For Immediate Release
Date: Dec 14th, 2009
Contact: By Gretchen M. Stein, Ph.D.*
Challenging the Myth of the Suicide-Prone Dentist
There is a widely discussed belief, long held both inside and outside the profession that dentists are at high risk for suicide. The professional and lay media often depict dentists as being suicide-prone. Even the popular TV show Seinfeld dedicated an episode to this belief.
To promote the health of dentists and the well-being of the profession of dentistry, this article challenges this belief and encourages Minnesota dentists to know the facts, stop perpetuating this belief even in humor, and become aware of the danger signs of suicide for themselves and their dentist colleagues.
Though one suicide is too many, suicide in the general U.S. population is relatively rare. Even if the most exaggerated research on suicide rates among dentists is true, (a big if), the estimated rate of suicide would be 80 in 100,000 dentists, hardly a figure that would merit notoriety for dentistry as the suicidal profession.
The Facts about Suicide in America
The Statistics. According to the American Association of Suicidology, which keeps the most current statistics available, suicide is the eighth leading cause of death in the U.S. Currently there are more than 30,000 suicides annually. This computes to 83 suicides per day, or 12 of every 100,000 Americans. Putting these numbers in context, about 1.3 percent of all death is the result of suicide.
Suicidal thoughts are common. Such threats, acts, and attempts are less so, yet much more frequent than most people realize. Suicide is the most common psychiatric emergency. Suicidal thoughts, feelings, and behavior are not rare.
Suicide rates in the U.S. have stabilized, with a slight tendency toward an increase. Historically, suicide rates decrease in times of war and increase in times of economic crisis. Although there are no official statistics on attempts, it is generally estimated that there are at least eight to 20 attempts for each suicidal death.
Predictors of suicide risk. Suicidal behavior is complex and difficult to attribute to one predictor (such as occupation). The risk factors frequently occur in combination. Described below are the major predictors of suicide risk.
Gender. Males complete suicide at a rate four times that of females. Females have generally been found to make three to four times as many attempts as males.
Age. The highest suicide rates are among people age 65 and over, whose suicide rates are more than 50 percent higher than the national population. White men 85 and older have a suicide rate six times that of the national rate.
Why so high for this group? According to the National Institute of Mental Health, white males are more deliberate in suicidal intentions, they use more lethal methods (firearms), and are less likely to talk about their plans. It may also be that older persons are less likely to survive attempts because they are less likely to recuperate.
Youth ages 15 to 24 suicide rates increased more than 200 percent from the 1950s to the late 70s. Since then, rates have remained stable or decreased slightly. Suicide ranks third (after accidents and homicide) as a cause of death among young Americans aged 15 to 24.
Race. White suicide rates are approximately twice those of non-whites. Blacks and Hispanics, when ranked among worldwide statistics and reporting, exhibit lower risk. Native Americans are the racial/ethnic group with the highest overall suicidal rate, but tribal group differences exist.
Marital status. Suicide rates are highest among the divorced, separated, and widowed, and lowest among the married.
Availability of lethal means. Firearms in the home and easy accessibility to lethal doses of pharmaceuticals significantly increase risk of suicide. Firearms are currently the most used method by essentially all groups: males, females, young, old, whites, and non-whites. Firearms account for 59 percent of all suicides. White men commit 73 percent of all suicides and 79 percent of all firearm suicides. The second most common method for men is hanging; for women, it is self-poisoning, including drug overdose.
Mental health. Psychological case studies post-mortem show that more than 90 percent of suicides have depression or another diagnosable mental illness or substance abuse disorder. At particular risk are those with depression, schizophrenia, alcohol and/or other chemical dependency, and panic disorders. In light of the high number of depressed people in the U.S. population, it is important to note that most depressed people are not suicidal. However, most suicidal people are depressed. Feelings of hopelessness or that there is no solution to a problem are found to be more predictive of suicide risk than a diagnosis of depression per se. According to Bill Blackburn, author of What You Should Know about Suicide, there is a very high correlation between alcoholism and suicide,
with an estimated 20 percent of all alcoholics ending their lives by suicide. Many people who are not alcoholic drink heavily prior to killing themselves.
Adverse Life Events. Adverse life events in combination with other risk factors may lead to suicide. Suicide and suicidal behaviors are not normal responses to the stress experienced by most people. Most people experience one or more predictors and are not suicidal. Other predictors include family history of suicide, family violence, bi-polar disorder, major depression, schizophrenia, alcohol and substance abuse. This does not mean suicide is inevitable for persons with family history; it simply means they may be more vulnerable and should take steps to reduce their risks by getting evaluation and treatment at the first sign of problems. Still other predictors include major loss such as a divorce, traumatic death, incarceration, loss of license, loss of practice, malpractice, or loss of prestige.
Are Dentists at Higher Risk for Suicide?
Statements about which occupation has the most suicides float around like urban legends. According to Jim Weed, analyst for the National Center for Health Statistics, various occupation groups have called to confirm that their occupation has the highest rates of suicide, but statistics on suicides related to occupation just are not clear. There is no national data set on occupation and suicide. Statistics are surprisingly difficult to gather. Only about half the states put occupation on their death certificates, and when they
do, there are questions of accuracy. Statistical conclusions are also hampered by the fact that when the 30,000 annual U.S. suicides are divided into occupations, the numbers for many job categories are relatively small.
In discussion of the major predictors for suicide, occupation alone is never mentioned as a major factor. Ronald Maris, Ph.D., Director, Center for the Study of Suicide and Life Threatening Behavior, University of South Carolina, points out, Occupation is not a major predictor of suicide, and it does not explain much about why the person commits suicide.
It is a combination of the factors discussed above that determines level of risk. The happily married male dentist thriving in his practice with no history of mental illness or substance abuse is far less likely to attempt or commit suicide than a male with a less stressful job, say a Buddhist monk, who is single with an opium addiction and a family history of abuse. Researchers attempts to assess occupational risk of suicide are challenged by whether or not persons in alleged high risk occupations have said risk because of stress associated with the occupation or because of its demographic composition.
As discussed, males are at higher risk of suicide than females. Though many more women are becoming dentists, the vast majority remains men. This alone increases dentists risk rate. Though more non-whites are entering the field, the majority of dentists are white. This also increases the risk for this occupation. There is no conclusive research to suggest dentists have more or less marital discord, family history of mental illness, or loss than the average person. Increased risk of suicide may exist in that dentists, through their medical training and the availability of pharmaceuticals, have a greater understanding of the method to end life and access to the means. The simple fact that most dentists are white males with medical knowledge and access to drugs puts them at higher risk. It is not that the practice of dentistry is overly stressful or damaging to ones mental health.
Dozens of studies over the past 40 years have looked at occupation and suicide. Unfortunately, most have lumped dentists, physicians, and nurses under a general category called health care workers, then concludes that health care workers take their own lives at a higher than average rate. The fact is physicians do, but it is questionable whether or not dentists do.
The highest rate of risk described in professional literature is found in the research of Steven Stack, the Department of Criminal Justice, Wayne State University. Stack used demographic controls in the assessment of occupational risk of suicide. His Suicide Risk among Dentists: A Multivariate Analysis was published in Deviant Behavior in 1996. In comparing effects of race, gender, and other co-variants of dentistry, he determined that dentists were 6.64 times more likely than the working age population to die of suicide.
Mr. Stacks findings have been strongly questioned. Roger E. Alexander, D.D.S., in Stress Related Suicide by Dentists and Other Health Care Workers: Fact or Folklore (Journal of the American Dental Association June 2001) conducted a thorough review of the literature on dentists and suicide. Alexander wrote that Stacks analyses were flawed by the use of hearsay, public perception, assumption, and currently outdated practice that may no longer be applicable.
One study of 24 states reported data on causes of death by occupation and came up with food batch makers as those at highest risk, followed by physicians and health aides including nurses, then lathe and turning machine operators. Dentists rank fifth in this study.
Suicide-by-occupation research is inherently difficult. Suicide is often concealed as accidental death, and many states do not list the deceaseds occupation. Equally important from a statistical standpoint is the problem of small numbers. Dentists represent only a small fraction of the total population, only a small fraction of them die in a given year, and only a small fraction of those are suicides. Much of the research is flawed by grand conclusions based on tiny samples.
The research on physician rates of suicide seems more thorough and reliable. It is physicians, not dentists, who have the highest rate of suicide among professionals. They are more than twice as likely as the general population to kill themselves. Psychiatrists commit suicide at the highest rate of all physicians. They account for seven percent of the total physician deaths and 12 percent of the 593 suicides in a study of 18,730 physician deaths. (Suicides by Psychiatrists: A Study of Medical Specialists by Rich et al Journal of Clinical Psychiatry, August 1980).
Are dentists at a higher risk of suicide than others? The answer would have to be that dentists are not the occupation with the highest risk. Beyond that point, the research is conflicting. Some say suicide among white male American dentists is higher than average. Others, including the June 2001 JADA article, say there is little evidence dentists are more prone to stress-related suicide than the general population. Even if Stacks findings are true, dentists suicide rate would be 6.64 times 12 for a rate of 80 dentists committing suicide per 100,000 dentists annually. A consoling fact is that dentists death rates from other causes are lower than the general populations and, on average, dentists live several years longer than the general population.
Suicide is a Preventable Tragedy
Whether or not dentists are at higher risk for suicide than the average person is not as important as the question What are dentists going to do to prevent suicide in the profession?
The first step is to stop perpetuating the belief that dentists are suicidal. Challenge this living legend whenever you think it, hear it, or see it. Youd be surprised how many people believe it is fact. Even if we are to believe the highest estimates given, we are talking about a very small percentage of dentists who actually commit suicide. Certainly the widely held belief that dentists have a high rate of suicide is impacting the well-being of dentists, their family members, those looking to dentistry as a prospective career, and potential patients of dentists.
Take steps to manage your stress. Though no such study exists, it would be revealing to compare the work-stress level and suicide rates of dentists with those of other small business owners. Running a solo practice and practicing the art and science of dentistry require tremendous skill, talent, time, and resources. It is no wonder so many dentists suffer from professional stress and burnout.
The professional counselors of the Minnesota Dentist Assistance Program are available to help any dentist in Minnesota assess stressors in his or her life and create an individualized plan of stress management. This service is free and brought to you by the Minnesota Dental Association.
Here are 12 steps to consider to beat professional stress.
1. Take better care of yourself. Dont try to fix employees, family, and friends.
2. Get involved in things that used to make you happy.
3. Avoid self-medication and abusing substances like drugs, alcohol, caffeine, nicotine, and food. Liquor and drugs reduce the perception of stress, but they dont reduce stress.
4. Be flexible. Accept that you cant control everything.
5. Plan for stress. Set realistic goals that leave time for breaks, and limit work.
6. Learn to praise yourself and accept praise. Turn off that constant censure that always says, You should or You are never good enough.
7. Keep a sense of humor with you at all times.
8. Start thinking soulfully about what you really want out of life.
9. Take a mental health day. Dust off those golf clubs, tennis racquets, and running shoes.
10. Let people know what you want. Dont sulk or expect them to read your mind.
11. Develop an attitude of gratitude. Stop focusing on what isnt right and start counting the good things in your life.
12. When life becomes difficult and stress overwhelms you, seek professional help.
Learn the danger signals of potential suicide. While some suicides occur without any outward warning, most do not. The most effective way to prevent suicide is to learn to recognize the signs of someone at risk, take those signs seriously, and know how to respond to them. The depression and emotional crisis that so often precede suicide are in most cases both recognizable and treatable.
Previous suicide attempts. Between 20 and 50 percent of people who kill themselves had previously attempted suicide. Those who have made serious suicide attempts are at a much higher risk for actually taking their lives.
Talking about death or suicide. People who commit suicide often talk about it directly or indirectly. Be alert to such statements as My family would be better off without me, Who cares if Im dead anyway, Im tired of life; I just cant go on. Sometimes people contemplating suicide may talk as if they are saying goodbye or going away.
Planning for suicide. People contemplating suicide often arrange to put their affairs in order. They may give away articles they value, pay off debts or a mortgage, or change a will.
Depression. Although most depressed people are not suicidal, most suicidal people are depressed. Watch for a loss of pleasure or withdrawal from activities that have been enjoyable.
If someone you know shows signs of potential suicide, take him or her very seriously. In 75 percent of most suicides, some warning of intention was given to a colleague, friend, or family member.
Be willing to listen and take the initiative to ask what is the matter. Persist to overcome a reluctance to talk. Dont be afraid to ask whether he or she is considering suicide or even if there is a plan or method in mind. Asking if someone is suicidal does not make him or her more suicidal.
Be actively involved in seeking professional help. Since suicidal people often dont believe they can be helped, you may have to do more to get them to the help they need. In acute crisis, it may be necessary to take the person, or to have him or her transported, to an emergency room for psychiatric treatment. Do not leave the person alone until help is available. Remove from the vicinity of the potentially suicidal person any firearms, drugs, razors, dental instruments, or scissors that could be used as aids to suicide.
Be aware of feelings, thoughts, and behaviors. Nearly everyone at some time in his or her life thinks about suicide. Most everyone decides to live because they come to realize that the crisis is temporary but death is not. People in the midst of crisis often see no escape from problems.
If you experience any of the following feelings, get help.
Cant stop the pain.
Cant think clearly.
Cant make decisions.
Cant see any way out.
Cant sleep, eat, or work.
Cant get out of the depression.
Cant make the sadness go away.
Cant see the possibility of change.
Cant see themselves as worthwhile.
Cant get someones attention.
Cant seem to get control.
(American Association of Suicidology)
If you know someone who exhibits these feelings, offer help.
Help is Available
One year ago, the Minnesota Dental Association established the Minnesota Dental Assistance Program, a professional counseling program to help dentists and their family members cope with the many stressors of dental life. This program is available 24 hours a day, seven days a week, and is provided by The Sand Creek Group, a behavioral health care corporation with excellent customer care and professional credentials.
All dentists in Minnesota are eligible for this service at no cost. In-person counseling offices are available in more 300 locations across Minnesota and in every county seat. The MDAP is confidential and here to help with the wide range of life problems from minor stress-related concerns to thoughts of suicide or death.
Please give a call to 1-800-632-7643. The assistance program is here for you, your family, and your dentist colleagues.
*Dr. Stein is President and CEO, The Sand Creek Group Ltd., providers of the Minnesota Dentist Assistance Program.
Copyright (volume 83 - number 1, January - February 2004) Minnesota Dental Association.
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|Oct 15th, 2015||Our New Mission will require the Efforts of All|
|Oct 15th, 2015||Oral Health Literacy as a Primary Goal and Not an Afterthought |
|Oct 15th, 2015||Still Crazy after Just One Year|
|Oct 15th, 2015||Womens Forum Enjoys Perfect Weather, Perfect Setting and Engaging Dialogue!|
|Aug 14th, 2015||Calling ALL Members and Non-Members: We Need Organized Dentistry!|
|Aug 14th, 2015||Can You Hear Me, Now?|
|Aug 14th, 2015||First, Do No Harm?|
|Aug 14th, 2015||A Plan for Our Future, and a New Mission StatementHelping Member Dentists Succeed and Serve|
|Jun 23rd, 2015||Our new KDA Mission: Helping Member Dentists Succeed and Serve|
|Jun 23rd, 2015||Weve got a Plan!|
|Jun 23rd, 2015||Irrelevance|
|Jun 23rd, 2015||My Introduction: A Smidge of Trepidation, Overwhelmingly Full of Pride and Anticipation|
|Jun 23rd, 2015||Part II: The KDAs Dental Access Summit A Report|
|Jun 18th, 2015||Medicare Part D: Q&A - American Dental Association - May 29, 2015|
|Apr 28th, 2015||Thank You for the Opportunity|
|Apr 28th, 2015||Ask not What Your KDA Can Do for you|
|Apr 28th, 2015||The View from No Mans Land|
|Apr 28th, 2015||KDAS Dental Access Summit Saturday, January 31, 2015 Report to KDA Part I|
|Feb 20th, 2015||Think Big!|
|Feb 20th, 2015||Its all about the membership in 2015!|
|Feb 20th, 2015||For the Record|
|Feb 20th, 2015||Into the Belly of the Beast|
|Dec 29th, 2014||Things are Moving Faster than Fast!|
|Dec 29th, 2014||Who Wouldnt Want to Be a Part of This?|
|Dec 29th, 2014||When Is the Right Time?|
|Oct 24th, 2014||Dental Insurance Direct Deposit Through A Virtual Credit Card; What Does It Cost Me?|
|Oct 21st, 2014||Who Can I Hire for $100 a Month?|
|Oct 21st, 2014||Last Call|
|Oct 21st, 2014||Im here to Help|
|Oct 21st, 2014||Get passionate! This is Our Profession!|
|Oct 21st, 2014||Postscript for an Editors Passing|
|Oct 21st, 2014||and he did what?!: Giving a Professional Second Opinion|
|Aug 21st, 2014||Your KDA is Working Hard for You!|
|Aug 21st, 2014||Nobody Goes Into Dentistry Because They Love Molars!|
|Aug 21st, 2014||Synergy|
|Aug 21st, 2014||KENTUCKY HEALTH NOW: The GOALS of our GOVERNOR|
|Jun 16th, 2014||Think Big. Think Positively. Think Proactively.|
|Jun 16th, 2014||Denigration|
|Jun 16th, 2014||YOU HAD TO BE THERE!|
|Jun 16th, 2014||New Friendships and Lasting Connections Creating a Stronger Interest in Organized Dentistry|
|Jun 16th, 2014||New Friendships and Lasting Connections Creating a Stronger Interest in Organized Dentistry|
|Apr 24th, 2014||I Only Have A Loose Screw!|
|Apr 24th, 2014||Dare to Dream!|
|Apr 24th, 2014||I am the KDA! You are the KDA! WE are the KDA!|
|Apr 24th, 2014||The Dentists Guide to Social Media Marketing|
|Feb 20th, 2014||Where Do We Go From Here?|
|Feb 20th, 2014||Medicaid: An Example of Missing the Goals for Oral Health in Kentucky|
|Feb 20th, 2014||UKCDs First Regional Dental Program: The First Ten Years|
|Feb 20th, 2014||UofL Brightening the Smiles of Children|
|Feb 20th, 2014||Go Tell It on the Mountains|
|Dec 23rd, 2013||Letting the Secret Out|
|Dec 23rd, 2013||It Is What They Left Behind|
|Dec 23rd, 2013||Dr. John Thompson Awarded Distinguished Editor Award|
|Dec 23rd, 2013||Teamwork Creates Champions: the Kentucky Meeting: March 13-16, 2014|
|Dec 23rd, 2013||Listen to Interviews with our Speakers!|
|Dec 23rd, 2013||Welcome Dental Students and New Dentists!|
|Dec 23rd, 2013||2014 Kentucky Meeting Details|
|Oct 17th, 2013||I Still Like Maps!|
|Oct 17th, 2013||Ground Game|
|Oct 17th, 2013||Kentucky Department of Insurance, HB 497 and Non-covered Services|
|Oct 17th, 2013||Dr. Janet Faraci Lees Legacy|
|Oct 17th, 2013||Dr. Janet Faraci Lee Leadership Development Award|
|Aug 12th, 2013||The Affordable Care Act: What does it mean for Our Members?|
|Aug 12th, 2013||All Membership Is Local|
|Aug 12th, 2013||White Crosses|
|Aug 12th, 2013||KDA MembershipWhere Do We Go from Here?|
|Aug 12th, 2013||Thoughts from a New Dentist: the Top Three Reasons that I am Involved with Organized Dentistry|
|Aug 12th, 2013||How can KDAIS Benefit You, as a KDA member?|
|Aug 12th, 2013||Beyond the Website: Marketing on the Modern Web|
|Aug 12th, 2013||Delinquent Accounts.Collections..YUCK! |
|Aug 12th, 2013||Every Patient Matters. So Does Every Transaction.|
|Jun 13th, 2013||Preaching to the Choir|
|Jun 13th, 2013||Something I Wish I Didn't Know!|
|Jun 13th, 2013||The Foundation of the Kentucky Dental Association: Positioned to Make a Powerful Statement|
|Apr 15th, 2013||Participate in Your KDPAC! Contribute and Deliver|
|Apr 15th, 2013||The Pediatric Dental Benefit: Must Offer, May Purchase|
|Apr 15th, 2013||Exchange What?|
|Apr 15th, 2013||So Long, Farewell, Auf Wiedersehen, Adieu|
|Apr 15th, 2013||United We Stand, Divided We Fall|
|Feb 12th, 2013||Its a Dentist Thing|
|Feb 12th, 2013||A Profession in Flux|
|Feb 12th, 2013||Living Is What You Do When Life Gets In the Way|
|Feb 12th, 2013||The Tip of the Iceberg: Actions by the Kentucky Department for Medicaid Services Which May Sink KMAP|
|Oct 19th, 2012||Membership Matters|
|Oct 19th, 2012||House Bill 1 and What It Means to You|
|Oct 19th, 2012||Self-Regulation|
|Aug 21st, 2012||The Perception of Dentistry|
|Aug 21st, 2012||Sarrell Dental: Beyond the Operatory|
|Jun 18th, 2012||Leadership or Politics?|
|Jun 18th, 2012||What Part of the “Affordable Care Act” Has Been Affordable?|
|Jun 18th, 2012||I Had an Uncle…|
|Apr 6th, 2012||Many Thanks for a Great and Memorable Year|
|Apr 6th, 2012||What a Year, so far!|
|Apr 6th, 2012||The "New Old" Still have Teeth|
|Feb 21st, 2012||Happy New Normal|
|Feb 21st, 2012||All for One and One for All!|
|Dec 19th, 2011||Access to Care?|
|Dec 19th, 2011||The Wide World of Sports|
|Oct 28th, 2011||Report of the Sixth District Trustee|
|Oct 28th, 2011||To the KDA Executive Board and the entire KDA|
|Oct 18th, 2011||Word-of-Mouth on Steroids!|
|Oct 18th, 2011||Managed Care and Dentistry in Kentucky: a Dentist’s Dilemma|
|Oct 18th, 2011||Why We Shouldn't Lose Sight of Our Purpose...|
|Aug 4th, 2011||Mentor a Young Dentist and Change a Life|
|Aug 4th, 2011||OMG, what is EBD?|
|Aug 4th, 2011||CAPWIZ: Legislative Advocacy Made Easy|
|Jun 13th, 2011||I Might Soon Be Coming to a Town Near You...|
|Jun 13th, 2011||Outside Our Line|
|Apr 18th, 2011||Let Me Ask For a Minute of Your Time|
|Apr 18th, 2011||I Pledge to Be your Humble Servant…|
|Apr 18th, 2011||Blindsided|
|Apr 18th, 2011||On Your Side, Not Your List|
|Feb 17th, 2011||Dr. Andy Elliott for President-elect of the American Dental Association|
|Feb 4th, 2011||A Little Planning Really Helps|
|Feb 4th, 2011||Adjusting Attitudes|
|Jan 4th, 2011||Dental Management of Patients Taking Antiplatelet Medications|
|Nov 30th, 2010||Holiday Greetings to All|
|Nov 30th, 2010||Delegates Report from the 2010 American Dental Association House of Delegates, Orlando, Florida|
|Nov 30th, 2010||Dental Education Found Worthy|
|Oct 25th, 2010||Delegates Report from the 2010 American Dental Association House of Delegates, Orlando, Florida|
|Oct 7th, 2010||What Happens in Alaska, doesn’t Stay in Alaska|
|Oct 7th, 2010||We Need To Do a Better Job of Communicating|
|Oct 7th, 2010||What If …?|
|Oct 7th, 2010||I’m in a Hurry!|
|Oct 7th, 2010||Who Will Speak for Me?|
|Aug 6th, 2010||The Times They Are Changing|
|Aug 6th, 2010||Kentucky's Dental Practice Act: The Passing of an Old Friend|
|Jun 10th, 2010||How a Star was Born|
|Jun 10th, 2010||I Need Your Help…|
|Apr 20th, 2010||KDA and Louisville Water Company Share 150th Birthday and Public Health Vision|
|Apr 20th, 2010||President's Message MA 2010|
|Apr 20th, 2010||Getting It Right!|
|Feb 25th, 2010||What is a Legacy?|
|Feb 25th, 2010||Please Join Us for an Exciting, Event-Filled Year Ahead!|
|Dec 14th, 2009||Holiday Reflections…|
|Dec 14th, 2009||Challenging the Myth of the Suicide-Prone Dentist|
|Dec 14th, 2009||There is Hope: Suicide Awareness and Prevention in Kentucky|
|Nov 6th, 2009||Don’t Balance Health Care Books by Shortchanging Physicians|
|Nov 6th, 2009||Break your Right Arm and Suddenly You have Time to Study Economics.|
|Jun 26th, 2009||Making the World a Better Place, One Village at a Time!|
|Apr 13th, 2009||Breaking Glass|
|Feb 20th, 2009||At the Heart of any Worthy Project is a Committed Volunteer|