Greg Miday was a promising young doctor with a prestigious oncology fellowship in St. Louis. He spoke conversational Spanish, volunteered with the homeless, and played the piano as if he’d been born to it. He had rugged good looks, with dark wavy hair and a tall, athletic build. Everybody—siblings, patients, friends, nurses, professors, fellow doctors, and above all, his physician-parents—adored him.

On the evening of June 21, 2012, Greg drew a bath, lit candles, and put his iPod on speaker. He drank a copious quantity of vodka, and placed family photos on the ceramic ledge of the tub. At some point, he scribbled out a note that read: “Dear Some,

My Family, I love you. To others who have been good friends, I love you too. This is just the end of the line for my particular train. Earth wasn’t a particularly great place for me. We’ll see what else is out there. Will miss you all! Am sorry for what it’s worth. Greg Miday.”

Then he climbed into the warm water and with surgical skill, punctured the arteries carrying blood to his hands and feet.

His parents called the next morning, but got no answer. Frantic, they reached his landlady, who summoned the St. Louis police after she heard music playing from the apartment but could not get Miday to open the door.

St. Louis police found the body. He was 29 years old.

***

Miday was one of a growing number of doctors who die by suicide each year. While no organization collects official data on physician suicides, Pamela Wible, a family medicine doctor in Eugene, Oregon, who writes about the phenomenon, says that at least 400 doctors kill themselves annually. That’s the size of an entire medical school class.

Wible believes that the numbers are higher than that, since doctors close ranks around each other and prod coroners to rule the cause of doctor deaths as “unplanned”—even when they are obviously not. “Accidental overdoses?” Wible asks. “You’ve got to be kidding me. Doctors calculate doses for a living.”

Because doctors have the knowledge of anatomy as well as access to lethal doses of drugs, they have a far higher suicide “completion” rate than the general population. A 2005 essay published in JAMA found that male doctors killed themselves at a rate 70 percent higher than other professionals; among female doctors, that rate ranged from 250 to 400 percent higher.

“Unfortunately,” says Bradley Hall, a Bridgeport, West Virginia, addiction medicine physician, “suicide is one thing doctors are pretty good at.”

The little-noticed, little-discussed trend has enormous implications. Since the average annual caseload of most family doctors is roughly 2,300 patients, 400 physician deaths could mean that a million Americans lose their doctors to suicide each year.

There are many theories about why so many doctors kill themselves. They face the pressures of “assembly-line medicine,” merciless scheduling demands, fights with insurance companies, growing regulations, and an explosion in scientific literature with which their knowledge must remain current. Their debt burdens often total hundreds of thousands of dollars, and they work in constant fear of malpractice suits.

Internists routinely screen their patients for depression and anxiety—it’s considered the standard of care for an annual physical. But doctors, Wible says, must live up to a different set of standards. In medical school, professors teach their driven young students to put their own emotions aside, even as they attend to tragedy. “In general, we’re in a profession that will shun you if you show weakness or suffering in any way,” she says.

But the taboo on discussing mental illness in medicine is beginning to waver. Wible’s 2014 “Medscape” story on doctor suicide had more than 100,000 readers and attracted 800 comments, the most in the website’s 20-year history. In a related article, she recounted the story of a retired surgeon whose medical school professor told his students that if they decided to commit suicide, they should do it right. He then provided detailed instructions.

Small wonder, then, that many medical students report being depressed but consider it a weakness to ask for help themselves. One study found that only 22 percent of medical students who screened positive for depression sought help from a therapist, and that only 42 percent of those who had suicide ideation received treatment.

Instead, many self-medicate. About 9 percent of the U.S. population suffers from an alcohol- or substance-use disorder. Among doctors, that figure is between 10 to 15 percent.

In most states, doctors must disclose a mental health diagnosis or treatment history when applying for or renewing their medical license. A 2011 Current Psychiatry article notes that medical boards increasingly ask applicants about their mental health.

“Acknowledging a history of mental health or substance abuse treatment triggers a more in-depth inquiry by the medical board,” wrote Dr. Robert Bright, a psychiatry professor at the Mayo Clinic in Scottsdale, Arizona. “The lack of distinction between diagnosis and impairment further stigmatizes physicians who seek care and impedes treatment.”

Doctors who acknowledge problems with substances or mental health are typically referred to a physicians health program, or PHP. These organizations evaluate, monitor, and treat physicians. Established initially in the 1970s, PHPs, which exist in almost every state, were intended to divert physicians suffering from alcohol or drug problems from censure from their state medical boards. PHPs are incorporated as nonprofits and have autonomy from the boards. But some PHPs breach confidentiality if they fear a doctor is a danger to the public. And some state medical boards also fund their PHPs. Since the boards hold the keys to licensure, many say this is a conflict of interest.

There are growing concerns about whether PHPs have the right approach to the job. They typically send doctors to rehab programs rooted in the faith-and-abstinence principles of Alcoholics Anonymous. While AA’s 12 steps might work for some with alcohol-use disorders, critics say most PHP recommendations are ill suited for patients with mental health problems.

J. Wesley Boyd, a Harvard psychiatrist who left his post as assistant director of the Massachusetts PHP over a disagreement about practices there, says PHPs routinely intimidate their clients. In an article he co-wrote for the Journal of Addictions Medicine in 2012, Boyd noted that many doctors who seek or are referred by colleagues for treatment are mandated to attend pre-selected rehabilitation facilities for 60 to 90 days. Afterward, they must agree to monitoring and drug testing, typically at their own cost. When doctors resist PHP recommendations, they risk losing their livelihood and their licenses.

The last night of his life, Greg Miday was fearful that authorities at the Missouri PHP, which in 2009 had ordered him to 90 days in a 12-step rehab and five years of random drug tests, would make drastic sanctions after he had failed at their forced plan of abstinence.

For almost three years, Miday had worked hard to square his intellect with what AA calls “this simple program.” Its slogans urge members, “Don’t Think. Don’t Drink,” and its literature warns that those unable to follow the 12 steps are “constitutionally incapable of being honest with themselves.” But like the vast majority of ordinary Americans who try it, Miday couldn’t make the program stick. In The Sober Truth, a 2014 book that examined the 12-step rehab industry, Lance Dodes, a retired Harvard psychiatrist, reported AA’s success rate to be between 5 and 10 percent.

Suicide, of course, is never rational, and those who can best explain their decision are no longer here. But on the night of June 21, 2012, the choices before Miday seemed unbearable. His mother is convinced the prospect of getting his license suspended—or worse—was too devastating to contemplate.

“When you threaten doctors with the loss of everything they’ve worked so hard for, what do you think it’s going to do?” asks his mother, Karen Miday, a psychiatrist. “It’s going to make them feel like they have no way out.”

She pauses for a second. “I treat severely depressed people all the time, but they don’t go out and kill themselves.”

***

Greg Miday was born with talent, wit, sensitivity, and passion—and it all seemed to appear early. At age 7, the future doctor took special note of how Claude Monet’s physical limitations—cataracts—dimmed the artist’s genius. In second grade, he greeted each new page of his journal as if it were an old friend. “Hello,” the entries begin. He observed the fluctuating stock market, condemned Saddam Hussein for invading Kuwait, lamented the rise in gas prices, and described Monet’s new style of painting as “mostly smudges.”

At Walnut Hills, Cincinnati’s most academically rigorous public high school, Miday was salutatorian, mastering science and piano competitions. He breezed through his AP courses, often tutoring those with lesser gifts, and completed the New York Times crossword puzzle each day. But his external successes seemed no match for his self-doubt and anxiety. He quit tennis when others surpassed him, and he could be bitingly condescending to his family and closest friends. Late in high school, his doctor prescribed him an antidepressant.

At Northwestern University, Miday balanced his art history major with pre-med classes, graduating with a near-perfect GPA in just three years. Between his long hours studying, his mother says, he would unwind with alcohol. He often drank to excess, but that didn’t differentiate him from many other college students. “He liked drinking,” Karen says. “It gave him confidence. He loved being the life of the party.”

But it gave him another sensation, too. He told his father, Bob Miday, a research physician, that his brain didn’t “feel normal” until after his second drink.

Greg rendered his unease in a university art class self-portrait, transforming his chiseled features and easy smile into the tormented expression reminiscent of Munch’s lonely figure in “The Scream.” With blazing eyes, a furrowed brow, and his mouth open in an anguished cry, Miday looks as if he is facing a brutal enemy.

At Ohio State medical school, Miday breezed through his classes and labs. By his third year in 2007, he spent much of his weekends binge drinking. He also used cocaine, and his roommates grew so concerned about his habits they reported his behavior to the dean. Miday was ordered to attend an outpatient alcohol treatment program based on Alcoholics Anonymous.

AA serves as the foundation for the majority of alcohol treatment programs in this country even though many newer, science-based approaches have been shown more effective in treating alcohol problems. One expansive review of the literature found little to inspire confidence in AA’s approach. “No experimental studies unequivocally demonstrated the effectiveness of AA or TSF [12-step facilitation] approaches for reducing alcohol dependence or problems.”

Miday kept his grades up and flourished outside the classroom, too. That spring, he signed up to participate in the school talent show by playing “Moonlight Sonata,” practicing the allegro portion so forcefully he sometimes bloodied his fingers. He worked hard to stay sober, drawing support from a mentor and medical school professor who had struggled with alcohol himself.

After his 2008 medical school graduation, Miday left Ohio for a residency at Washington University in St. Louis. The move coincided with his mentor’s apparent—but hushed—suicide. Miday took the news fatalistically. “You either work the program, or die,” he told his parents, repeating one of AA’s maxims.

But several months later, he began drinking and using cocaine again. In 2009, his behaviors raised enough alarm that a hospital colleague reported Miday to the Missouri physician health program.

Miday spent three months at an Illinois rehab facility that he later described to his parents as hellish. He agreed to abstain from alcohol for five years, during which he would submit to random alcohol tests at his own cost.

***

Not long after Greg returned from rehab, a medical honor society journal published a literary essay he had written at Ohio State. In it, he examined the role of alcohol—a central character itself, really—in Hemingway’s For Whom the Bell Tolls.

Miday cited decades of studies on alcoholism, as the condition was called until recently. (Researchers now favor the term “alcohol use disorder,” which denotes a spectrum of severity.) But his writing clearly hinted at his personal familiarity with the subject. He notes the description of absinthe’s healing powers: “If you have anything wrong, this will cure it.” He uses the language of AA’s bible, “The Big Book,” to describe alcohol’s lure: “baffling, powerful.” And he describes Pablo, Hemingway’s fearless guerrilla leader, as having an “alcoholic charm” that makes him a magnet to others—a technique alcoholics develop, he writes, to mask their illness. Alcohol offers Pablo an escape from two terrible choices: the dead end after the war, or life as a fugitive.

Greg concluded the piece with a call to action: “The real outrage of alcoholism, and a heavy burden on the medical profession, is that it is under-recognized, under-researched, and under-treated.” He noted new treatments shown effective in reducing drinking, and cautioned fellow doctors to look for alcohol problems among their patients. “[Their] disease is deadly but treatable,” he wrote, “and [they] need your help.”

While the essay earned him kudos, Miday feared that he had outed himself as an alcoholic, his mother says. And he struggled mightily with abstinence. The guy who loved being the life of the party found himself left out of friends’ bachelor parties and self-conscious around potential dates. “Let’s be realistic: People drink when they go out,” Karen says. “Doctors, especially, drink when they go out. He felt it set him apart, personally and professionally.”

Still, Miday worked 80 hours a week as a hospital physician, paying off more than $100,000 of student loan debt. By 2011, he was an instructor of medicine at Washington University, where he was also awarded a respected oncology fellowship. In an email to his parents in March 2012, Miday, noted proudly that he had personally examined and admitted more patients in one night than anyone previously.

But soon the upbeat emails began to falter. In mid-May, he attached the grueling schedule he faced at the beginning of his July 1 fellowship. He described two deaths he’d overseen the night before, and a frail, elderly cancer patient to whom he would be administering chemotherapy later that day. “I have a feeling it ain’t gonna go so well,” he wrote.

In late May, Miday was concerned about his difficulty abstaining. “If I can’t get into good recovery that seems sustainable by the time of my fellowship (from now on) I will stop practicing clinical medicine and find another career plan,” he wrote in an email.

Two weeks later, he flew with a new girlfriend, an oncology nurse, for a brief trip to Puerto Rico. There, the powerful lure of alcohol was too much to resist. He overdid it—a lot, and the getaway unraveled. Miday and the young woman quarreled, and back in St. Louis, she left him at the airport. Greg’s mother says that he feared his girlfriend would report his drinking to the medical board if he didn’t do it himself.

On the evening of June 20, Miday, distraught, phoned his mother. She urged him to keep his appointment with his psychiatrist, and to disclose his drinking to the PHP, too. His despair was so palpable, Karen asked him to promise that he would stay safe that night.

The next morning Miday met with his psychiatrist, and made a plan to check into a local inpatient treatment program that afternoon. He also reported his vacation drinking to authorities at the Missouri PHP.

His final calls on the afternoon of June 21 were to the Missouri PHP.

After Greg’s death, Robert Miday says, he spoke with the PHP’s clinical director, Bob Bondurant, a registered nurse. As the father recalls the conversation, Bondurant said the organization did not support Greg Miday’s decision to be treated at a local rehab center, but would give no further details about the Midays’ son.

Reached by phone, Bondurant declined to comment.

***

Medical boards have the duty to protect patients from doctors who may be compromised. But critics say the lengthy stays in rehab, followed by mandated abstinence, monitoring, and random drug testing are so coercive, they dissuade many doctors from acknowledging they need help.

Proponents of PHPs say the situation is more complex. Bradley Hall, the West Virginia doctor who is medical director of his state’s PHP, said that 75 percent of those who enter treatment manage to abstain from drugs and alcohol for five years. That’s a notably higher success rate than is typically seen in the notoriously difficult field of addictions medicine. But to be fair, many doctors who enter the programs are highly motivated, since their licenses are at stake. (Karen says her son always passed the screens, too, and knew to schedule his drinking around them.)

Paul Earley, an addiction medicine physician and medical director of the Georgia PHP in Atlanta, acknowledges that the one-size-fits-all treatment approach for those with alcohol and drug problems is imperfect. But for doctors found to have an addiction disorder, he says, five years of abstinence was a reasonable goal, given the risks posed by impaired doctors.

"Are we being tougher on physicians than the general population?” Earley asks. “Yes, we are. Frankly, if you sign up to be a physician and put other people's lives in your hands, you have a greater responsibility to the public than if you work in retail.”

Many doctors believe these limited options are at odds with what modern medicine has learned about treating mental health conditions or addiction, which is that the approach should be tailored to the patient. When doctors are referred to the PHPs, Boyd writes, they are often compromised, have little power, and are in no position to voice what might be legitimate objections to a PHP’s practices. Almost certainly, Greg Miday felt that way.

It is, of course, impossible to understand what drove a brilliant young man to take such a drastic, irrevocable step, and whether a more empathic response from the Missouri PHP would have changed the outcome. Without doubt, Greg Miday was far more troubled than anyone understood. He died with a blood alcohol level more than three times the legal limit, scribbling last words that explained little to those who loved him the most.

The Midays wonder daily what they might have done differently to save their child. For her part, Karen Miday has become a reluctant activist. She sifts through her son’s emails, texts, and essays, searching for clues as an epidemiologist might examine the spread of a deadly virus. She, like Pamela Wible, believes something has gone very wrong with a system that loses hundreds of doctors a year to suicide. She posts public comments on doctor’s blogs and websites, and writes to policymakers in the fervent hope that compassion might replace coercion for those most in need.

For all her years as a psychiatrist, nothing has galvanized her so much as making sure that troubled doctors like her son are offered the range of treatments and approaches she provides her patients. “I cannot bring our son back,” she says, “but unless we continue this dialogue about medicine’s deep, dark secret, we risk losing many more Gregs.”