contribute in taking away hope from victims of veterinary malpractice that one day their voices will be heard. It is commendable to want to help a profession prevent suicide within its ranks, but it is not admirable to do so by stepping on the necks of the victims who have been betrayed by members of that profession.