Being a physician is a dangerous business. One reason why doctors make a lot of money is that part of it is combat pay. We live and practice in a critical war zone. The absence of the sounds of bullets and bombs does not diminish the risk. The medical soldier isn't just the emergency specialist who on Friday and Saturday night is an honorary member of the gun and knife club. It could be an ear nose and throat doctor. It could be a resident just starting out or an OB or family doc.

The risk of dying early is not from a stray bullet or an improvised explosive device. Doctors of medicine are at risk of self-destruction. The national average for suicide is 11 per 100,000. For physicians it may be up to 33 per 100,000, or three times most other professions. There are a variety of deaths. There is the stopping of the heart; there is the cessation of brain activity or brain death. There is also the patient where the breathing keeps going but the living has stopped. These other forms of dying are self-destruction with drugs, marital infidelity, or emotional insensitivity or instability.

Addiction, depression, ruined marriages don't have to be the price of medical school, but the seeds are there from the beginning. The selection of the best and the brightest carries the risk of recruiting the most vulnerable and the most driven. Sensitivity toward others is desirable, but over-sensitivity could be hidden underneath the white coat. Hard work is necessary, but overworking can be the outcome. High expectations are appropriate, but unreachable heights can lead to falls. The stress to do right all the time can become the unbearable tension when things don't go right. Invincibility can be protective when dealing with other's lives and limbs, but there is a chink in every type of armor.

Suicide is the product when the personal pain is greater than the skills to manage them. For physicians, the other variables are the means and know-how. We are trained to save lives but by simple reverse engineering it is not too tough to take the lessons of healing and turn them into practices of dying.

Medicine needs to drag this reality into the light of day. Let this be a subject of reason and research. Give permission to be human but build the systems and safeguards to do super-human work.

Death comes mostly when one is alone. Reconstruct social networks not just insurance networks. Show institutional sensitivity to mirror the compassion that needs to be displayed every day in caring for others.

Use mediation and arbitration to reform liability laws so the victims and errors are compensated, but not on the backs of personal attacks and financial ruin.

Teach within the halls of medical learning diagnostic skills to uncover disease in others, but also train the medical students in the abilities to recognize the signs and symptoms of their own personal disaster.

Reward those who pay the emotional price of knowing patients and their troubles and not those who merely know the game of insurance coding or who place technology between them and the human suffering.

Set up processes of early detection and early intervention for doctors before the damage is done. Don't punish humans for being humans. Recognize arrogance as weakness and the extreme concern as a risk for burnout.

I attended a funeral of a physician who had for years been one of the walking dead headed toward destruction with drugs and alcohol. Fortunately, as a daily act of great heroism he had stopped before a fatal outcome. His death in his old age was a testament to his victory over himself. This memory united the family in a common belief of his genuine nobility.

Healing is the job and calling of a physician. Self-healing is the need and necessity for the profession.

Joseph Cramer, M.D., is a fellow of the American Academy of Pediatrics, practicing pediatrician for more than 25 years and an adjunct professor of pediatrics at the University of Utah. He can be reached at