Carrie Cunningham puffed out her cheeks and exhaled. She looked out at the audience filled with 2,000 of her peers, surgeons who were attending the annual meeting of the Association of Academic Surgery, a prestigious gathering of specialists from universities across the United States and Canada.
Cunningham, president of the organization, knew what she was about to reveal could cost her promotions, patients and professional standing. She took a deep breath.
“I was the top junior tennis player in the United States,” she began. “I am an associate professor of surgery at Harvard.
“But I am also human. I am a person with lifelong depression, anxiety, and now a substance use disorder.”
The room fell silent.
Cunningham knew others in the room were struggling, too. Doctors are dying by suicide at higher rates than the general population. Somewhere between 300 to 400 physicians a year in the US take their own lives, the equivalent of one medical school graduating class annually.
Surgeons have some of the highest known rates of suicide among physicians. Of 697 physician suicides reported to the CDC’s national violent death reporting system between 2003 and 2017, 71 were surgeons. Many more go unreported.
For years, no one in surgery talked publicly about mental distress in the profession; surgeons have long experienced a culture of silence when it comes to their personal pain. They have a reputation as stoic, determined and driven. They are taught, throughout a decade of grueling training, to dissociate themselves from their body’s natural cues, telling them that it is time to rest, eat or urinate.
The patient’s needs always come first – that’s part of what makes a good surgeon. But this approach can have consequences for a surgeon’s own mental health.
Cunningham had already lost one friend to suicide. She decided that if her job was to save lives, she would begin with her own and those of her colleagues.
She started to tell her story.
When Cunningham was seven, her stepfather put a tennis racket in her hand and discovered a prodigy. She quickly became a star, competing in international tournaments barely three years after she’d first hit a ball.
By 12, she had her own psychologist and nutritionist. She was put on a 3,330-calorie-a-day diet, aiming to gain 3lbs each month on her 4ft 7in frame. She’d run so hard that she’d hyperventilate. Her legs bore constant bruises from banging her racket against them.
She was praised for being scrappy and mentally tough, for being a perfectionist.
In 1987, when she was 16, World Tennis Magazine named her the top junior female player of the year. The next year, she made her debut as a professional player. In one of her first major tournaments, the teenage Cunningham faced the top-ranked Steffi Graf in the Australian Open and lost, but barely.
A psychologist taught her to hide her feelings from her opponents. Never let them know you are struggling, went the mantra. So Cunningham mastered the art of disguising her emotions. An outside observer would see a determined athlete; inside, Cunningham felt riddled with anxiety.
When she was 18, she lost in the French Open. The defeat sent her into her first major depressive episode. She sat in a Paris hotel room, alone with shades drawn, and hardly ate for a week.
After graduating high school, she climbed to No 32 in the world. She appeared to be thriving, but she was racked with loneliness. She did not earn the kind of income that allowed her to travel with family or friends. In an era before cellphones and widespread email, she was on her own. Her closest friends were her fellow competitors – people who understood what her life was like, but not people she could talk to about her struggles or doubts.
Just after she turned 20, she injured her wrist and took six months off to rehabilitate and take university courses. By the time she was healthy enough to return to play, she did not want to go back on the road and decided to retire.
She spiraled into another bout of depression – again, undiagnosed. She’d lost her identity. Cunningham dealt with her feelings the only way she knew how: busying herself with everything but her distress.
She moved to Ann Arbor to study at the University of Michigan, loaded her schedule with extra classes and began training for a marathon.
“I was awake for weeks,” she says. “I don’t remember sleeping at all. But yet, I would still work out in the day.”
She does not believe her depression was perceptible to anyone else. She got high marks, dated and went to parties. But she often felt that she was separated from the rest of the world. “It’s like being alone in a room full of people.”
She was drawn to medicine, with its intellectual challenge and the satisfaction that came from making a difference. She graduated in 2001 and married one of her classmates. The same skills that made her a tennis phenom made her an excellent doctor. Together, she and her husband were accepted for residency training at one of the country’s most prestigious programs, at Weill Cornell Medicine in New York City. After that, they moved to Harvard Medical School in Boston to do fellowships.
Cunningham was on her way to becoming an endocrine surgeon who could care for patients with diseases affecting their thyroid, parathyroid or adrenal glands. She loved the action of the operating room and working with her hands; she thrived in the long hours and fraternity of people who were taking on the seemingly impossible.
On the outside, Cunningham was winning.
Inside was another story.
In medical school and residency, doctors in training work around the clock. They eat or sleep when they can. Often, they are pushed to their limits.
“They feel miserable,” says Jessica Gold, a psychiatrist at Washington University in St Louis School of Medicine who specializes in physician wellness. “We basically think that feeling bad is part of medicine, and we can’t identify that we’re doing poorly, or that we should take time for ourselves and figure out that we actually might be depressed.”
Surgery, especially, has always been cruel to its practitioners, who suffer high rates of burnout, ergonomic injuries, miscarriages and infertility. They are trained in an apprenticeship model that lasts a minimum of five years, but usually seven or eight. Residents begin as juniors and progress up the hierarchy, adopting the skills and behaviors of those who came before them.
See one, do one, teach one is shorthand for this system. It’s how surgeons develop their technical skillset, but also how they conform to the cultural norms of the profession.
The training system was developed by William Halsted, a pioneering surgeon who worked at Johns Hopkins hospital in the late 19th and early 20th century. Halsted battled addiction throughout his career, even as he revolutionized surgery by developing new surgical techniques, advancing anesthesia and promoting infection control. He became hooked on cocaine in 1884 while conducting experiments with the drug. Using morphine to help wean himself off cocaine, he developed a new addiction that plagued him until his death at 69. He became erratic and withdrawn, sometimes disappearing for weeks at a time. His oddities, though, were tolerated because of the enormity of his achievements.
“This man created a culture where you lived in the hospital,” says Michael Maddaus, a retired surgeon who developed a narcotics addiction while working as a professor of surgery at the University of Minnesota. “Part of the ethos of that is you don’t complain … You just do your work and shut up and have discipline to be strong and pretend you’re OK when everything’s not.”
In 2003, the Accreditation Council for Graduate Medical Education, which oversees medical training in the US, ruled that trainees could work a maximum of 80 hours a week in clinical care. The first time that any national limit had been set on trainee work hours, it cut into the 100-hour-plus weeks that were often the norm for surgical trainees. But many surgeons protested that the reduced schedule did not leave enough time to adequately train surgical residents. (When an 80-hour workweek for residents was first rolled out in New York state in 1989, surgical trainees were exempt.) In respons
